Correlations of perioperative coagulopathy, fluid infusion and blood transfusions with survival prognosis in endovascular aortic repair for ruptured abdominal aortic aneurysm

Background: Factors associated with survival prognosis among patients who undergo endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms (rAAA) have not been sufficiently investigated. In the present study, we examined correlations between perioperative coagulopathy and 24-h and 30-day postoperative survival. Relationships between coagulopathy and the content of blood transfusions, volumes of crystalloid infusion and survival. Methods: This was a retrospective study of the medical records of all patients who underwent EVAR for rAAA at Chiba-Nishi General Hospital during the period from October 2013 to December 2015. Major coagulopathy was defined using the international normalized ratio or activated partial thromboplastin time (APTT) ratio of at least 1.5, or platelet count less than 50 × 10/l. We quantified the amounts of blood transfusions and crystalloid infusions administered from arrival to the hospital to admission to ICU following operations. Results: Coagulopathy among patients with rAAA was found to progress even after they had presented at the hospital. No statistically significant correlation between preoperative coagulopathy and mortality was found, although a significantly greater degree of postoperative coagulopathy was seen among patients who died both within 24-h and 30 days postoperatively. Among patients with postoperative coagulopathy, lesser quantities of fresh frozen plasma (FFP) compared with red cell concentrate (RCC) were used during the period from hospital arrival to postoperative ICU entry. In both groups of patients who did not survive after 24-h and 30 days, FFP was used less than RCC. Large transfusions of crystalloids administered during the periods from hospital arrival to surgery and from hospital arrival to the end of surgery were associated with postoperative incidence of major coagulopathy, death within 24-h, and death within 30 days. Conclusion: Coagulopathy progressed during care in the emergency outpatient clinic and operations. Postoperative coagulopathy was associated with poorer outcomes. Smaller FFP/RCC ratios and larger volumes of crystalloid infusion were associated with development of coagulopathy and poorer prognosis of survival

CIN after endovascular aortic repair

Objective : This study aimed to determine the perioperative predictors of contrast medium-induced nephropathy (CIN) after endovascular aortic repair (EVAR). Materials and Methods : The data of 203 consecutive patients who underwent elective EVAR for thoracic and abdominal aortic aneurysm between January 2014 and September 2014 were retrospectively analyzed. CIN was defined according to the diagnostic criteria of the European Society of Urogenital Radiology. Results : Fourteen patients (6.9%) developed CIN after EVAR. Contrast medium volume (CV), preoperative serum creatinine, estimated glomerular filtration rate (eGFR), and the CV/eGFR ratio were significantly related with CIN development after EVAR. The CV/eGFR ratio was significantly higher in patients with CIN than those without CIN. Receiver operator characteristic curve analysis showed that the area under the curve of the CV/eGFR ratio was 0.782, indicating that it was the most important predictor. The appropriate CV/eGFR ratio cutoff was >1.62. Sensitivity and specificity were 85.7% and 65.6%, respectively. Conclusions : The CV/eGFR ratio was a useful predictor of contrast medium-induced nephropathy after EVAR. It is possible that the score can be used in patients when managing the EVAR techniques and contrast medium volume

C-arm Cone-beam CT-guided Needle Biopsies through the Erector Spinal Muscle for Posterior Thoracic Pulmonary Lesions

This study investigated retrospectively the diagnostic yield and complication rate of transthoracic needle biopsies for posterior thoracic pulmonary lesions using C-arm cone-beam computed tomography （CBCT）. The risk factors for pulmonary hemorrhage were evaluated. Our study included 113 patients with 113 posterior pulmonary lesions （mean longest diameter: 30.6mm, and mean depth: 4.7mm） through the erector spinal muscles using a 19/20-gauge coaxial system. The diagnostic performances of procedures for malignant lesions and the incidence of complications after biopsies were also assessed. The patient-related and procedure-related variables were investigated. Risk factors for pulmonary hemorrhage were analyzed with a multivariate logistic regression analysis. Findings revealed 99 malignant, 13 benign, and one intermediate lesion. Sensitivity, specificity, and diagnostic accuracy rates were 100％ （99/99）, 92.3％ （12/13）, and 99.1％ （111/112）, respectively. Air embolization, hemothorax, hemoptysis, pneumothorax, and pulmonary hemorrhage, occurred in 0, 2, 12, 48, and 70 procedures. The averaged spinous process-pleura depth and the traversed lung parenchyma depth achieved by the introducer needles were 54.2mm and 27.4mm, respectively. The needle position at the pleural puncture site within the intercostal space was in middle （31％） and inferior （69％） areas. The incidence of pulmonary hemorrhage was significantly higher in smaller lesions （p＝0.001）. Manual evacuation was performed in five procedures for patients with pneumothorax. The chest tube placement （trocar＞8 Fr） was performed in two procedures in patients with hemothorax and pneumothorax. In conclusion, the biopsy method with a posterior intercostal approach for posterior thoracic pulmonary lesions yielded high diagnostic accuracy and few major complications

