Safety and efficacy of inferior vena cava filter retrieval: a 5-year single center retrospective review from a tertiary care center.

BACKGROUND: Inferior vena cava (IVC) filter retrieval is typically accomplished with standard snare technique. When this fails, more advanced techniques are necessary, especially when removal falls outside a 12-month window. Complications during filter retrieval depend heavily on technique, type of filter, and filter position. In this study we examined safety and efficacy of 536 filter retrievals at a tertiary care center and compared complication rates between standard snare and endobronchial forcep retrieval. METHOD: We reviewed 536 cases between August 2015 and August 2020, recording retrieval success rates, patient comorbidities, and complication rates at the time of removal. RESULTS: Total overall retrieval success was 97.9% (525/536), and complications occurred in approximately 6.0% (32/536) of all cases. Success and complications with standard snare technique alone were 99.4% (345/347) and 1.7% (5 Grade I/II, 1 Grade III) and advanced forcep technique 98.8% (171/173) and 14.5% (22 Grade I/II, 2 Grade III, and 1 Grade IV), respectively. There was no significant difference between the technical success rates of the standard snare technique and forceps techniques (p = 0.60) despite a significantly longer dwell time in patients undergoing forceps retrieval (p < 0.001). CONCLUSION: To our knowledge, this is the largest cohort of forceps directed IVC filter retrieval present in the literature. Rates of successful endobronchial forceps and standard snare retrievals in this study are similar to previous reports. Although use of endobronchial forceps may be associated with higher complication rates, this is likely due to prolonged dwell times, filter tilt, and attempted removal of non retrievable filters. Overall, forceps-directed retrieval offers a safe, effective means of removal in difficult cases. LEVEL OF EVIDENCE: Level 3, Large Retrospective Study.

Cystic Fibrosis Transmembrane Conductance Regulator Modulators During Pregnancy: A Case Series.

Cystic fibrosis (CF) is the most common genetic disease in the United States (US) and, with the development of newer therapeutics, there is increased fertility among women with CF. We present a series of pregnant patients taking novel CF transmembrane conductance regulator (CFTR) modulators and summarize pertinent clinical considerations. All women conceived within four months after starting elexacaftor-ivacaftor-tezacaftor. Pulmonary function was stable before and during pregnancy. One patient developed transaminitis necessitating discontinuation of the medication mid-trimester. All patients delivered healthy neonates between 36-38 weeks of gestation with uncomplicated postpartum courses. No birth defects were encountered. Given that newly introduced CFTR modulators may increase fertility among CF patients, contraception counseling, pulmonary function monitoring, liver function monitoring, and multi-disciplinary care are important pillars of management.

Hepatic adenoma rupture following portal vein embolization.

Hepatic adenomas are benign liver tumors typically found in females of reproductive age. Though benign, hepatic adenomas are highly vascularized tumors, thus rupture and consequent hemorrhage present a feared complication. We report a case of a 31-year-old woman with hepatic adenoma who underwent preoperative portal vein embolization and subsequently suffered a rupture of her tumor. We postulate that the change in blood flow after portal vein embolization, a phenomenon known as the hepatic artery buffer response, may have contributed to the tumor rupture, though the possibility that the rupture was purely incidental remains. There is currently no prior report of such rupture occurring following portal vein embolization, and this case brings to light a potentially fatal complication of a generally safely regarded procedure in patients with hepatic adenoma.

Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma.

METHODS: We queried our Trauma Quality Improvement Program registry for patients who presented between 6/1/2011 and 9/1/2015 with severe (injury severity score (ISS)>15) blunt traumatic injury during anticoagulant use. Patients were then grouped into those prescribed warfarin and patients prescribed any of the available novel Direct Oral Anticoagulants (DOAC) medications. We excluded severe (AIS≧4) head injuries. RESULTS: There were no differences between DOAC and warfarin groups in terms of age, gender mean ISS, median hospital or intensive care unit lengths of stay, complication proportions, numbers of complications per patient, or the proportion of patients requiring transfusion. Finally, excluding patients who died, the observed proportion of discharge to skilled nursing facility was similar. In our sample of trauma patients, DOAC use was associated with significantly lower mortality (DOAC group 8.3% vs. warfarin group 29.5%, p<0.015). The ratio of units transfused per patient was also lower in the DOAC group (2.8±1.8 units/patient in the DOAC group vs. 6.7±6.4 units per patient in the warfarin group; p=0.001). CONCLUSION: In conclusion, we report an association with decrease in mortality and a decrease in transfused blood products in severely injured trauma patients with likely minimal or no head injury taking novel DOACs over those anticoagulated with warfarin for outpatient anticoagulation.

