Azithromycin versus ceftriaxone for the treatment of uncomplicated typhoid fever in children

A total of 108 children aged 4-17 years were randomized to receive 7 days of azithromycin (10 mg/kg/day; maximum, 500 mg/day) or ceftriaxone (75 mg/kg/day; maximum, 2.5 g/day), to assess the efficacy of the agents for the treatment of uncomplicated typhoid fever. Salmonella typhi was isolated from the initial cultures of blood samples from 64 patients. A total of 31 (91%) of the 34 patients treated with azithromycin and 29 (97%) of the 30 patients treated with ceftriaxone were cured (P>.05). All 64 isolates were susceptible to azithromycin and ceftriaxone. Of the patients treated with ceftriaxone, 4 subsequently had relapse of their infection. No serious side effects occurred in any study subject. Oral azithromycin administered once daily appears to be effective for the treatment of uncomplicated typhoid fever in children. If these results are confirmed, the agent could be a convenient alternative for the treatment of typhoid fever, especially in individuals in developing countries where medical resources are scarce.

Does the surgeon's experience impact on radiocephalic fistula patency rates?

Establishing successful long-term hemodialysis access remains a major challenge. The primary aims of this study were to determine whether primary success and primary and secondary patency rates of a series of consecutive radio-cephalic fistulae (RCF) were affected by the experience of the surgeon. The secondary aims were to assess complications, and to compare results with patency rates from the literature. All native fistulae (AVF) created in our unit between January 1, 2002 and December 31, 2005 were analyzed retrospectively. The RCF were identified and divided into group A (RCF fashioned by the consultant surgeon), and group B (fashioned by the junior surgeons within the unit). Demographic characteristics, risk factors, primary success rate (patent fistula at discharge), and primary and secondary patency rates were compared between each group using chi-squared test. During this period, 552 AVF were created. Of the 195 RCF, there were 153 fistulae in group A and 42 in group B. Median follow-up was 22 months for both groups. There was no difference with regards to age, sex ratio, prevalence of diabetes, and cardiovascular disease. The primary success rate in group A and B was 94.2% and 81%, respectively (p < 0.01). Primary and secondary patency rates at 22 months were 80%, 93%* and 74%, 81%* in group A and B, respectively (*p < 0.025). Even within group B, these results compare very favorably with the published literature. These results suggest that the placement of a RCF should be performed by the most experienced member of a team dedicated to vascular access creation or at least under his supervision.

ASDIN Original Investigations: Inflow Reduction by Distalization of Anastomosis Treats Efficiently High-Inflow High-Cardiac Output Vascular Access for Hemodialysis

The arteriovenous fistula used for vascular access for hemodialysis may contribute to development of congestive heart failure. Theses patients can present with frequent episodes of congestive hear failure. Traditional management of high-inflow, a high-cardiac-output fistula generally involves either closure or banding. Although high-output state can be controlled, the lifeline of the patient is lost. We describe a series of 17 hemodialysis patients (10 men and 7 women) in whom a novel inflow reduction method was employed. All patients had symptoms of heart failure (15 brachiocephalic fistulas and two brachioaxillary bypass grafts) and a fistula inflow rate above 1600 ml/min. The inflow reduction procedure included ligation of the brachial anastomosis and reconstruction of the fistula by using an expanded polytetrafluoroethylene (Gore-Tex Intering) vascular graft in a bypass from the radial artery. The mean (+/- SD) time between fistula creation and the inflow reduction procedure was 30 +/- 17 months. The mean access inflow rate decreased significantly after the inflow reduction procedure, from 3135 +/- 692 to 1025 +/- 551 ml/min (p =0.0001). The mean cardiac output rate decreased from 8 +/- 3.1 to 5.6 +/- 1.7 l/min (p = 0.001) with resolution of symptoms. During the follow-up period thrombosis or stenosis developed in seven patients, three of whom underwent surgical revision. Thirteen of the seventeen accesses (77%) subjected to the inflow reduction procedure remained patent. Access loss was due to failed fistuloplasty or thrombosis. To our knowledge, this is the first report demonstrating that inflow reduction obtained by distalization of the anastomosis of the access fistula is feasible and safe for managing high-inflow, high-cardiac-output fistulas. Longer and larger studies of the inflow reduction procedure and its benefits are needed.

