Economic Evaluation of Pharmacogenetic Tests in Patients Subjected to Renal Transplantation: A Review of Literature

Renal transplantation is the treatment of choice for the patients with end-stage renal failure. Genetic factors, among others, can influence variability in response to immunosuppressive drugs. Nowadays, due to restrictive health resources, the question arises whether routine pharmacogenetic analyses should be done in the renal transplant recipients or not. The aim of this literature review was to present the up-to-date information considering the economic feasibility of pharmacogenetic testing in patients subjected to renal transplantation. The organization United Network for Organ Sharing in the United States estimated that total costs per renal transplant concerning these analyses were $334,300 in 2014. Pharmacogenetic testing prior to treatment initiation could be helpful to predict and assess treatment response and the risks for adverse drug reactions. This kind of testing before treatment initiation seems to be one of the most promising applications of pharmacokinetics. Although pharmacogenetic tests were found to be a cost-effective or cost-saving strategy in many cases, some authors represent another opinion. However, if the real costs of renal transplantation are recognized, the application of these tests in the standard daily practice could be considered more realistic, which additionally emphasizes the importance of future studies assessing their cost-effectiveness

Long-term Survival After Endovascular and Open Repair of Ruptured Abdominal Aortic Aneurysms

Pla general interior de l'estació de Roquetes Andana central de 8m. d'ample, 100m de llargada i a 50m profunditat, amb bancs de pedra de color blanc en el centre

Vascular graft infections

Vascular graft infections are rare complications after surgical and endovascular treatment of aortic diseases. This condition is characterized by complexity in diagnosis and medico-surgical management. Moreover, even if properly treated, morbidity and mortality rates are high. Although several advances have been made over the years and guidelines of treatment have been published, there is still debate on the optimal care for this disease. With local microbiological patterns and multiresistant strains conditioning antimicrobial treatment as well as several surgical debridement techniques in the armamentarium, it is difficult to offer recommendations that can be generalized for every single case. In this review, we aim at describing thoracic and abdominal vascular graft infections and providing current information on diagnosis, medical treatment, and surgical management

Imaging characteristics and diagnostic accuracy of FDG-PET/CT, contrast enhanced CT and combined imaging in patients with suspected mycotic or inflammatory abdominal aortic aneurysms

PURPOSE To evaluate the diagnostic accuracy and specific imaging characteristics of positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (PET/CT), contrast enhanced CT (CE-CT), and a combined imaging approach (CE-PET/CT) in patients with infectious/mycotic (MAA), inflammatory (IAA), and non-infected, non-inflammatory abdominal aortic aneurysm (AAA). MATERIALS AND METHODS In this single-center retrospective cohort study, all imaging data sets of 29 consecutive patients with clinically suspected MAA or IAA were anonymised with different, reshuffled identification numbers and retrospectively and independently analysed by two experienced readers, blinded to all clinical patient data. Readers determined the presence or absence and MAA, IAA and AAA and of predefined imaging characteristics (e.g. fluid collection), and measured metabolic activity and wall thickness of all aneurysms. A multidisciplinary team of specialists served as standard of reference and re-evaluated every clinical case, considering all clinical, laboratory, microbiological, histopathological and imaging results, including all follow-up examinations. RESULTS Diagnostic accuracy was higher in PET/CT as compared to CE-CT in differentiating AAA from MAA and IAA: area under the receiver operating characteristic curve (AUC-ROC) 0.81 (95% confidence intervals 0.69-0.92) and 0.63 (0.52-0.74) (P = 0.027). Specific imaging characteristics were significantly associated with different types of aneurysms (P<0.05), i.e. very high metabolic activity and dorsal sparing of metabolic activity in PET/CT and wall thickening in CE-CT were indicative for IAA; fat stranding and fluid collections in CE-CT were associated with MAA; while low metabolic acitivity and absence of wall thickening in PET/CT, and less fat stranding and absence of wall thickening in CE-CT were indicative for non-infected, non-inflammatory AAA. CONCLUSION Specific imaging characteristics of PET/CT and CE-CT may be helpful in differentiating between MAA, IAA, and non-infected, non-inflammatory AAA

Negative microbiological results are not mandatory in deep sternal wound infections before wound closure†