チアノーゼ性心疾患に対する肺動脈絞扼術

The early and late results of pulmonary artery banding (PAB) for cyanotic heart defects in early infancy were reviewed. Nine patients were divided into two groups : Group F (five patiens) in which Fontan type repairs were expected as definitive repair in the near future ; Group A (four patients) in which anatomical repairs were programmed in the near future. Six patients had a good early postoperative course, and then consisted of three patients of Group A and three patients of Group F. The band circumference, intraoperative pulmonary-to-systemic systolic pressure ratio and arterial oxygen tension after PAB in the good cases of Group A were 20.0±1.7 mm + 1 mm for each kilogram of the infant's weight, 0.52±0.07 and 46.4±11.3 mmHg respectively. These indices in the good cases of Group F were 21.1±1.7 mm + 1 mm for each kilogram of the infant's weight, 0.55±0.02 and 38.8±1.0 mmHg respectively. The standard deviations of every index for PAB in Group F were small. Three patients of Group A have undergone successful total correction. Intraoperative pulmonary-to-systemic systolic pressure ratio of 0.5 as the index of PAB is preferable to Group A. However, only two patient of Group F were waiting for Fontan type definitive repair. For the patient especially in Group F, careful observation and well-timed staged repair with regard to subaortic stenosis and restrictive atrial septal defect and ventricular septal defect are necessary after accurate PAB as mentioned above

Alternative Starting Position for CT Coronary Angiography

We examined whether the superior margin of the left main bronchus is the best landmark for the starting position of computed tomography coronary angiography（CTCA）. We retrospectively evaluated 693 consecutive CTCAs. From the scout scanogram, the superior margin of the left main bronchus was noted. The relationships among and distance between the superior margin of the left main bronchus and the left coronary system were analyzed. The superior margin of the left main bronchus extended caudally to the superior margin of the left coronary system in 13 patients（1.9％）. The addition of 1cm to the superior margin of the left main bronchus kept it caudal to the superior margin of the left coronary system in only one patient（0.1％）. On the scout scanogram, 1cm above the superior margin of the left main bronchus is the most appropriate starting position for CTCA

Surgical management of infants with mitral valve stenosis or atresia without diminutive ascending aorta

The surgical strategy in infants with mitral valve stenosis or atresia without diminutive ascending aorta remains to be established, including the potential for biventricular repair as a definitive operation. Our surgical experience of six infants with mitral valve stenosis (4patients) or atresia (2patients) without diminutive ascending aorta was evaluated based on three important factors:left ventricular volume;the nature of the systemic outflow obstruction; and the type of mitral valve anomaly. Two patients with systemic outflow tract diameter less than 65% of normal underwent systemic outflow tract reconstruction, and the other patients with outflow tract diameter more than 68%of normal were able to maintain systemic circulation without repair. Only one patient with mitral valve stenosis without left ventricular outflow tract obstruction underwent a successful open mitral valvotomy as a biventricular repair after first-stage palliation. The left ventricle of the other patients did not grow after first-stage palliation. Due to progressive subaortic narrowing, pulmonary artery banding should be avoided in patients with mitral atresia due to absent atrioventricular connection who are future Fontan candidates. Most patients with this lesion can be expected to become candidates for safe Fontan-type repair

Evaluation of complex physical therapy for lymphedema of the unilateral lower limbs

We evaluated the effectiveness of the complex physical therapy (CPT) for lymphedema of the unilateral lower limbs of eleven patients who had been admitted to Tokushima Rehabilitation Hospital. Ten patients were of secondary lymphedema, nine of which were after treatment of uterine cancer and one was of primary lymphedema. Our CPT consited of skin care, manual lymph drainage (MLD), compression therapy with elastic bandages or elastic stockings, and exercise therapy under compression. MLD functionally operates to enhance the lymph drainage more proximally in both contralateral and ipsilateral truncal quadrants of the torso, then in the proximal limb, and only thereafter from the distal to proximal portion of the edematous extremity. Swelling ratio of all patients on admission was 26.9± 11.8% and that at discharge was 16.8±9.4%. Edema reduction ratio (ERR) of the entire patients was 41.5± 16.5%, and 81.8% of cases were recognized as effective, in which ERR showed more than 30% at discharge. In a consensus document about the diagnosis and treatment of peripheral lymphedema in 1995, the International Society of Lymphology Executive Committee reported that most operations designed to alleviate peripheral lymphedema have not as yet been perfected or usually are still inferior to combined physiotherapy. At present lymphedema should be accurately diagnosed in the early stage and be treated with CPT correctly by clinicians who understand lymphedema thoroughly and are well trained

AUTS2 Governs Cerebellar Development, Purkinje Cell Maturation, Motor Function and Social Communication

Autism susceptibility candidate 2 (AUTS2), a risk gene for autism spectrum disorders (ASDs), is implicated in telencephalon development. Because AUTS2 is also expressed in the cerebellum where defects have been linked to ASDs, we investigated AUTS2 functions in the cerebellum. AUTS2 is specifically localized in Purkinje cells (PCs) and Golgi cells during postnatal development. Auts2 conditional knockout (cKO) mice exhibited smaller and deformed cerebella containing immature-shaped PCs with reduced expression of Cacna1a. Auts2 cKO and knock-down experiments implicated AUTS2 participation in elimination and translocation of climbing fiber synapses and restriction of parallel fiber synapse numbers. Auts2 cKO mice exhibited behavioral impairments in motor learning and vocal communications. Because Cacna1a is known to regulate synapse development in PCs, it suggests that AUTS2 is required for PC maturation to elicit normal development of PC synapses and thus the impairment of AUTS2 may cause cerebellar dysfunction related to psychiatric illnesses such as ASDs