Maximizing the Volume of Latissimus Dorsi Flap in Autologous Breast Reconstruction with Simultaneous Multisite Fat Grafting

BACKGROUND

The pedicled latissimus dorsi (LD) flap serves an important function in breast reconstruction, but its utility is limited by its inability to provide sufficient breast volume.

OBJECTIVES

The purpose of this preliminary report was to review the techniques and outcomes of utilizing fat-grafted, volume-enhanced LD flap transfer with fat grafting recipient sites in autologous breast reconstruction.

METHODS

A retrospective study was performed of 10 patients (14 breasts) who underwent autologous breast reconstruction utilizing the LD flap transfer technique and simultaneous fat grafting between August 2012 and September 2014. Multilayer, multisite fat grafting was performed to the LD muscle, LD skin paddle, mastectomy skin flaps, and the pectoralis major and serratus muscles simultaneously with the LD flap transfer.

RESULTS

Three patients underwent an immediate breast reconstruction, four underwent a delayed breast reconstruction, and four underwent a tertiary breast reconstruction following previously failed breast reconstructions (one patient underwent each of the first two procedures, one on each breast). The average age of the patients was 55 years (range, 39-76 years), the average body mass index of the patients was 29.3 (range, 19.6-39.9), and the average fat grafting volume for the patients was 176 mL (range, 50-300 mL). There was 100% flap survival and complete wound healing. No seroma or fat grafting-related complications were clinically detected. Three patients required additional fat grafting.

CONCLUSIONS

The fat-grafted, volume-enhanced LD flap procedure with fat grafting recipient sites offers a simple and safe technique for autologous breast reconstruction, with low morbidity and fast recovery. It can be a useful alternative to utilizing abdomen-based flaps in autologous breast reconstruction or could be performed to salvage both implant-based and free-flap breast reconstructions. LEVEL OF EVIDENCE 4: Therapeutic.

Randomized clinical trial comparing decellularized bovine ureter with expanded polytetrafluoroethylene for vascular access

BACKGROUND

The SynerGraft model 100 (SG 100) is a decellularized bovine uereter graft developed to improve on prosthetic conduits for vascular access. Its clinical performance was compared with polytetrafluoroethylene (ePTFE) in a prospective, pilot randomized study.

METHODS

Patients requiring haemodialysis with no native vein options were included. Between June 2004 and June 2007, 29 patients received SG 100 and 27 ePTFE grafts. Forty-five patients had undergone previous access surgery. All grafts were between the brachial artery and the axillary vein.

RESULTS

Clinical details were similar between the groups; overall mean(s.d.) follow-up was 469(398) days. After 1 year, there were no significant differences in primary patency (28 per cent for SG 100 versus 48 per cent for ePTFE; P = 0.290), assisted primary patency (52 versus 64 per cent; P = 0.430) or secondary patency (57 versus 68 per cent; P = 0.370). Freedom from infection at 1 year was 96 per cent for SG 100 and 91 per cent for ePTFE (P = 0.410). Fifty-seven further procedures (18 endovascular and 39 surgical) were needed to maintain patency in 50 grafts (23 SG 100 and 27 ePTFE).

CONCLUSION

Both grafts were adequate conduits for haemodialysis and were amenable to repair. Anticipated advantages for SG 100 were not seen in either patency or stability.

Asdin Original Investigation: Complex Bypasses and Fistulas for Difficult Hemodialysis Access: A Prospective, Single-Center Experience

