[Remote management of musculoskeletal pain : A pragmatic approach to the implementation of video and phone consultations in musculoskeletal practice. German version]. / Telemedizinisches Schmerzmanagement von muskuloskeletalem Schmerz : Ein pragmatischer Ansatz zur Implementierung von Video- und Telefonsprechstunden in der muskuloskeletalen Schmerztherapie. Deutsche Fassung.

INTRODUCTION: Remote consultations through phone or video are gaining in importance for the treatment of musculoskeletal pain across a range of health care providers. However, there is a plethora of technical options for practitioners to choose from, and there are various challenges in the adaptation of clinical processes as well as several special considerations regarding regulatory context and patient management. Practitioners are faced with a lack of high-quality peer-reviewed resources to guide the planning and practical implementation of remote consultations. OBJECTIVES: This Clinical Update seeks to provide practical guidance for the planning and implementation of remote consultations for the management and treatment of people with musculoskeletal pain. METHODS: Recommendations are based on a brief overview of the relevant research regarding phone and video consultations for musculoskeletal practice and derived from the literature, relevant guidelines, and practical experience. RESULTS: The technical feasibility of remote consultations for musculoskeletal complaints is good, patient satisfaction is high, and a growing body of evidence supports its comparative effectiveness to in-person consultations in some circumstances for improving pain and functioning. We consider in detail practical aspects such as the choosing of hardware and software, we touch on the legal and regulatory context, and we focus on the adaptation of clinical processes and communication. CONCLUSION: This Clinical Update draws together best-practice evidence in a practically applicable format, enabling therapists who are working with people with pain to directly apply this knowledge to their individual clinical settings and the requirements of their patients.

Rituximab for the Treatment of Refractory Cardiac Sarcoidosis: A Single-Center Experience.

BACKGROUND: We sought to examine the effect of anti-B-cell therapy (rituximab) on cardiac inflammation and function in corticosteroid-refractory cardiac sarcoidosis. Cardiac sarcoidosis (CS) is a rare cause of cardiomyopathy characterized by granulomatous inflammation involving the myocardium. Although typically responsive to corticosteroid treatment, there is a critical need for identifying effective steroid-sparing agents for disease control. Despite increasing evidence on the role of B cells in the pathogenesis of sarcoidosis, there is limited data on the efficacy of anti-B-cell therapy, specifically rituximab, for controlling CS. METHODS AND RESULTS: We reviewed the clinical experience at a tertiary care referral center of all patients with CS who received rituximab after failing to improve with initial immunosuppression therapy, which included corticosteroids. Fluorodeoxyglucose positron emission tomography (FDG PET/CT) images before and after rituximab treatment were evaluated. All images were interpreted by 2 experienced nuclear medicine trained physicians. We identified 7 patients (5 men, 2 women; mean age at diagnosis, 49.0 ± 7.9 years) with active CS who were treated with rituximab. The median length of follow-up was 5.1 years. All individuals, but 1, had received prior steroid-sparing agents in addition to corticosteroids. Rituximab was administered either as 1000 mg intravenously ×1 or ×2 doses, separated by 2 weeks. Repeat dosing, if appropriate, was considered after 6 months. All tolerated the infusions well. Inflammation as assessed by maximum standardized uptake value on cardiac FDG PET/CT uptake significantly decreased in 6 of 7 patients (median 6.0-4.5, Wilcoxon signed rank z -1.8593, W 3), whereas the left ventricular ejection fraction improved or stabilized in 4 patients but decreased in 3. The mean left ventricular ejection fraction was 40.1% and 43.3% before and after treatment, respectively (P = .28). Three patients reported improved physical capacity, and 5 patients showed improved arrhythmic burden on Holter monitoring or implantable cardioverter-defibrillator interrogation. One patient subsequently developed a fungal catheter-associated infection and sepsis requiring discontinuation. CONCLUSIONS: Rituximab was well-tolerated and seemed to decrease inflammation, as assessed by cardiac FDG PET/CT in all but 1 patient with active CS. These data suggest that rituximab may be a promising therapeutic option for CS, which deserves merits further study.

