Bleeding on the cutting edge: A systematic review of anticoagulant and antiplatelet continuation in minor cutaneous surgery.

BACKGROUND: Anticoagulant and antiplatelet (AC/AP) use is common and practice surrounding AC/AP continuation or cessation peri-operatively for minor cutaneous surgery lacks evidence-based consensus. OBJECTIVE: To determine the risks of haemorrhagic and thromboembolic complications associated with the continuation or cessation of AC/AP therapy in minor cutaneous surgery. METHODS: A systematic literature search was conducted using PubMed, MEDLINE, Embase and CENTRAL, to identify all articles involving the use of AC/AP in patients undergoing minor cutaneous surgery, including skin grafts and local flaps. Eligible studies were randomised control trials, prospective studies and retrospective studies in the English language. Studies investigating free-flap repairs, oculoplastic surgery and hand surgery were excluded. RESULTS: 30 studies included data from over 14,000 patients, of which more than 5000 took regular AC/AP therapy. Thromboembolic events were rare but carry high morbidity and even mortality, and in these studies three events were associated with cessation of AC/AP. There was no increase in haemorrhagic complications in patients taking aspirin monotherapy, but evidence is conflicting regarding warfarin and clopidogrel monotherapy, which shows a small increase in rate of bleeding complications. However, no increase in wound dehiscence, graft failure, wound infection or cosmetic outcome was seen. Too few studies investigated DOAC use to draw reliable conclusions. Data are sparse in comparing multiple versus single AC/AP regimens. Use of skin grafts or local flaps may have a greater complication rate than direct closure in patients on one or more AC/AP, but evidence is limited. CONCLUSION: A case-by-case risk assessment is warranted in all patients but where possible, clinicians should prioritise meticulous haemostasis over cessation of agents.

T1 and T2 Mapping in Recognition of Early Cardiac Involvement in Systemic Sarcoidosis.

Purpose To determine whether quantitative tissue characterization with T1 and T2 mapping supports recognition of myocardial involvement in patients with systemic sarcoidosis. Materials and Methods Fifty-three consecutive patients with a biopsy-proven extracardiac diagnosis of systemic sarcoidosis (21 men; median age, 45 years; interquartile range, 22 years) and 36 normotensive previously healthy control subjects (14 men; median age, 43 years; interquartile range, 18 years) underwent cardiovascular magnetic resonance imaging, which was performed to assess cardiac function and late gadolinium enhancement, and T1 and T2 mapping. A follow-up substudy was performed in 40 patients (mean follow-up interval, 144 days ± 35 [standard deviation]); of these 40 patients, 18 underwent anti-inflammatory treatment for systemic symptoms. Binary logistic regression and receiver operating characteristic curve analyses were used to assess discrimination between health and disease; Wilcoxon signed rank test was used to assess the effect of treatment. Results When compared with control subjects, patients had higher ventricular volume, higher myocardial native T1 and T2, and lower longitudinal strain and ejection fraction (P < .05 for all). Myocardial native T1 and T2 had higher discriminatory accuracy (area under the receiver operating characteristic curve [AUC]: 0.96 and 0.89, respectively) for separation between control subjects and patients when compared with the standard diagnostic criteria (AUC < 0.67). Native T1 was the independent discriminator between health and disease (specificity, 90%; sensitivity, 96%; accuracy, 94%). There was a significant reduction of native T1 and T2 in the patients who underwent treatment (z score: -3.72 and -2.88; P < .01) but not in the patients who did not (z score, -1.42 and -1.38; P > .15). Conclusion Quantitative myocardial tissue characterization with T1 and T2 mapping may enable noninvasive recognition of cardiac involvement and activity of myocardial inflammation in patients with systemic sarcoidosis. Future studies will be performed to confirm their role in risk stratification and guidance of clinical management. © RSNA, 2017 Online supplemental material is available for this article.

AST-to-platelet ratio index in non-invasive assessment of long-term graft fibrosis following pediatric liver transplantation.