The purpose of this article is to describe several complex vascular access procedures and the outcomes achieved with them in 24 patients (mean age 60 years) undergoing hemodialysis in whom all other accesses had failed and neither peritoneal dialysis nor transplantation was possible. Patients underwent either a necklace bypass (n = 5), axillary loop (n = 1), contralateral internal jugular vein bypass (n = 6), femorofemoral crossover bypass (n = 1), superficial femoral vein transposition (n = 5), axillary artery to popliteal vein bypass (n = 5), or femoral artery to right atrium bypass (n = 1). All grafts implanted were 6 mm, internally reinforced prostheses made of expanded polytetrafluoroethylene (Gore-Tex Intering Vascular Graft). Postoperatively patients had bimonthly clinical examinations in which the thrill, bruit, skin, cannulation sites, and adequacy of dialysis were reviewed. A bimonthly ultrasound dilution assessment that included estimation of the graft inflow rate, recirculation rate, and cardiac output was also performed. There was one serious postoperative complication: rapid-onset severe steal syndrome that required immediate tie off of the fistula. During the median follow-up time of 22 months, three patients died of causes unrelated to their vascular access. Nineteen dilatations and 10 surgical revisions were done. Primary patency rates were 83%, 63.5%, and 63.5%, respectively, at 6 months, 1 year, and 2 years; secondary patency rates were 91%, 77%, and 77%. Complex vascular access procedures can provide patients some additional good-quality time on hemodialysis.

Preclinical models for human pre-embryo biopsy and genetic diagnosis. I. Efficiency and normalcy of mouse pre-embryo development after different biopsy techniques

OBJECTIVE

To compare the usefulness of three micromanipulative methods at two different stages of pre-embryo development and to assess possible effects on postbiopsy survival and development.

DESIGN

Four-cell and eight-cell mouse pre-embryos were biopsied using enucleation, aspiration, or extrusion of single blastomeres. After biopsy, pre-embryos were observed for in vitro and in vivo development.

SETTING

Laboratories of The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School.

PATIENTS, PARTICIPANTS

Only mice were used.

INTERVENTIONS

Pre-embryo biopsy, developmental normalcy and pre-embryo transfer were studied.

MAIN OUTCOME MEASURE(S)

Few pre-embryos died as a result of biopsy trauma. High postbiopsy survival rates were associated with normal intrauterine and postnatal development.

RESULTS

Expanded blastocyst formation rates from four-cell and eight-cell pre-embryos were 94.6%, 96.7% (controls); 80.7%, 89.1% (enucleation); 90.1%, 91.7% (aspiration); 83.1%, 91.5% (extrusion), respectively. Live birth rates at the four-cell stage were slightly lower in the enucleation group than in the blastomere aspiration and extrusion groups or controls (49.2% versus 58.8%, 56.3% and 66.7%, respectively). For the eight-cell stage, there were no differences between the groups. No developmental abnormalities were found in body or organ weights, in neonates or at 3 weeks of age, or in their subsequent ability to reproduce a second generation.

CONCLUSIONS

Biopsy of mouse pre-embryos produces only a small loss of viability because of trauma and permits normal prenatal and postnatal development among surviving pre-embryos.

Environmental exposure of the pediatric age groups in Cairo City and its suburbs to cadmium pollution

In a trial to assess the exposure of subjects in the pediatric age group to cadmium (Cd) pollution, serum Cd was estimated by atomic absorption spectrometry in 405 subjects, birth-18 years old, from Cairo City and its suburbs. Serum Cd mean concentrations were: 0.92 microg/l in 32 neonates (birth-4 weeks); 1.33 microg/l in 70 infants (4 weeks-2 years); 1.11 microg/l in 100 children in the preschool period (2-6 years); 1.34 microg/l in 103 primary school children (6-12 years); and 1.24 microg/l in 100 adolescents (12-18 years). In neonates, serum Cd was higher in babies with weights and heights that remained below the 5th percentile for age. Breast-fed infants had a serum Cd geometric mean level (1.25 microg/l) that was not in accordance to that of their mothers' milk (0.52 microg/l, P < 0.001), suggesting alternative routes of exposure. Environmental tobacco-smoke exposure was the most important determinant of Cd status in the school-aged children, the geometric mean being 1.42 microg/l in passive smokers vs. 1.2 microg/l in non-exposed children (P < 0.05). Moreover, adolescents who were active smokers had a significantly higher serum Cd level (1.7 microg/l) as compared to non-smokers (1.2 microg/l). Gender did influence the Cd status in adolescents, being higher among males, probably related to smoking, or to the difference in lifestyle of adolescents according to gender in the community. Alpha-1-microglobulinuria was accompanied by a higher serum Cd concentration in the group of adolescents only, suggesting a subclinical renal effect after several years of cumulative exposure. The residential classification, whether urban or suburban, did not influence the serum Cd status; neither did the present or past history of bronchial asthma. These findings certainly justify further evaluation of the problem of Cd pollution among Cairene individuals, knowing the long-term consequences of exposure to it. Systematic efforts for the proper disposal of Cd wastes and prevention of smoking in public places are recommended.