OBJECTIVES To define the outcome of treatment for deep sternal wound infections (DSWIs) using direct wound closure (DC) or vacuum-assisted therapy (VAT) based on negative vs. positive microbiological results. METHODS Between 1999 and 2008, 7746 patients underwent median sternotomy for cardiac surgery at our institution. Patients were screened for DSWI and out of the cohort 159 were identified (2%). These patients were treated, either using DC or VAT with delayed wound closure. Outcomes were retrospectively analysed to determine the effect of negative cultures at the time of closure. RESULTS The indication for sternotomy was CABG 51%, isolated valve 18%, CABG/valve 18% and other related cardiovascular procedures 14%. Sixty-five percent of the wound infections was diagnosed during rehabilitation period. One hundred and five (66%) patients were treated with VAT vs. 54 (34%) patients with direct closure. Coagulase negative staphylococci were found in 48% of bacterial cultures. In 75% of the patients, the microbiological results were positive at time of wound closure (69.2% VAT vs. 87.0% direct closure, P=0.014). Out of 159 patients, 5.0% were with positive microbiological results at the time of closure readmitted vs. 5.1% with negative microbiological results (P=1.0). Patients with VAT stayed significantly longer in the hospital (mean 21±16 vs. 13±12, P=0.002). CONCLUSIONS Negative microbiological results are not mandatory before wound closure, as the rate of readmissions for recurrence of infection showed no difference between groups. Our results also suggest that shortening of VAT despite positive microbiological results may be feasibl

Branch ligatures and blood aspiration for post-traumatic superficial temporal artery pseudoaneurysm: surgical technique

The aim of this study is to report a new minimally invasive technique of superficial temporal artery (STA) pseudoaneurysm treatment. Several surgical options have been employed to treat STA pseudoaneurysms. To address this rare condition, the employed techniques are ligation and excision of the aneurysm, endovascular coil embolization or percutaneous ultrasound-guided thrombin injection. Between techniques no significant differences are reported in terms of outcomes. The decision to adopt a technique depends on STA pseudoaneurysm morphology and surgeon preference. In the present report, STA pseudoaneurysm afferent and efferent branches were identified by ultrasound in a 92-year-old female. Under local anaesthesia, these branches were ligated through small skin incisions. STA pseudoaneurysm decompression was obtained by an ‘over the needle aspiration'. A compressive dressing was left in space for 48h

Branch ligatures and blood aspiration for post-traumatic superficial temporal artery pseudoaneurysm: surgical technique

The aim of this study is to report a new minimally invasive technique of superficial temporal artery (STA) pseudoaneurysm treatment. Several surgical options have been employed to treat STA pseudoaneurysms. To address this rare condition, the employed techniques are ligation and excision of the aneurysm, endovascular coil embolization or percutaneous ultrasound-guided thrombin injection. Between techniques no significant differences are reported in terms of outcomes. The decision to adopt a technique depends on STA pseudoaneurysm morphology and surgeon preference. In the present report, STA pseudoaneurysm afferent and efferent branches were identified by ultrasound in a 92-year-old female. Under local anaesthesia, these branches were ligated through small skin incisions. STA pseudoaneurysm decompression was obtained by an 'over the needle aspiration'. A compressive dressing was left in space for 48 h

The sac evolution imaging follow-up after endovascular aortic repair:An international expert opinion-based Delphi consensus study

Objective: Management of follow-up protocols after endovascular aortic repair (EVAR) varies significantly between centers and is not standardized according to sac regression. By designing an international expert-based Delphi consensus, the study aimed to create recommendations on follow-up after EVAR according to sac evolution. Methods: Eight facilitators created appropriate statements regarding the study topic that were voted, using a 4-point Likert scale, by a selected panel of international experts using a three-round modified Delphi consensus process. Based on the experts' responses, only those statements reaching a grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement &lt;5%) were included in the final document. Results: One-hundred and seventy-four participants were included in the final analysis, and each voted the initial 29 statements related to the definition of sac regression (Q1-Q9), EVAR follow-up (Q10-Q14), and the assessment and role of sac regression during follow-up (Q15-Q29). At the end of the process, 2 statements (6.9%) were rejected, 9 statements (31%) received a grade B consensus strength, and 18 (62.1%) reached a grade A consensus strength. Of 27 final statements, 15 (55.6%) were classified as grade I, whereas 12 (44.4%) were classified as grade II. Experts agreed that sac regression should be considered an important indicator of EVAR success and always be assessed during follow-up after EVAR. Conclusions: Based on the elevated strength and high consistency of this international expert-based Delphi consensus, most of the statements might guide the current clinical management of follow-up after EVAR according to the sac regression. Future studies are needed to clarify debated issues.</p