Surveillance of a Transplant Kidney Harboring a Stable Renal Artery Aneurysm: A Case Report.

Renal artery aneurysms (RAAs) may occur in patients with transplanted kidneys, either through de novo development or as a preexisting feature of the donor kidney. How this vascular condition progresses in patients on immunosuppressive therapy after transplantation is poorly understood, and to our knowledge, consensus guidelines for treating transplant patients with RAA have not been developed. We present the case of a kidney allograft recipient on triple immunosuppressive therapy in whom postoperative imaging revealed a 13-mm renal artery aneurysm in the renal hilum not amenable to endovascular intervention. We review systemic influences on aneurysm formation and how matrix metalloproteinases may interact with immunosuppressive medications. Surveillance imaging over 5 years has shown a stable aneurysm, and the patient has maintained stable renal function with adequate creatinine levels and no adverse symptoms.

Does the ultrasound appearance of the endometrium during treatment with assisted reproductive technologies influence pregnancy outcomes?

We evaluated endometrial pattern, defined as the relative echogenicity of the endometrium on a longitudinal uterine ultrasonic section, as a surrogate for endometrial receptivity in an attempt to evaluate the association between endometrial pattern and pregnancy outcome in women who underwent ART treatment. The primary outcome was live birth and secondary outcomes were clinical intrauterine pregnancy and miscarriage. Potential associations were evaluated using cluster-weighted generalized estimating equations to account for within-couple correlation among repeated ART cycles while adjusting for potentially confounding variables. There were 1034 ART cycles with embryo transfer (778 fresh, 256 frozen) among 695 women (median age: 31.0 (6.0) years). The average number of embryos transferred per cycle was 2.1. The clinical intrauterine pregnancy rate per transfer was 56.0% for fresh and 54.3% for frozen cycles. The overall live birth rate per embryo transfer was 48.4%. Live birth rates were unchanged when the endometrium was semi-trilinear (RR:0.91 CI:0.74,1.12) or unilinear (RR:1.15 CI:0.89,1.49) in comparison to trilinear endometrium after controlling for potentially confounding variables. Results were similar when analysed separately for fresh and frozen cycles and when evaluating associations with clinical intrauterine pregnancy and miscarriage rates. It appears that endometrial pattern does not significantly affect live birth in ART and our data do not support cancelling an ART cycle if the endometrium is less than trilinear.

Risk Factors Associated With Readmission After Pancreatectomy: A Single-Institution Retrospective Cohort Study.

BACKGROUND: Pancreatectomy has a significant rate of procedure-specific morbidity which can result in readmission. Readmission has been proposed as a measure of quality. The goal of this study is to determine what factors are associated with readmission after pancreatectomy and whether readmission can be prevented. METHODS: A retrospective review of a single institution's pancreatectomies between January 2011 and April 2015 was performed. Demographic, perioperative, and outpatient data were collected from the medical record. Primary outcome was 90-day readmission. Univariate and multivariable analyses were performed to determine which factors were associated with increased risk for readmission. RESULTS: A total of 257 patients met inclusion criteria; the 90-day readmission rate was 32.7%. The median time to readmission was 13 days. Readmitted patients were more likely to have a postoperative pancreatic fistula (POPF) on univariate analysis. Surgical site infections were more common in readmitted patients (18% vs 6.4%, P = .0138). Upon multivariable adjustment, only POPF (P = .0005) remained significant. A positive dose-response relationship was noted between POPF grade and the odds of readmission with odds ratios (ORs) ranging from 1.6 (95% Confidence Interval (CI): .6-4.1) for grade A to 16.7 (95% CI: 1.8-156.8) for grade C, albeit with limited precision. CONCLUSIONS: Readmission after pancreatectomy is a common occurrence despite the many advancements in perioperative care. Our data suggest that POPF is a risk factor for readmission after pancreatectomy. Presently, this factor is not clearly preventable. This suggests that readmission may not be the best measure of quality to utilize in the evaluation of pancreatic surgery.

Association of Interfacility Helicopter versus Ground Ambulance Transport and in-Hospital Mortality among Trauma Patients.

