Advancements in left ventricular assist devices to prevent pump thrombosis and blood coagulopathy.

Mechanical circulatory support (MCS) devices, such as left ventricular assist devices (LVADs) are very useful in improving outcomes in patients with advanced-stage heart failure. Despite recent advances in LVAD development, pump thrombosis is one of the most severe adverse events caused by LVADs. The contact of blood with artificial materials of LVAD pumps and cannulas triggers the coagulation cascade. Heat spots, for example, produced by mechanical bearings are often subjected to thrombus build-up when low-flow situations impair washout and thus the necessary cooling does not happen. The formation of thrombus in an LVAD may compromise its function, causing a drop in flow and pumping power leading to failure of the LVAD, if left unattended. If a clot becomes dislodged and circulates in the bloodstream, it may disturb the flow or occlude the blood vessels in vital organs and cause internal damage that could be fatal, for example, ischemic stroke. That is why patients with LVADs are on anti-coagulant medication. However, the anti-coagulants can cause a set of issues for the patient-an example of gastrointestinal (GI) bleeding is given in illustration. On account of this, these devices are only used as a last resort in clinical practice. It is, therefore, necessary to develop devices with better mechanics of blood flow, performance and hemocompatibility. This paper discusses the development of LVADs through landmark clinical trials in detail and describes the evolution of device design to reduce the risk of pump thrombosis and achieve better hemocompatibility. Whilst driveline infection, right heart failure and arrhythmias have been recognised as LVAD-related complications, this paper focuses on complications related to pump thrombosis, especially blood coagulopathy in detail and potential strategies to mitigate this complication. Furthermore, it also discusses the LVAD implantation techniques and their anatomical challenges.

Safety and efficacy of pimecrolimus versus vehicle for the treatment of atopic dermatitis in adults and paediatric population: a systematic review and meta-analysis.

Atopic dermatitis remains a widespread problem affecting various populations globally. While numerous treatment options have been employed, pimecrolimus remains a potent and viable option. Recently, there has been increasing interest in comparing the safety and efficacy of pimecrolimus with its vehicle. Methods: The authors conducted a comprehensive search of several databases, including PubMed, COCHRANE, MEDLINE, and Cochrane Central, from inception to May 2022, using a wide search strategy with Boolean operators. The authors also employed backward snowballing to identify any studies missed in the initial search. The authors included randomized controlled trials in our meta-analysis and extracted data from the identified studies. The authors used Review Manager (RevMan) Version 5.4 to analyze the data, selecting a random-effects model due to observed differences in study populations and settings. The authors considered a P-value of 0.05 or lower to be statistically significant. Results: The authors initially identified 211 studies, of which 13 randomized controlled trials involving 4180 participants were selected for analysis. Our pooled analysis revealed that pimecrolimus 1% was more effective at reducing the severity of atopic dermatitis than its vehicles. However, no significant difference was observed in adverse effects between pimecrolimus and vehicle, except for pyrexia, nasopharyngitis, and headache, which were increased with pimecrolimus. Conclusion: Our meta-analysis showed that pimecrolimus 1% is more effective than vehicle, although the safety profile remains inconclusive. Pimecrolimus reduced the Investigator's Global Assessment score, Eczema Area and Severity Index score, and severity of pruritus when compared to its vehicle, indicating a higher efficacy profile. This is one of the first meta-analyses to assess the efficacy and safety profile of pimecrolimus 1% against a vehicle and may assist physicians in making informed decisions.

Adherence to hydroxyurea, health-related quality of life domains and attitudes towards a smartphone app among Irish adolescents and young adults with sickle cell disease.

INTRODUCTION: SCD patients experience declines in health-related quality of life (HRQOL) domains compared with healthy controls. Despite evidence supporting the benefits of hydroxyurea, medication non-adherence remains problematic, especially in adolescents and young adults (AYA). Adherence barriers include forgetfulness and lack of knowledge. Recently, increased interest in technology-based strategies to improve medication adherence has emerged. No data currently exists on hydroxyurea adherence, HRQOL or perceptions of technology-based tools in the Irish SCD population. METHODS: In order to interrogate these domains among Irish AYA SCD patients we administered an anonymous survey at two tertiary referral centres in Dublin, Ireland, in July 2019. RESULTS: Sixty-three patients participated; 63% female and 37% male, with a median and mean age of 17 and 19 years, respectively. Average monthly adherence was 76% using a visual analogue scale. Recall barriers were present in 62% while 26% omit hydroxyurea for reasons other than forgetting. Reviewing HRQOL; only 36.5% felt always physically able to engage in recreational activities, while 51% experienced disruption to school/college/work due to pain. Eighty-one percent reported that anxiety about health interferes with their lives and non-adherence correlated with worse HRQOL outcomes. Interest in a smartphone app was expressed by the majority, with daily medication reminders being the most popular feature. Sharing adherence data with doctors and discussion forums were less appealing. CONCLUSIONS: Representing over 10% of the Irish SCD population, our survey provides novel and valuable insights into medication adherence and HRQOL domains. Preferred app features may inform future technology-based interventions to improve medication adherence in SCD and other chronic health conditions.