Evaluation of prestyloid recess morphology and ulnar-sided contrast leakage in CT arthrography of the wrist.

BACKGROUND: In wrist arthrograms, aberrant contrast material is frequently seen extending into the soft tissue adjacent to the ulnar styloid process. Since the prestyloid recess can mimic contrast leakage in CT arthrography, this study aims to provide a detailed analysis of its morphologic variability, while investigating whether actual ulnar-sided leakage is associated with injuries of the triangular fibrocartilage complex (TFCC). METHODS: Eighty-six patients with positive wrist trauma history underwent multi-compartment CT arthrography (40 women, median age 44.5 years). Studies were reviewed by two board-certified radiologists, who documented the morphology of the prestyloid recess regarding size, opening type, shape and position, as well as the presence or absence of ulnar-sided contrast leakage. Correlations between leakage and the presence of TFCC injuries were assessed using the mean square contingency coefficient (rɸ). RESULTS: The most common configuration of the prestyloid recess included a narrow opening (73.26%; width 2.26 ± 1.43 mm), saccular shape (66.28%), and palmar position compared to the styloid process (55.81%). Its mean length and anterior-posterior diameter were 6.89 ± 2.36 and 5.05 ± 1.97 mm, respectively. Ulnar-sided contrast leakage was reported in 29 patients (33.72%) with a mean extent of 12.30 ± 5.31 mm. Leakage occurred more often in patients with ulnar-sided TFCC injuries (rɸ = 0.480; p < 0.001), whereas no association was found for lesions of the central articular disc (rɸ = 0.172; p = 0.111). CONCLUSIONS: Since ulnar-sided contrast leakage is more common in patients with peripheral TFCC injuries, distinction between an atypical configuration of the prestyloid recess and actual leakage is important in CT arthrography of the wrist.

Bilateral Transverse Upper Gracilis Flaps for Unilateral Breast Reconstruction: A 4-Year Retrospective Study of the "2-in-1" Technique and a Systematic Review With Meta-analysis.

INTRODUCTION: The transverse upper gracilis (TUG) flap is a reliable alternative to abdominally based breast reconstruction because of its advantageous anatomy. However, the limited tissue volume prevents reconstruction of large breasts. The bilateral TUG flaps for unilateral breast reconstruction can overcome this problem. METHODS: A retrospective analysis was performed regarding unilateral breast reconstruction with bilateral TUGs at the Queen Victoria Hospital from 2015 to 2019. Associations between categorical variables were examined with Fisher exact test, and any differences in continuous variables by complication status were evaluated with Mann-Whitney-Wilcoxon test for independent samples. A relevant systematic review was conducted with a meta-analysis of proportions using the Freeman-Tukey arcsine transformation for the estimation of the overall survival rates. RESULTS: Ten cases were identified with 6 having a delayed reconstruction. Median age and body mass index were 50.8 years and 23.9 kg/m 2 , respectively, and average flap weight was 268.3 g. One flap was placed superiorly with its pedicle anastomosed to the retrograde internal mammary vessels, except of half of the cases where a second anterograde vein was used. The mean follow-up was 21.4 months, and all flaps survived. Two patients returned to theater, and 4 experienced donor-site problems. The presence of complications was not associated with age, ever smoking, body mass index, TUG weight, or anastomosis to retrograde internal mammary vein. The systematic review resulted in 8 eligible articles with a total sample of 156 flaps. The overall survival rate was 96.8%. In 6 cases, the indication was Poland syndrome (7.7%), and in 48.7%, axillary vessels were also used as recipient vessels. The estimated overall flap survival rate was 100% (95% confidence interval, 99%-100%), and no significant heterogeneity was noted ( I2 = 0%, P = 0.71). CONCLUSIONS: The "2-in-1" technique can lead to symmetrical aesthetically pleasant results for both recipient and donor sites. Our case series and the conducted systematic review reiterate the reliability of this approach.