BACKGROUND: Relatively few studies have compared outcomes between helicopter transport (HT) and ground transport (GT) for the inter-facility transfer of trauma patients to tertiary trauma centers (TTC). Mixed results have been reported from these studies ranging from a slight increase in odds of survival for the severely injured to no evident benefit for HT patients. We hypothesized there was no adjusted difference in mortality between patients transported interfacility by HT or GT taking into account distance from TTC. METHODS: Data from an inclusive statewide trauma registry was used to conduct a retrospective cohort study of adult (18+ years old) trauma patients who initially presented to a non-tertiary trauma center (NTC) before subsequent transfer by HT or GT to a TTC. Records from the NTC and TTC were linked (N = 9880). We used propensity adjusted, multivariable Cox proportional hazards models to assess the association of HT on mortality at 72-hour and within the first 2 weeks of arrival at a TTC; these multivariable analyses were stratified by distance (miles) between NTC and TTC: 21-90, and greater than 90. RESULTS: Mean distance between NTC and TTC was greater for HT patients, 96.7 miles versus 69.9 miles for GT. A higher proportion of patients among the HT group had an ISS of 16 or higher (24.6% vs 10.9%), an initial SBP < 90 mmHg (7.3% vs 2.8%), and GCS < 10 (12.5% vs 3.7%) than the GT group. HT was associated with significantly decreased 72-hour mortality (HR 0.65, 95%CI 0.48-0.90) for patients transferred from a NTC <90 miles from the TTC. No association was seen for patients transferred more than 90 miles to the TTC. No significant association of HT and 2-week mortality was seen at any distance from the TTC. CONCLUSIONS: Only for patients transferred from an NTC <90 miles from the receiving TTC was HT associated with a significantly decreased hazard of mortality in the first 72 hours. Many HT patients, especially from the most distant NTCs, had minor injuries and normal vital signs at both the NTC and TTC suggesting the decision to use HT for these patients was resource-driven rather than clinical.

Survival Benefit of Treatment at or Transfer to a Tertiary Trauma Center among Injured Older Adults.

Objective: It is well established that seriously injured older adults are under-triaged to tertiary trauma centers. However, the survival benefit of tertiary trauma centers (TC) compared to a non-tertiary trauma centers (Non-TCs) remains unclear for this patient population. Using improved methodology and a larger sample, we hypothesized that there was a difference in hospital mortality between injured older adults treated at TCs and those treated at Non-TCs. Methods: This was a retrospective cohort study of injured older adults (> =55 years) reported to the Oklahoma statewide trauma registry between 2005 and 2014. The outcome of interest was 30-day in-hospital mortality and the exposure variable of interest was level of definitive trauma care (TC vs Non-TC). Overall survival benefit of treatment at a TC as well as the survival benefit of transferring injured older adults to a TC were evaluated using multivariable survival analyses as well as propensity score-adjusted analyses. Results: Of the 25,288 patients eligible for analysis, 43% (10,927) were treated at TCs. Multivariable Cox regression analyses revealed effect modification by age group and time. After adjusting for potential confounders within the age strata, overall, patients treated at TCs were significantly less likely to die within 7 days of admission and this effect was stronger for patients aged 55-64 years (HR 0.41, 95% CI 0.31-0.52) compared to those > =65 years (HR 0.62, 95% CI 0.55-0.70). Overall survival benefit of TCs beyond 7 days was also observed (HR 0.68, 95% CI 0.56-0.83). Similarly, for the survival benefit of transferring injured older adults, after adjusting for the propensity to be transferred and other confounders, transfer to a TC was associated with lower 30-day mortality both for patients less than 65 years old (HR 0.36, 95% CI: 0.27-0.49) and those 65 years and older (HR 0.55, 95% CI: 0.48-0.64). Conclusions: Our results suggest a survival benefit for injured older adults treated at TCs. This benefit was also observed for patients transferred from non-tertiary trauma centers. Further research should focus on identifying specific subgroups of patients who would especially benefit from this level of care to minimize trauma triage inefficiencies.

A prospective study of severity of complications associated with use of misoprostol and other abortion methods in South West Nigeria.

OBJECTIVES: To assess the severity of complications following misoprostol used to induce abortion compared with other methods among women admitted for postabortion complications. METHODS: A cross-sectional study of women who presented with complications of induced abortion at nine secondary and tertiary hospitals in South West Nigeria between April 1, 2013 and May 31, 2014. Face-to-face interviews were conducted and information on the current admission was extracted from patient records. Associations between abortion method used and severity of abortion complications were evaluated using χ2 and Fisher exact tests. RESULTS: Of 522 women included in the study, 177 reported an induced abortion: 41 women (23.2%) had used misoprostol at the first attempt to induce abortion, whereas 79 (44.6%) women had undergone surgical abortion. Occurrence of fever (P=0.06), bleeding (P=0.3), and lower abdominal pain (P=0.32) was not significantly different between the misoprostol and surgical abortion/other methods groups. Severe complications were rare with misoprostol, but more common among women in the surgical abortion/other methods group. Maternal mortality occurred only among women in the surgical abortion/other methods group. CONCLUSION: Use of misoprostol for induced abortion was associated with fewer complications and no maternal mortality compared with surgical abortion/other methods.

Narratives of women presenting with abortion complications in Southwestern Nigeria: A qualitative study.