Long-term graft fibrosis occurs in the majority of pediatric liver transplant recipients. Serial biopsies to monitor graft health are impractical and invasive. The APRI has been evaluated in pediatric liver disease, but not in the context of post-transplantation fibrosis. We aimed to investigate the validity of APRI as a predictor of long-term graft fibrosis in pediatric liver transplant recipients. This was a retrospective, observational study of a cohort of children who underwent liver transplantation at King's College Hospital between 1989 and 2003, with a relevant dataset available. Protocol liver biopsies were performed at 10-yr follow-up and fibrosis was graded using the Ishak scoring system, with S3-6 denoting "significant fibrosis." APRI was calculated concurrently with biopsy. A total of 39 asymptomatic patients (20 males; median age at transplant, 1.43 yr) underwent protocol liver biopsies at a median of 10.39 yr post-transplantation. APRI was associated with significant fibrosis (p = 0.012). AUROC for APRI as a predictor of significant fibrosis was 0.74 (p = 0.013). The optimal cutoff APRI value for significant fibrosis was 0.45 (sensitivity = 0.67; specificity = 0.79; PPV = 0.67; NPV = 0.79). APRI appears to be a useful non-invasive adjunct in the assessment of significant graft fibrosis in the long-term follow-up of pediatric liver transplant survivors.

Knowledge gaps and acceptability of abbreviated alcohol screening in general practice: a cross-sectional survey of hazardous and non-hazardous drinkers.

BACKGROUND: General practice provides a unique setting where hazardous alcohol consumption can be screened for and behavioural interventions can be implemented in a continuous care model. Our aim was to assess in a general practice population, the prevalence of hazardous drinking, the knowledge and attitudes surrounding alcohol, and the acceptability of brief interventions in alcohol. METHODS: A cross-sectional survey in a practice in South London, performed as part of a wider service evaluation. Questionnaires were offered to adult patients awaiting their appointments. Responses were stratified according to hazardous drinking, as per the abbreviated 'Alcohol Use Disorders Identification Test' (AUDIT-C). RESULTS: Of 179 respondents (30 % male), 34 % yielded an AUDIT-C ≥5 and 18 % reported that they never drink alcohol. Male and Caucasian patients were more likely to self-report hazardous drinking, who in turn were more likely to believe in the health benefits of moderate consumption. Little over half of patents thought that alcohol is a risk factor for cancer and were misinformed of its calorific content, suggesting two targets for future improvement. Patients' knowledge about what is a single 'unit' of alcohol was below that expected by random chance 66 % agreed that alcohol screening should feature in all GP consultations. CONCLUSIONS: While awareness of alcohol related health risks is generally good, future efforts may benefit from focusing on the association with cancer and calories. Our findings question the utility of the 'unit' system, as well as dissemination of suggested 'health benefits' of moderate consumption. General practice initiatives in screening and brief advice for alcohol deserve further study.

Prediction of esophageal varices in biliary atresia: Derivation of the "varices prediction rule", a novel noninvasive predictor.

BACKGROUND AND AIMS: Liver fibrosis and cirrhosis are nearly inevitable following Kasai portoenterostomy (KPE) for biliary atresia (BA), though the formation of varices is not. We sought to assess the value of noninvasive indices of portal hypertension (PHT), in predicting significant esophageal varices, and to develop a novel prediction model through regression modeling. METHODS: This is a retrospective, observational study with analysis of routine biochemical and ultrasound data. Five indices were examined: AST-to-platelet ratio index (APRi); hepatic artery resistance index (HARI); spleen size z score (SSAZ); platelet count-to-SSAZ ratio (P/SSAZ); and clinical prediction rule (CPR) [(0.75 × platelets)/(SSAZ+5)]+(2.5 × albumin), each at specific time points following KPE (6 months, 1 year and 2 years). Significant varices were defined as grade ≥ 2 at endoscopy (screening or following a gastrointestinal bleed). AUROC was calculated for all indices. Univariate analysis was used to assess variables' suitability for inclusion in a subsequent multivariate logistic regression model to generate a predictive index. Data are quoted as median (range). P values ≤ 0.05 were regarded as significant. RESULTS: 195 infants (median age at KPE of 55 days [11-216]) were analyzed. 42 (22%) had significant varices (median time to first presentation of varices of 1.20 [0.20-6.40] years). CPR and APRi (AUROCs ranging from 0.73-0.80 and 0.69-0.83 respectively) performed best overall. Multiple logistic regression modeling yielded a novel predictor at 6 months post-KPE: the Varices Prediction Rule (albumin × platelets/1000) (AUROC 0.75, sensitivity 86%, sensitivity 71%). CONCLUSIONS: Noninvasive indices such as CPR, APRi and now VPR can provide a tool for stratifying BA patients for elective endoscopy and possible preemptive intervention.