Suppressing physiologic 18-fluorodeoxyglucose uptake in patients undergoing positron emission tomography for cardiac sarcoidosis: The effect of a structured patient preparation protocol.

OBJECTIVE: Myocardial positron emission tomography (PET) to detect cardiac sarcoidosis requires adequate patient preparation; however, in many cases physiologic myocardial 18F-fluorodeoxyglucose (18F-FDG) uptake may not be adequately suppressed. We sought to evaluate the efficacy of a structured patient preparation protocol as recommended by the joint SNMMI/ASNC expert consensus document on the role of 18F-FDG PET/CT in cardiac sarcoid detection and therapy monitoring. The SNMMI/ASNC preparation protocol recommends at least two high-fat (> 35 g), low-carbohydrate (< 3 g) (HFLC) meals the day before testing followed by fasting for at least 4-12 hours. METHODS: All unique PET scans performed for cardiac sarcoidosis before (group 1) and after (group 2) application of the new preparation protocol were included in the study. In group 1, patients were given a preparation protocol of HFLC meals with suggested meals examples, while patients in group 2 received detailed diet instructions, together with accepted and non-accepted meal examples along. In group 2, reinforcement of instructions by nursing staff and review of dietary log were performed prior to testing. All PET images were evaluated for suppression of physiologic myocardial 18F-FDG uptake. RESULTS: Group 1 included 124 unique patients, and group 2 included 232 unique patients. There were no significant differences in baseline patient characteristics between the two groups. Suppression of physiologic myocardial 18F-FDG uptake was achieved in 91% of patients in group 2, compared to 78% of patients in group 1 (P < .001). A "diffuse" myocardial uptake pattern, indicating inadequate 18F-FDG suppression, was seen in 2% of studies in group 2 vs 12% in group 1 (P < .001). CONCLUSION: In this single-center study, application of a structured preparation protocol was highly successful in achieving suppression of physiologic myocardial 18F-FDG uptake in patients undergoing myocardial PET for cardiac sarcoidosis.

Osteoarthritis of the Wrist: Pathology, Radiology, and Treatment.

Osteoarthritis (OA) is a degenerative disease that can manifest in any synovial joint under certain conditions. It leads to destruction of articular cartilage and adjacent bone, as well as formation of osteophytes at the edges of afflicted joint surfaces. Regarding the wrist, typical degenerative arthritis affects particular joints at a specific patient age, due to asymmetric load distribution and repetitive microtrauma. However, in the presence of instability or systemic diseases, early-onset degeneration can also impair the range of motion and grip strength in younger patients. Although advanced stages of OA display characteristic signs in radiography, the detection of early manifestations frequently requires computed tomography or magnetic resonance imaging (in some cases with additional arthrography). If a wrist becomes unstable, timely diagnosis and precise treatment are essential to prevent rapid disease progression. Therefore, close collaboration between radiologists and hand surgeons is obligatory to preserve the carpal function of patients.

Biomarker-Informed Machine Learning Model of Cognitive Fatigue from a Heart Rate Response Perspective.

Cognitive fatigue is a psychological state characterised by feelings of tiredness and impaired cognitive functioning arising from high cognitive demands. This paper examines the recent research progress on the assessment of cognitive fatigue and provides informed recommendations for future research. Traditionally, cognitive fatigue is introspectively assessed through self-report or objectively inferred from a decline in behavioural performance. However, more recently, researchers have attempted to explore the biological underpinnings of cognitive fatigue to understand and measure this phenomenon. In particular, there is evidence indicating that the imbalance between sympathetic and parasympathetic nervous activity appears to be a physiological correlate of cognitive fatigue. This imbalance has been indexed through various heart rate variability indices that have also been proposed as putative biomarkers of cognitive fatigue. Moreover, in contrast to traditional inferential methods, there is also a growing research interest in using data-driven approaches to assessing cognitive fatigue. The ubiquity of wearables with the capability to collect large amounts of physiological data appears to be a major facilitator in the growth of data-driven research in this area. Preliminary findings indicate that such large datasets can be used to accurately predict cognitive fatigue through various machine learning approaches. Overall, the potential of combining domain-specific knowledge gained from biomarker research with machine learning approaches should be further explored to build more robust predictive models of cognitive fatigue.