Unsafe abortion continues to impact negatively on women's health in countries with restrictive abortion laws. It remains one of the leading causes of maternal mortality and morbidity. Paradoxically, modern contraceptive prevalence remains low and the unmet need for contraception continues to mirror unwanted pregnancy rates in many countries within sub-Saharan Africa. This qualitative study assessed women's knowledge; their expectation and experiences of the methods employed for abortion; and their health care-seeking decisions following a complicated abortion. Women who presented with abortion complications were purposively sampled from seven health facilities in south-west Nigeria. In-depth interviews were conducted by social scientists with the aid of a semi-structured interview guide. Coding schemes were developed and content analysis was performed with WEFTQDA software. Thirty-one women were interviewed. Misoprostol was used by 16 women; 15 women used other methods. About one-fifth of respondents were aged ≤ 20 years; almost one-third were students. Common reasons for terminating a pregnancy were: "too young/still in school/training"; "has enough number of children"; "last baby too young" and "still breastfeeding". Women had little knowledge about methods used. Friends, nurses or pharmacists were the commonest sources of information. Awareness about use of misoprostol for abortion among women was high. Women used misoprostol to initiate an abortion and were often disappointed if misoprostol did not complete the abortion process. Given its clandestine manner, women were financially exploited by the abortion providers and only presented to hospitals for post-abortion care as a last resort. Women's narratives of their abortion experience highlight the difficulties and risks women encounter to safeguard and protect their sexual and reproductive health. To reduce unsafe abortion therefore, urgent and synergized efforts are required to promote prompt access to family planning and post-abortion care services.

Direct Air Versus Ground Transport Predictors for Rural Pediatric Trauma.

OBJECTIVE: Traumatic injury is the leading cause of mortality in children and the most common cause of emergency medical services transport in pediatric populations. We aimed to identify what factors are currently associated with selection for helicopter transport (HEMS) over ground ambulance (GEMS) in a primarily rural state. METHODS: We performed a retrospective case-control study of trauma patients younger than 18 years old reported to the Oklahoma State Trauma Registry between 2005 and 2014 who received direct transport from the scene of injury to a tertiary trauma center within the state. Factors associated with HEMS transport over GEMS were identified by multivariate regression analysis. RESULTS: Of the 1,700 patients in the study group, 50.8% were transported by HEMS. Increased distance (odds ratio [OR] = 6.1-18.6), lower Glasgow Coma Scale (OR = 2.5), multisystem injury (OR = 1.5), intubation (OR = 2.7), motor vehicle collision-related injuries (OR = 2.1), and elevated heart rate (OR = 1.8) were all associated with increased odds of HEMS transport, with distance being the strongest factor. CONCLUSION: This study found that the principal determinants of triage to HEMS transport in the case of pediatric trauma in a rural state were primarily distance to a major trauma center and clinical factors relating to the type and severity of injury.

Trends in misoprostol use and abortion complications: A cross-sectional study from nine referral hospitals in Nigeria.

OBJECTIVE: The study aimed to assess the use of misoprostol and complications associated with abortions in referral hospitals in Nigeria, a country with restrictive abortion laws. METHODS: A cross-sectional study at nine referral hospitals in South-west Nigeria. Nine years' data were retrieved from medical records, including 699 induced abortions. Independent variable was the method of abortion; dependent variables were complications, need for treatment and mortality. Statistical significance was tested with Chi-square, Fishers' exact and chi-square for trend tests (p<0.05). RESULTS: There were 699 induced abortions amongst 2,463 abortions found in records. Nearly 70% were surgical abortions, but misoprostol use significantly increased over the study period in a linear trend (Χ2 trend: 30.96, P <0.001). Patients who used misoprostol were significantly less likely to have infectious morbidity, genital tract injuries or medical complications. There was no difference in incomplete abortion in the groups. Patients were more likely to have in-patient care with surgical abortions (p<0.001), to need prolonged antibiotic regimens (p = 0.003), need further surgeries or additional specialist care (p = 0.009). CONCLUSION: Misoprostol abortion has significantly increased over time, and was associated with less morbidity and need for further treatment, in this study. It appears to be the safer option.

Total laparoscopic hysterectomy: A case report from ILE-IFE, Nigeria.

Total laparoscopic hysterectomy (TLH) is an advanced gynecological laparoscopic procedure that is widely performed in the developed world. However, its feasibility in resource-poor settings is hampered by obvious lack of equipments and/or skilled personnel. Indeed, TLH has never been reported from any Nigerian hospital. We present a 50-year-old multipara scheduled for hysterectomy on account of pre-malignant disease of the cervix, who had TLH with bilateral salpingo-oophorectomy in the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, southwestern Nigeria and was discharged home on the first post-operative day. She was seen in the gynecology clinic a week later in stable condition and she was highly pleased with the outcome of her surgery. This case is presented to highlight the attainability of operative gynecological laparoscopy, including advanced procedures like TLH in a resource-constrained setting, through the employment of adequate local adaptation and clever improvisation.