Surgical Versus Medical Management of Necrotizing Enterocolitis With and Without Intestinal Perforation: A Retrospective Chart Review.

Background Necrotizing enterocolitis (NEC) is a debilitating disease that predominantly afflicts premature neonates, although it can also affect term neonates. The clinical features of the ailment vary widely and range from transient feed intolerance to life-threatening complications such as septicemia and disseminated intravascular coagulation. While surgery is usually only reserved for severe cases, such as those presenting with intestinal perforation, the role of surgical management in cases of NEC without perforation remains elusive. Methods A retrospective chart review of patients, three years in duration, was conducted and studied confirmed cases of NEC. The clinical presentations studied included cases of NEC with pneumatosis intestinalis, fixed bowel loop, pneumoperitoneum, and abdominal wall erythema. The patients were divided with regards to their intestinal perforation status and with pertinence to the treatment modality employed (medical or surgical). The results in either group were eventually analyzed in terms of the overall survival rate. Results A total of 48 patients were included in the study, of which 79.16% presented without perforation and 20.83% with perforation. Of the study participants included, 26 were females and 22 were males. Pertinently, no gender predominance was appreciated. In patients without perforation, medical management was noted to boast a lower mortality rate when compared with surgical intervention (15.6% vs 50.0%, respectively). In patients with perforation, the overall mortality was noted to hover at 50.0%, which was higher than that encountered in the non-perforation group. Conclusion In patients with NEC without perforation, surgical treatment confers no comparative therapeutic advantage when compared with medical management alone. Conservative management with broad-spectrum antibiotics including metronidazole yields equally favorable outcomes in such cases.

Wilkie's Syndrome as a Rare Cause of Duodenal Obstruction: Perspicacity Is in the Radiological Details.

Superior mesenteric artery syndrome, or Wilkie's syndrome, is an unexpected cause of upper gastrointestinal tract obstruction. The exact incidence of the condition remains unknown, and limited case reports are present in the literature. The obstruction results in the compression of the third part of the duodenum between the superior mesenteric artery and aorta. It is widely known that a lack of subcutaneous tissue in the area can precipitate the obstruction by significantly reducing the aortomesenteric angle. Wilkie's syndrome presents a clinically diagnostic challenge as patients initially remain undiagnosed with relapsing episodes of upper abdominal pain and bilious vomiting. In some cases, an acute obstruction may arise. Undertaking an initial contrast study of the upper gastrointestinal tract and a CT scan are required to confirm the diagnosis of the condition. In the present study, we elucidate the case of a 12-year-old girl who presented with upper abdominal pain and bouts of bilious vomiting. Upon extensive diagnostic evaluation, Wilkie's syndrome was diagnosed. Since the patient failed to respond to conservative treatment, a laparotomy with subsequent duodenojejunostomy was undertaken. The postoperative recovery of the patient was uneventful with no recurrence of symptoms on follow-up.

Management of Early Post-Operative Complications of Esophageal Atresia With Tracheoesophageal Fistula: A Retrospective Study.