The effect of prenatal maternal physical activity and lifestyle in perinatal outcome: results from a Greek study.

BACKGROUND: Several maternal characteristics, including lifestyle, have been associated with perinatal outcomes and birth anthropometric characteristics of the offspring. This study aimed to identify whether physical activity (PA) and other lifestyle parameters of the mother are associated with the pregnancy outcomes or with the infant's birth anthropometric characteristics. METHODS: Participants were recruited in Mitera Maternity Hospital, Athens, Greece. Socio-demographic, medical history and anthropometric assessment took place. PA during pregnancy was assessed with the Pregnancy Physical Activity Questionnaire. Dietary assessment was conducted with the Food Frequency Questionnaire and adherence to the Mediterranean diet was evaluated with the MedDiet score. Birth weight and gestational age data were also collected. RESULTS: Sedentary-intensity activity scores increased with increased educational level, while moderate-intensity activity scores decreased with increased educational level. Pregnant women who delivered large for gestational age infants had lower sports activity score. Higher vigorous and sports activity score was demonstrated in cases with a vaginal delivery compared with caesarean section. PA score was significantly and positively correlated with several nutrient intakes and PA was higher in women with a healthier nutritional pattern. Increased MedDiet scores were found in mothers with increased educational level. CONCLUSIONS: Overall, PA was higher in women with a healthier nutritional pattern. An increased vs. a low activity level during pregnancy is positively associated with vaginal delivery and with the size of the offspring.

The Use of the Bipedicled Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction: A Systematic Review and Meta-analysis.

INTRODUCTION: The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction. METHODS: The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables. RESULTS: Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate. CONCLUSIONS: Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

The impact of combined cardiopulmonary exercise testing and SPECT myocardial perfusion imaging on downstream evaluation and management.

OBJECTIVE: The diagnostic yield of combined cardiopulmonary exercise testing (CPET) and myocardial perfusion imaging (MPI) in patients referred for stress testing has received limited study. METHODS: We evaluated consecutive patients who underwent combined CPET-MPI at a single tertiary referral center between 2011 and 2015. An abnormal CPET was defined as any of the following: reduced oxygen consumption, cardiac output impairment, or pulmonary impairment. Normal MPI was defined as the absence of resting or stress perfusion defect. The primary study outcome was change in clinical decision-making after CPET-MPI including management of pulmonary disease, management of deconditioning, heart failure management, and referral for cardiac catheterization. Outcomes of patients with normal and abnormal MPI were presented based on the specific CPET abnormality. RESULTS: 415 patients were included in the study. Of the 269 patients that had normal MPI, 206 (77%) had abnormal CPET. Patients with abnormal CPET and normal MPI, compared with patients that had normal CPET and normal MPI, were more frequently diagnosed with pulmonary disease (11.7% vs 3.2%, P = .04) and deconditioning (33.5% vs 17.4%, P = .01). Of the 146 patients that had abnormal MPI, 128 (88%) had abnormal CPET. Patients with abnormal CPET and abnormal MPI, compared with patients that had normal CPET and abnormal MPI, did not statistically differ with regard to the study outcome. CONCLUSION: An abnormal CPET, if the MPI was normal, prompted further evaluation and led to management of pulmonary disease and deconditioning.

Optimizing Radiation Safety in the Cardiac Catheterization Laboratory: A Practical Approach.