Experimental studies and nuclear model calculations on proton-induced reactions on natSe, 76Se and 77Se with particular reference to the production of the medically interesting radionuclides 76Br and 77Br

Excitation functions of the reactions (nat)Se(p,x)(75,76,77,82)Br, (76)Se(p,xn)(75,76)Br, (76)Se(p,x)(75)Se and (77)Se(p,xn)(76,77)Br were measured from their respective thresholds up to 40 MeV, with particular emphasis on data for the production of the medically important radionuclides (76)Br and (77)Br. The conventional stacked-foil technique was used. The samples were prepared by a sedimentation process. Irradiations were performed using the compact cyclotron CV 28 and the injector of COSY, both at the Research Centre Jülich. In order to validate the data, nuclear model calculations were performed using the code ALICE-IPPE which is based on the preequilibrium-evaporation model. Good agreement was found between the experimental and theoretical data, except in the high-energy region where the calculated data were somewhat higher. All the measured excitation curves were compared with the data available in the literature. From the experimental data the theoretical yields of all the investigated radionuclides were calculated and plotted as a function of proton energy. The calculated yield of (77)Br from the (nat)Se(p,x)(77)Br process over the energy range E(p)=25-->15 is 72.7 MBq/microAh and from the (77)Se(p,n)(77)Br reaction over E(p)=15-->6 MeV it is 86.2 MBq/microAh. The yield of (76)Br from the (76)Se(p,n)(76)Br reaction for E(p)=15-->8 is 360.1 MBq/microAh and from the (77)Se(p,2n)(76)Br reaction for E(p)=28-->18 MeV it is 879.2 MBq/microAh. The radionuclidic impurity levels are discussed.

The Vascular Anatomy of the Scaphoid: New Discoveries Using Micro-Computed Tomography Imaging

PURPOSE

The purpose of this study was to investigate the intraosseous vascular anatomy of the scaphoid using recent advances in micro-computed tomography (micro-CT) imaging and 3-dimensional reconstruction. We also studied the effect of scaphoid shape and screw position on the intraosseous vascular structure.

METHODS

Thirteen upper extremities were injected with a contrast agent. The scaphoid bones were extracted and scanned using a micro-CT scanner. The vascular impact of screw insertion at various axes through the scaphoid was calculated and compared using the generated 3-dimensional models. The specimens were 3-dimensionally-printed and the morphology was assessed according to bone dimensions. A relationship between the internal vascular patterns and these morphological features was determined.

RESULTS

All specimens received vascular inflow from the dorsal ridge forming a vascular network that supplied an average of 83% of the bone's volume. This network was supplemented in 4 specimens with volar vessels entering at the waist. Another network was identified, created by vessels entering volarly at the tubercle, which supplied the remainder of the scaphoid. One specimen did not receive any vessels at the tubercle. With regards to screw placement, screws placed in the central axis were the least disruptive to the internal vascularity, followed by the antegrade (dorsal) insertion axis. Two morphological bone types were identified: type I or full scaphoids and type II or slender scaphoids. Type I possessed a more robust internal vascular network than type II scaphoids.

CONCLUSIONS

This study identifies 2 distinct types of scaphoid morphology with 1 of them having a less robust blood supply, which may prove to be related to development of nonunion, avascular necrosis, or Preiser disease. Central axis and antegrade (dorsal) screw fixation may be least disruptive to the internal blood supply.

CLINICAL RELEVANCE

Safer fixation of the scaphoid bone may be achieved by knowledge of intraosseous vascular patterns.

The Vascular Anatomy of the Capitate: New Discoveries Using Micro-Computed Tomography Imaging

PURPOSE

To study the intraosseous 3-dimensional microvasculature of the capitate bone using a novel high-resolution micro-computed tomography (μCT) imaging technology, and to examine the blood supply as it relates to the most common fracture types.