Background Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a rare congenital malformation of the trachea and the esophagus. While the condition can result in a debilitating clinical picture, its outcomes have significantly ameliorated in recent times. The diminishing mortality associated with the disease can be attributed to a myriad of factors, including surgical advances, specialized anesthetic care, and categorical ventilator provision. These advances have resulted in increased survival rates even in premature infants who present with exceedingly low birth weights. Nevertheless, the mortality surrounding the condition still remains exceedingly high in some parts of the world, including the Middle East and Asia. The aim of the present study is to identify and outline the management of the postoperative complications that are intricately linked with soaring mortality rates. Methods We conducted a single-center retrospective study, three years in duration, of all the patients who were operated for esophageal atresia with tracheoesophageal fistula. The exclusion criteria included patients who died before the operation and those who were referred to other centers for management. The study evaluated several factors, including the various postoperative complications, their adept management, and the eventual outcomes. Data pertaining to the patient demographics, treatment, and radiological and laboratory findings was obtained and eventually analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp., Armonk, NY, USA) software. Results The present study included a total of 12 cases diagnosed in our hospital during the aforementioned study period. Of these patients, two patients (16.7%) died before operation because of associated severe congenital anomalies such as cardiac pathologies. Three patients were referred to other centers for management. These patients were excluded from our analysis. The remaining seven patients were included in our analysis. In our study, gastroesophageal reflux was the most common postoperative complication and was noted in six patients. Leakage of anastomosis was noted in two patients. Lung collapse was noted in merely one patient and was thus the least common complication. The overall mortality rate hovered around 28.6%. Conclusions While most patients who are surgically managed for esophageal atresia with tracheoesophageal fistula develop postoperative complications, these complications are amenable to conservative management through the means of antibiotics, ventilator support, and total parenteral nutrition.

Antimicrobial Prophylaxis in Clean Pediatric Surgical Procedures: A Necessity or Redundancy?

Background The clinical utility of antimicrobial prophylaxis in clean pediatric surgical cases remains enigmatic. The present study aims to evaluate the prevalence of surgical site infections in instances where antibiotic prophylaxis is not employed prior to clean pediatric surgical procedures. Methods A retrospective cross-sectional study that included data of all pediatric clean surgical procedures from January 2018 till January 2020 was conducted. All children undergoing clean surgical procedures who did not receive antibiotics at least two weeks prior to the procedure were included in the study. The exclusion criteria included patients with congenital heart disease, ventriculoperitoneal shunt, nephrotic syndrome, immunodeficiency, and prior administration of antimicrobial prophylaxis. All patients were followed for two to four weeks for any signs of surgical site infections. Results Of the 178 patients included, 119 were male and 59 were female, with the mean age hovering at 8.19 ± 2.87 years. Orchidopexy and herniotomy were the most commonly performed surgical procedures, and were performed in 56 (31.46%) and 54 (30.33%) patients, respectively. Only one case of postoperative surgical site wound infection was reported, accounting for a prevalence rate of 0.56%. Conclusion In clean pediatric surgical procedures, the risk of surgical site infections is exceedingly low. The unnecessary use of antibiotics in children can cause deleterious adverse effects and promote antimicrobial resistance. In a carefully selected pediatric population, administration of antibiotic prophylaxis might confer no added benefit.

The Spectrum of Testicular Pathologies Upon Scrotal Exploration for Acute Scrotum: A Retrospective Analysis.

Background The term acute scrotum encompasses a plethora of testicular pathologies that are detrimental to the survival and sustenance of testes. The aim of the present study is to determine the spectrum of these testicular pathologies upon scrotal exploration performed in the aftermath of acute scrotal pain in the pediatric population. Methods This multicenter retrospective cross-sectional study was conducted at the department of pediatric surgery at two hospitals. During the study period, the clinical characteristics of the 76 patients that underwent scrotal exploration for acute scrotum were assessed. These included age, duration of symptoms on presentation, and identification of the etiology underlying scrotal pain. The data obtained was eventually analyzed using the Statistical Package for the Social Sciences (SPSS) 23.0 software (IBM Corp., Armonk, NY). Results A total of 76 scrotal exploration procedures were performed. The involvement of the left side of the scrotum was more common than the right side. Most of the patients who presented were older than five years of age. A majority of the patients presented after 24 hours of the commencement of their symptoms. Of the included participants, 36 patients (47.47%) were found to have an underlying torsion of appendix testes that was appropriately managed. Testicular torsion was observed in 15 patients, out of which eight viable testes were salvaged with a subsequent orchidopexy while seven torsions required orchiectomy owing to their non-viability. Other findings included epididymo-orchitis and infected hydrocele. A total of 19 testes appeared completely normal upon scrotal exploration. Conclusion Scrotal exploration should be considered as part of the medical and surgical workup and in the management of acute scrotum, as it divulges the specific underlying testicular pathology. Prompt scrotal exploration can aid in ascertaining the underlying etiology and is, therefore, pivotal in the apt management of the underlying pathology.