Reducing radiation exposure during cardiovascular catheterization is of paramount importance for both patient and staff safety. Over the years, advances in equipment and application of radiation safety protocols have significantly reduced patient dose and operator exposure. This review examines the current status of radiation protection in the cardiac and vascular catheterization laboratory and summarizes best practices for minimizing radiation exposure.

Determinants of operator and patient radiation exposure during cardiac catheterization: Insights from the RadiCure (RADIation reduction during cardiac catheterization using real-timE monitoring) trial.

BACKGROUND: In the RadiCure study 505 catheterization procedures were 1:1 randomized to use or no use of real-time radiation monitoring. Use of the Bleeper Sv monitor resulted in a significant reduction in operator radiation exposure. METHODS: We examined the association between several baseline and procedural parameters with operator and patient radiation exposure using univariable and multivariable analysis in the 505 patients that were enrolled in RadiCure. All baseline demographic and procedure characteristics recorded were included in the univariable analysis. RESULTS: Median fluoroscopy time was 6.2 (2.5-12.5) minutes, median patient air kerma dose was 0.908 (0.602-1.636) Gray and median first operator exposure was 10 (5-22) µSv. For analysis purposes, the 505 procedures were dichotomized based on the median operator exposure (10 µSv) and median patient radiation dose (0.908 Gray). On multivariable analysis, factors associated with high (above median or >10 µSv) first operator radiation exposure included radial access (odds ratio [OR] 5.44, 95% Confidence Interval [CI] 2.88-10.76), chronic total occlusion (CTO) intervention (OR 12.78, 95% CI 4.42-43.60), real-time radiation monitoring (OR 0.42, 95% CI 0.26-0.66), and use of a radioabsorbent drape (OR 0.53, 95% CI 0.28-0.96). High patient radiation dose (above median or >0.908 Gray) was associated with body mass index>30 kg/m2 (OR 3.22, 95% CI 1.99-5.29), prior MI (OR 2.26, 95% CI 1.29-4.04), prior cerebrovascular disease (OR 0.34, 95% CI 0.15-0.75), hypertension (OR 2.40, 95% CI 1.05-5.82), prior coronary artery bypass graft surgery (OR 2.46, 95% CI 1.40-4.39) and CTO intervention (OR 12.93, 95% CI 3.28-87.31), but was not associated with real-time radiation monitoring and use of a radioabsorbent drape. CONCLUSIONS: Several clinical and procedural factors are associated with higher patient and operator radiation exposure. Real-time radiation monitoring and use of disposable radiation shields were associated with lower operator, but not patient, radiation dose. © 2015 Wiley Periodicals, Inc.

Lymphoepithelioma-like carcinoma of the bladder: A case report.

type of low differentiated carcinoma of the nasopharyngeal region characterized by marked infiltration of lymphocytes in the area involved by tumor. However, carcinomas with this peculiar morphologic feature have been also described in various anatomic locations and they are generally designated «lymphoepithelioma-like carcinomas¼. Those of the urinary bladder are uncommon as they account of 0.4%-1.3% of all bladder carcinomas. They may coexist with the conventional urothelial carcinoma. Given their rarity, there is poor information regarding their behaviour. Here we present a new case of lymphoepithelioma-like carcinoma in the bladder and we discuss its characteristics and prognosis.

Effect of Different Ablation Settings on Acute Complications Using the Novel Irrigated Multipolar Radiofrequency Ablation Catheter (nMARQ).