METHODS

Ten cadaveric wrists were injected with a lead-based contrast agent. The capitates were harvested and imaged using a μCT scanner. The intraosseous vascularity was incorporated into a 3-dimensional image. We measured the vascular pattern as well as the vessels' cross-sectional area, number, and distribution. An average capitate fracture line was calculated using clinical data from 22 patients with capitate fractures. The fracture line was projected on the representative capitate to assess its relation with the nutrient vessels' entry points.

RESULTS

The capitate is a well-vascularized carpal supplied by dorsal and volar vascular systems that anastomose in 30% of cases. There was no predominance of one vascular system over the other. Most vessels enter the capitate at the distal half and supply the proximal pole in a retrograde fashion. In addition, most specimens (70%) also had at least one vessel entering the proximal pole through the volar capitate ligaments and supplying the proximal pole directly. The average fracture line had an oblique orientation, and 90% of the specimens had a blood vessel entering proximal to that line.

CONCLUSIONS

This μCT vascular study further verifies that the capitate receives most of its vasculature in a retrograde fashion, but the study also shows that most capitates have vessels supplying the proximal pole directly. These findings might explain why most capitate waist fractures do not progress to proximal pole avascular necrosis.

CLINICAL RELEVANCE

This study characterizes the microvasculature of the capitate and might shed light on processes involved in bone healing and the etiology of capitate avascular necrosis.

Nuclear data for production of the therapeutic radionuclides 32P, 64Cu, 67Cu, 89Sr, 90Y and 153Sm via the (n,p) reaction: evaluation of excitation function and its validation via integral cross-section measurement using a 14 MeV d(Be) neutron source

Nuclear data for production of the therapeutic radionuclides 32P, 64Cu, 67Cu, 89Sr, 90Y and 153Sm via (n,p) reactions on the target nuclei 32S, 64Zn, 67Zn, 89Y, (90)Zr and 153Eu, respectively, are discussed. The available information on each excitation function was analysed. From the recommended data set for each reaction the average integrated cross section for a standard 14 MeV d(Be) neutron field was deduced. The spectrum-averaged cross section was also measured experimentally. A comparison of the integrated value with the integral measurement served to validate the excitation function within about 15%. A fast neutron source appears to be much more effective than a fission reactor for production of the above-mentioned radionuclides in a no-carrier-added form via the (n,p) process. In particular, the possibility of production of high specific activity 153Sm is discussed.

Diagnosis and Management of Acute Scaphoid Fractures

The scaphoid is the most commonly fractured carpal bone; despite its frequent injury, the diagnosis of fracture can be complicated by the presence of normal radiographs at the time of presentation. Clinical intuition can be increased by physical examination and immediately available modalities such as ultrasound within the emergency department. Definitive diagnosis should be made with computed tomography and magnetic resonance to verify the presence of displacement. This article provides an overview of the incidence and presentation of acute scaphoid fractures with a surgical focus on percutaneous dorsal screw fixation.

Peripheral interventions and antiplatelet therapy: Role in current practice

Peripheral arterial disease (PAD) is a common disorder associated with a high risk of cardiovascular mortality and continues to be under-recognized. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease. Management includes exercise program, pharmacologic therapy and revascularization including endovascular and surgical approach. The optimal revascularization strategy, endovascular or surgical intervention, is often debated due to the paucity of head to head randomized controlled studies. Despite significant advances in endovascular interventions resulting in increased utilization over surgical bypass, significant challenges still remain. Platelet activation and aggregation after percutaneous transluminal angioplasty of atherosclerotic arteries are important risk factors for re-occlusion/restenosis and life-threatening thrombosis following endovascular procedures. Antiplatelet agents are commonly prescribed to reduce the risk of myocardial infarction, stroke and death from cardiovascular causes in patients with PAD. Despite an abundance of data demonstrating efficacy of antiplatelet therapy in coronary artery disease and cerebrovascular disease, there is a paucity of clinical information, clinical guidelines and randomized controlled studies in the PAD population. Hence, data on antiplatelet therapy in coronary interventions is frequently extrapolated to peripheral interventions. The aim of this review article is to elucidate the current data on revascularization and the role and duration of antiplatelet and anticoagulant therapy in re-vascularized lower limb PAD patients.