Compared to warfarin, direct oral anticoagulants are associated with lower mortality in patients with blunt traumatic intracranial hemorrhage: A TQIP study.

BACKGROUND: Falls represent the leading cause of traumatic brain injury in adults older than 65, with nearly one third experiencing a fall each year. Evidence suggests that up to 0.5% of anticoagulated patients suffer from intracranial hemorrhage (ICH) annually. Direct oral anticoagulants (DOACs) have become an increasingly popular alternative to warfarin for anticoagulation; however, there is a dearth of research regarding the safety of DOACs, in particular on the outcome of traumatic ICH while taking DOACs. METHODS: We queried our Trauma Quality Improvement Project registry for patients who presented with traumatic intracranial hemorrhage during anticoagulant use. Patients were grouped into those prescribed warfarin and patients prescribed DOAC medications. The groups were compared with respect to age, gender, Glasgow Coma Score (GCS) on arrival, Abbreviated Injury Scale (AIS) (head), Injury Severity Score (ISS), mortality, need for operative intervention, hospital and ICU lengths of stay, proportion of patients transfused (and their transfusion requirements), and rates of discharge to skilled nursing facility. Poisson regression was conducted to determine the relationship between mortality and treatment group while controlling for covariates (comorbidities, ISS). RESULTS: There were no differences between DOAC and warfarin groups in terms of age, gender, median ISS, median AIS head, or median admission GCS. Mechanisms of injury, median hospital and ICU lengths of stay, ICU free days, and transfusion requirements were also not significantly different.DOAC use was associated with significantly lower mortality (4.9% vs. 20.8%; p < 0.008) and a lower rate of operative intervention (8.2% vs. 26.7%; p = 0.023) when compared with warfarin. Excluding patients who died, the observed rate of discharge to skilled nursing facility was lower in the DOAC group (28.8% compared with 39.7%; p = 0.03). Multivariate Poisson regression analysis demonstrated that warfarin use was associated with an increased mortality when controlling for injury severity, and comorbidities. CONCLUSIONS: We report improved mortality and reduced rates of operative intervention in patients with traumatic ICH associated with DOACs compared with a similar group taking warfarin. We also noted an association with decreased rate of discharge to SNF in patients taking DOACs compared with warfarin. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Smad4-independent, PP2A-dependent apoptotic effect of exogenous transforming growth factor beta 1 in lymphoma cells.

B-lymphoid tumor cells are often less sensitive than their normal counterparts or insensitive to transforming growth factor beta1 (TGFb) effects. We studied the apoptotic effect of exogenous TGFb in B-lymphoma cells, focusing on the activity and the role of Smad and protein phosphatase/kinase signals. Recombinant TGFb treatment and Smad4 siRNA transfection were used in HT58 B-NHL lymphoma cells in vitro. Gene expression and apoptosis were detected by RT-PCR, Western blot analysis and flow cytometry. The role of MEK1 kinase and PP2A activity--measured with a phosphatase assay--were assessed with the help of specific inhibitors. Smad4 siRNA treatment completely abolished TGFb-induced early gene upregulation, indicating the absence of the rapid activation of Smad signaling. Moreover, functional inhibition of Smad4 had no influence on TGFb-induced apoptosis, but it was dependent on PP2A phosphatase activation, ERK1/2 and JNK inactivation in lymphoma cells. The results prove that exogenous TGFb uses Smad4-independent, alternative (PP2A/PP2A-like dependent) signaling pathways for apoptosis induction in lymphoma cells. Further studies are needed to clarify the possible role and involvement of Smad4-independent effects of TGFb in normal and malignant lymphoid cells and in cells of the tumor microenvironment.