BACKGROUND: Single-shot ablation devices for pulmonary vein isolation (PVI) in patients with symptomatic atrial fibrillation (AF) have been increasingly used in clinical practice. OBJECTIVE: A novel mapping-system integrated irrigated multipolar circular ablation catheter (nMARQ) has been introduced for PVI but data on larger patient cohorts on acute safety and efficacy are lacking. METHODS: A total of 145 consecutive patients undergoing AF ablation treated with the nMARQ underwent endoscopic evaluation of esophageal thermal damage (EDEL) and brain MRI for detection of silent cerebral events (SCE). During the course of our experience different modifications of the ablation strategy, including energy delivery at the left atrial posterior wall, were evaluated. RESULTS: Effective PVI was achieved in 99% of all PVs during a mean procedure-duration of 115 (±36) minutes and ablation-duration of 18 (±8) minutes. Acute major complications occurred in 3 patients (2.1%) and asymptomatic complications like SCE in 26% and EDEL in 21%. There was a significant reduction in EDEL when not using a thermal esophageal probe (0% vs. 28%, P < 0.0001). Ablation under oral anticoagulation led to lower SCE incidences compared to interrupted anticoagulation regimen (15% vs. 31%, P = 0.7). Out of 65 patients with completed 12-month follow-up, 43 (66%) were in stable sinus rhythm. CONCLUSIONS: PVI using the nMARQ is safe and effective in patients with symptomatic AF. Not using an esophageal temperature probe during ablation has relevantly reduced the incidence of EDEL. Ablations under continued oral anticoagulation have reduced incidence of SCE. Further studies on long-term efficacy are needed.

Silent cerebral events/lesions related to atrial fibrillation ablation: a clinical review.

Brain magnetic resonance imaging (MRI) has identified a high incidence of cerebral ischemia in asymptomatic patients after atrial fibrillation (AF) ablation (silent). Detection of cerebral ischemic events on MRI is based on acute hyperintense lesions on diffusion-weighted imaging. In the literature, the incidence is related to specifications of MRI and depends on the definition applied. In comparative studies, silent cerebral events (SCE, diffusion-weighted MRI [DWI] positive only) appear to be approximately 3 times more common compared to using a definition of silent cerebral lesions (SCL; without fluid attenuated inverse recovery sequence [FLAIR] positivity). Whereas the FLAIR sequence may turn positive within days after the ischemic event, SCE definition is highly sensitive for early phases of ischemic brain damage. SCE/SCL appear to represent cerebral ischemic infarcts and determine the "embolic fingerprint" of a specific ablation technology and strategy used. The optimum time point for detecting SCE is early after AF ablation (24-72 hours), whereas detection of SCL can only be performed within the first 2-7 days (due to delay of FLAIR positivity). Different technology-, procedure-, and patient-related parameters have been identified to play a role in the multifactorial genesis of SCE/SCL. In recent years, evidence has been gathered that there may be differences of SCE/SCL rates depending upon the ablation technology used, but small patient numbers and a large number of potential confounders hamper all studies. As major findings of recent studies, mode of periprocedural and intraprocedural anticoagulation has been identified as a major predictor for incidences of SCE/SCL. Whereas procedural characteristics related to higher SCE/SCL-rates may be modified, unchangeable patient-related factors should be taken into account for future individualized risk assessment. Novel ablation devices introduced into the market should be tested for their potential embolic fingerprint and refinements of ablation procedures to reduce their embolic potential should be prompted. The knowledge of "best practice" in terms of low SCE/SCL rates has prompted changes in work-flow, which have been implemented into ablation procedures using novel ablation devices. So far, no study has linked SCE/SCL to neuropsychological decline and the low number of AF-ablation-associated events needs to be weighted against the multitude of preexisting asymptomatic MRI-detected brain lesions related to the course of AF itself. Future studies are needed to evaluate if more white matter hyperintensities due to AF may be prevented by AF ablation (producing only a small number of SCE/SCL).

Outcomes of preoperative bridging therapy for patients undergoing surgery after coronary stent implantation: a weighted meta-analysis of 280 patients from eight studies.