A snapshot of the low temperature stress transcriptome of developing rice seedlings (Oryza sativa L.) via ESTs from subtracted cDNA library

Rice (Oryza sativa L.) is sensitive to chilling particularly during early seedling development. Given the biochemical complexity of tolerance mechanisms, genetic potential for this trait depends on highly coordinated expression of many genes. We used a simple cDNA subtraction strategy to develop Expressed Sequence Tags (ESTs) that represent an important subset of cold stress-upregulated genes. The 3,084 subtracted cDNA clones represent a total of 1,967 unigenes from 1,354 singletons and 613 contigs. As expected in the developing seedlings, genes involved in basic cellular processes, i.e., metabolism, growth and development, protein synthesis, folding and destination, cellular transport, cell division and DNA replication were widely represented. Genes with stress-related and regulatory functions comprised 23.17% of the total ESTs. These categories included proteins with known function in cellular defenses against abiotic (drought, cold and salinity) and biotic (pathogen) stresses, and proteins involved in developmental and stress response signalling and transcription. Based on the types of genes represented, tolerance mechanisms rely on precise integration of developmental processes with stress-related responses. A large fraction of the ESTs (38.7%) represents unknown proteins. This EST library is a rich source of cold stress-related genes, and supplements for other publicly available libraries for comprehensive analysis of the stress-response transcriptome.

COVID-19. An update for orthopedic surgeons

The COVID-19 pandemic has affected our world in a short period of time, and the orthopedic surgery practice was not an exclusion. Elective care was deferred in most health care facilities and emergency care was continued with strict precautions. With rapid progression of the pandemic, the response of the medical community is also rapidly changing in all aspects of delivering care. This led to a large number of publications with reports, guidelines, measures, ways to react to the crisis, and post-pandemic predictions and speculations. In this review we aimed at summarizing all the relevant information to the orthopedic surgery community. To do this, a comprehensive search was performed with all related terms on two scientific search engines, PubMed and SCOPUS, and the results were filtered by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. The result was 72 articles that were further reduced to 33 articles after full text reading. The resultant information was organized under 5 main headings; the impact of pandemic on the orthopedic practice, COVID-19 and the trauma patient, elective and emergency surgeries during the pandemic, peri-operative management of the patient with COVID-19, Miscellaneous effects of the pandemic such as those on training programs and the evolution of telemedicine. This review represents the most up to date information published in the literature that is a must-know to every orthopedic surgeon.

Synthesis of Graphene Oxide Interspersed in Hexagonal WO3 Nanorods for High-Efficiency Visible-Light Driven Photocatalysis and NH3 Gas Sensing

WO₃ nanorods and GO (at 1 wt% loading) doped WO₃ were synthesized using a template free deposition-hydrothermal route and thoroughly characterized by various techniques including XRD, FTIR, Raman, TEM-SAED, PL, UV-Vis, XPS, and N₂ adsorption. The nano-materials performance was investigated toward photocatalytic degradation of methylene blue dye (20 ppm) under visible light illumination (160 W, λ> 420) and gas sensing ability for ammonia gas (10–100 ppm) at 200°C. HRTEM investigation of the 1%GO.WO₃ composite revealed WO₃ nanorods of a major d-spacing value of 0.16 nm indexed to the crystal plane (221). That relevant plane was absent in pure WO₃ establishing the intercalation with GO. The MB degradation activity was considerably enhanced over the 1%GO.WO₃ catalyst with a rate constant of 0.0154 min⁻¹ exceeding that of WO₃ by 15 times. The reaction mechanism was justified dependent on electrons, holes and •OH reactive species as determined via scavenger examination tests and characterization techniques. The drop in both band gap (2.49 eV) and PL intensity was the main reason responsible for enhancing the photo-degradation activity of the 1%GO.WO₃ catalyst. The later catalyst initiated the two electron O₂ reduction forming H₂O₂, that contributed in the photoactivity improvement via forming •OH moieties. The hexagonal structure of 1%GO.WO₃ showed a better gas sensing performance for ammonia gas at 100 ppm (R_a-R_g/R_g = 17.6) exceeding that of pure WO₃ nanorods (1.27). The superiority of the gas-sensing property of the 1%GO.WO₃ catalyst was mainly ascribed to the high dispersity of GO onto WO₃ surfaces by which different carbon species served as mediators to hinder the recombination rate of photo-generated electron-hole pairs and therefore facilitated the electron transition. The dominancy of the lattice plane (221) in 1%GO.WO₃ formed between GO and WO₃ improved the electron transport in the gas-sensing process.