BACKGROUND: Preoperative bridging with a glycoprotein IIb/IIIa inhibitor is often performed in patients with prior coronary stents undergoing surgery who require antiplatelet therapy discontinuation, but its safety and efficacy have received limited study. We performed a weighted meta-analysis of the outcomes in patients with coronary stents undergoing bridging with glycoprotein IIb/IIIa inhibitors prior to surgery. METHODS: We conducted a weighted meta-analysis of preoperative bridging studies published between 2002 and 2013 in patients with coronary stents undergoing surgery. Data on in-hospital mortality, stent thrombosis, bleeding, hemoglobin decrease, blood transfusion, time to hospital discharge and myocardial infarction were collected. RESULTS: A total of eight studies with 280 patients were included. Pooled estimates of outcomes were as follows: in-hospital mortality 3.5% (95% confidence interval [CI] 1.7-5.9%); stent thrombosis 1.3% (95% CI 0.3-3.0%); major bleeding 7.4% (95% CI 2.8-14.1%); any bleeding 20.6% (95% CI 4.8-43.2%); mean decrease in hemoglobin 2.8 g/dL (95% CI 2.5-3.0 g/dL); mean blood loss 271 mL (95% CI 211-311 mL); blood transfusion 13.9% (95% CI 1.0-38.2%); time to hospital discharge 5.9 days (95% CI 4.4-7.3 days); and myocardial infarction 1.6% (95% CI 0.3-3.6%). CONCLUSIONS: Preoperative bridging with a glycoprotein IIb/IIIa inhibitor in patients undergoing surgery after coronary stenting does not abolish the risk of perioperative stent thrombosis and may carry increased risk for bleeding. © 2014 Wiley Periodicals, Inc.

Comparison of radiation dose between different fluoroscopy systems in the modern catheterization laboratory: Results from bench testing using an anthropomorphic phantom.

BACKGROUND: Variations in radiation dose between various X-ray systems have received limited study. OBJECTIVE: We examined the impact of X-ray system type on patient radiation dose during cardiac catheterization. METHODS: An anthropomorphic phantom was used in a series of standardized experiments that involved 15 sec of continuous cineangiography in 7 projections. Three to seven experiments were performed in four commonly used X-ray systems: Innova IGS (GE Healthcare), Integris Allura FD20 (Philips), Allura Clarity (Philips), and Artis one (Siemens). Phantom radiation dose was measured with a dedicated X-ray dosimetry system (Gafchromic radiology film and Film QA XR software, Ashland) that was precalibrated at 0, 1, 2, 3, and 4 Gray, and with the X-ray system built-in functions. RESULTS: Radiation dose was lowest with the Allura Clarity system [average film dose 4.2±0.1 cGray, peak film dose 18.3±1.6 cGray, Air Kerma (AK) dose 0.310±0.002 Gray, Dose Area Product (DAP) dose 23.72±0.84 Gray*cm2], intermediate with the Integris Allura FD20 (average film dose 4.4±1.1 cGray, peak film dose 29.4±15.5 cGray, AK 0.482±0.189 Gray, DAP 45.18±21.90 Gray*cm2), and highest with the Artis one system (average film dose 7.4±0.8 cGray, peak film dose 66.9±0.09 cGray, AK 0.746±0.085 Gray, DAP 75.93±9.11 Gray*cm2) and the Innova IGS system (average film dose 7.2±1.0 cGray, peak film dose 49.3±28.9 cGray, AK 0.874±0.340 Gray, DAP 92.28±14.73 Gray*cm2; P=0.011 for average film dose, P=0.019 for maximum film dose, P=0.033 for AK, and P=0.008 for DAP). CONCLUSIONS: The X-ray system type has significant impact on patient radiation dose during cardiac catheterization.

Procedural failure of chronic total occlusion percutaneous coronary intervention: Insights from a multicenter US registry.

BACKGROUND: The hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly increased procedural success rates, yet some cases still fail. We sought to evaluate the causes of failure in a contemporary CTO PCI registry. METHODS: We examined 380 consecutive patients who underwent CTO-PCI at 4 high volume CTO PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, complication, and efficiency outcomes were compared between successful and failed cases. Failed cases were individually reviewed by an independent reviewer to determine the cause of failure. RESULTS: Procedural success was 91.3%. Compared with patients in whom CTO PCI was successful, those in whom CTO PCI failed had similar baseline clinical characteristics, but were more likely to have longer occlusion length, more tortuosity, more proximal cap ambiguity and blunt stump, and higher mean J-CTO scores (2.8 ± 1.1 vs. 3.5 ± 1.0, P < 0.001), and less likely to have collaterals suitable for the retrograde approach (66% vs. 45%, P = 0.021). Failure was due to a complication in 10 cases (30%). In the remaining 23 cases (70%) failure was due to inability to wire the lesion (n = 21, 4 of which were CTOs due to in-stent restenosis), or poor antegrade flow after PCI (n = 5). CONCLUSIONS: Compared with successful cases, failed CTO-PCI cases are more likely to have higher J-CTO scores, longer occlusion length, ambiguous proximal cap and no appropriate collaterals for retrograde crossing. Development of novel CTO crossing techniques is needed to further increase CTO PCI success rates.

Transradial approach for coronary chronic total occlusion interventions: Insights from a contemporary multicenter registry.

OBJECTIVES: To examine the impact of transradial access on the procedural outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI). BACKGROUND: The efficacy and safety of transradial access in CTO PCI has received limited study. METHODS: We compared the technique and outcomes of transradial vs. transfemoral access among 650 CTO PCI cases performed between January 2012 and March 2014 at 6 US centers. RESULTS: Most patients were men (87%) with high frequency of diabetes mellitus (42%) and prior coronary artery bypass graft surgery (36%). The CTO target vessel was the right coronary (59%), left anterior descending (20%), or circumflex (17%) artery. TR access was used in 110 (17%) of the 650 cases, as follows: bilateral radial access (63%); bilateral radial access plus unilateral or bilateral femoral access (7%); unilateral radial access plus unilateral or bilateral femoral access (26%); and unilateral radial access (4%). Six and eight French guide catheters were used through the radial and femoral artery, respectively. Compared to transfemoral, transradial cases had similar technical (92.6% vs. 93.0%, P = 0.87) and procedural (91.1% vs. 90.0%, P = 0.95) success and major complication rates (1.7% vs 1.8%, P = 0.99). However, transradial access was associated with higher mean procedure (142 ± 83 vs. 120 ± 60 min, P = 0.008) and fluoroscopy (58 ± 40 vs. 49 ± 31 min, P <0.026) time, and number of crossing approach changes (0.7 ± 1.0 vs. 0.5 ± 0.7, P = 0.008). CONCLUSION: Transradial CTO PCI can be performed with similar success and complication rates with transfemoral CTO PCI, but is associated with longer procedural and fluoroscopy times. © 2015 Wiley Periodicals, Inc.

Treatment of urethral strictures with balloon dilation: A forgotten tale.

Urethral stricture is a common condition that can lead to serious complications such as urinary infections and renal insufficiency secondary to urinary retention. Treatment options include catheterization and dilation, urethroplasty and endoscopic internal urethrotomy as well. Although treatment option depends on the type, length and aetiology of stricture, the choice can be influenced to varying degrees by the simplicity of the method, the preferences of the patient the available accoutrements and the patient health condition. Both urethroplasty and endoscopic internal urethrotomy require anaesthesia and thus are not suitable for many elder and unfit for surgical treatment patients. On the other hand, dilations are easy to perform in every day clinical practice however they have been associated with iatrogenic urethral trauma. In contrast, balloon dilation under vision dilates by radial application of forces against the stricture, avoiding the potentially shearing forces associated with sequential rigid dilation. Since it reduces the possibility of an iatrogenic urethral trauma and the subsequent spongiofibrosis may lead into improved therapeutic outcomes. In this report we describe a technique for the treatment of urethral strictures with balloon dilation in elder and unfit for surgical treatment patients.