Pre-emptive angioaccess for haemodialysis in the elderly

BACKGROUND

The fastest growing population group in the UK is the elderly, particularly those aged ≥ 80 years. The primary aim of this study was to assess if age was a determining factor for successful first dialysis through a pre-emptive angioaccess. The secondary aim was to investigate what risk factors are associated with angioaccess failure and to assess their patency and complications in three different age groups of patients who had pre-emptive angioaccess.

METHODS

The study was carried out retrospectively on prospectively collected data for the period January 2006-December 2007. The study population included all patients who had pre-emptive angioaccess for haemodialysis during the time frame of the study. They were divided into three age groups including a control group (A) with age <70 years, a young old group (B) (70-79 years) and an old group (C) (≥80 years). Primary failure and primary, assisted primary and secondary patency rates were ascertained and compared using the Kaplan-Meier curves and log-rank testing.

RESULTS

Of 243 patients who had a pre-emptive vascular access, 110 (45%), 82 (35%) and 51 (21%) patients were in Groups A, B and C, respectively. The rates of successful first dialysis through the angioaccess, excluding patients not in end-stage renal disease yet, or those who received pre-emptive kidney transplant were 88, 71 and 87% for Groups A, B and C, respectively (P > 0.05). There were six deaths before dialysis could be commenced. The primary, assisted primary and secondary patency rates after 12, 24 and 36 months did not show any significant difference between the groups (P > 0.05).

CONCLUSIONS

Elderly patients should be considered for angioaccess as first line of venous access. Our study showed a successful first dialysis with angioaccess with failure and patency rates comparable to other age groups. However, we still recommend that patients >80 years old be assessed on a case-by-case basis.

Cardiovascular Imaging for Ischemic Heart Disease in Women: Time for a Paradigm Shift

Heart disease is the leading cause of death among men and women. Women have a unique phenotype of ischemic heart disease with less calcified lesions, more nonobstructive plaques, and a higher prevalence of microvascular disease compared with men, which may explain in part why current risk models to detect obstructive coronary artery disease (CAD) may not work as well in women. This paper summarizes the sex differences in the functional and anatomical assessment of CAD in women presenting with stable chest pain and provides an approach for using multimodality imaging for the evaluation of suspected ischemic heart disease in women in accordance to the recently published American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain. A paradigm shift in the approach to imaging ischemic heart disease women is needed including updated risk models, a more profound understanding of CAD in women where nonobstructive disease is more prevalent, and algorithms focused on the evaluation of ischemia with nonobstructive CAD and myocardial infarction with nonobstructive CAD.

Capitate Fractures: A Review of 53 Patients

PURPOSE

To describe the demographics, diagnosis, management, and outcomes of capitate fractures in the adult and pediatric population treated in our institution.

METHODS

We performed a retrospective chart and radiographic review of 53 patients with capitate fractures treated in our institution between 2002 and 2015. Patients' demographic characteristics, mechanism of injury, management including surgery-related data, and outcomes, including complications, were recorded. A radiographic evaluation of the location and pattern of the fracture was performed.

RESULTS

Capitate fractures were prevalent in young males and older females. Fracture location was variable with 9 different locations; in addition 80% of patients had an associated fracture in the wrist or hand. The most common fracture pattern was the transscaphoid, transcapitate perilunate dislocation. Most diagnoses were made with the aid of advanced imaging. Within this series, there was only 1 case (4%) of fracture nonunion and there were no cases of avascular necrosis of the proximal pole in limited follow-up. Isolated capitate fractures were significantly more common in children. In addition, children had better functional outcomes than adults.

CONCLUSIONS

This series provides updated information on this rare injury. Nonunion of the capitate, which was previously described as the most common complication, was rare in this cohort.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.