Two approaches for placenta accreta spectrum: B-lynch suture versus pelvic artery endovascular balloon.

Purpose: Management of patients with placenta accreta spectrum (PAS) varies widely, and scarce data exist concerning its management. The current study compared two different surgical approaches in the management of PAS: the B-lynch approach (Group A) compared to the endovascular balloon catheters (Group B)Methods: A retrospective cohort study in two tertiary university-affiliated hospitals between the years 2004 and 2015. Elective cesarean section was planned at 35-37 weeks of gestation. One center utilized the B-lynch approach and the second utilized the endovascular balloon catheter approach.Results: The cesarean hysterectomy rate was significantly higher in the Group A approach compared to Group B (36.1 versus 29.2%, p = .00). The number of packed cells units administered during and postoperatively were higher in the Group A compared with Group B (p = .006 and .043, respectively). Overall, surgery length and hospitalization duration were shorter in patients who underwent cesarean hysterectomy compared with those who underwent uterine preservation (B-lynch or endovascular balloon catheters) (p = .000 and p = .004, respectively).Conclusions: The endovascular balloon technique seems to be a better option for uterine preservation due to less blood loss and higher postoperative hemoglobin level. Nevertheless, for those women who have completed their family planning, cesarean hysterectomy with the placenta left in situ is the safer and more suitable option.

Intra-discal drain insertion for culture and drainage of pyogenic spondylodiscitis: A one-step diagnostic and therapeutic procedure.

BACKGROUND: Pyogenic spondylodiscitis is diagnosed in recent years at higher rates due to the aging population, increased survival of chronic and immune suppressed patients, and the higher rate of invasive procedures leading to bacterial seeding or direct contamination of the disc space. Treatment guidelines encourage bacterial sampling before initiation of antibiotic therapy, and drainage of pus collections. We present our experience with percutaneous CT-guided drain insertion into the disc space itself as a one-step procedure for both culturing and subsequent continuous drainage of the infected disc space. MATERIALS AND METHODS: We retrospectively reviewed all cases of pyogenic spondylodiscitis admitted to our spine surgery unit during the past five years and treated with CT-guided percutaneous drain insertion into the infected disc space. All patients were followed until complete resolution of the infection. RESULTS: We retrieved electronic records of 12 patients, none presenting with neurological compression symptoms. Cultures taken at the time of drain insertion were positive in 10 patients (83.3%), much higher than the reported yield for needle aspiration (14-48%) and comparable to the yield of open biopsy. In all patients complete resolution of the infection was reached, determined by clinical, laboratory, and imaging parameters. CONCLUSIONS: Our retrospective case series demonstrates the feasibility and effectiveness of intra-discal CT-guided drainage of an infected disc space. The procedure does not add much burden to current practice as disc-space sampling for culture is commonly performed anyway, and adds the benefit of direct drainage of the pus at its source.

The use of pre-caesarean prophylactic intra-arterial balloon catheters for suspected placenta accreta.

INTRODUCTION: The incidence of placenta accreta (PA) has markedly increased in the United States, from 1/30 000 in 1950 to 1/731 deliveries in 2011. Although placenta praevia after prior caesarean sections (CS) is the most important risk factor for PA, other risk factors make up 1-5% of PA occurrences. At our referral hospital, we use the pre-caesarean prophylactic balloon catheter with or without post-surgery embolisation in a hybrid room. Here, we evaluate the role of prior CS and placenta praevia on the outcome of this procedure. MATERIALS AND METHODS: This retrospective cohort analysis included 61 women during the years 2004-2016 with sonographic suspicion of PA who underwent balloon catheterisation prior to CS. RESULTS: Eleven women had no previous CS (18%). Mean previous CS rate was 1.85. Six women (9.8%) had previous dilatation and curettage (D&C); 36.4% of women with no previous CS had previous D&C compared with 4% of women with previous CS (P = 0.008). Placenta praevia was sonographically diagnosed in 55 women (90.2%). There was a higher rate of caesarean hysterectomy in women with previous CS than in those without (32% vs 0%, P = 0.052) but no significant difference in blood product requirements (45.5% vs 66%, P = 0.303). There was no significant difference in hysterectomy rate, blood transfusion or surgery duration between women with and without placenta praevia (P = 0.648, 0.594, 0.995, respectively). CONCLUSION: Previous CS rather than placenta praevia is a strong indicator of hysterectomy in cases of PA. Different risk factors for PA do not affect blood transfusion rates or surgery duration.

Prognostic and Added Value of Two-Dimensional Global Longitudinal Strain for Prediction of Survival in Patients with Light Chain Amyloidosis Undergoing Autologous Hematopoietic Cell Transplantation.

BACKGROUND: Autologous hematopoietic cell transplantation (HCT) is a first-line therapy for prolonging survival in patients with light-chain (AL) amyloidosis. Cardiac involvement is the most important determinant of survival. However, patients with advanced cardiac involvement have often been excluded from HCT because of high risk for transplantation-related mortality and poor overall survival. Whether baseline left ventricular global longitudinal strain (GLS) can provide additional risk stratification and predict survival after HCT in this high-risk population remains unclear. The aim of this study was to evaluate the prognostic implication of baseline GLS and the added value of GLS beyond circulating cardiac biomarkers for risk stratification in patients with AL amyloidosis undergoing HCT. METHODS: Eighty-two patients with newly diagnosed AL amyloidosis who underwent upfront HCT between January 2007 and April 2014 were included in the study. Clinical, echocardiographic, and serum cardiac biomarker data were collected at baseline and 12 months following HCT. GLS measurements were performed using a vendor-independent offline system. The median follow-up time for survivors was 58 months. RESULTS: Sixty-four percent of patients were in biomarker-based Mayo stage II or III. GLS, brain natriuretic peptide, troponin, and mitral E/A ratio were identified as the strongest predictors of survival (P < .0001). Other predictors included sex, creatinine, free AL, wall thickness, and ejection fraction. Mayo stage was significantly associated with outcome, with 5-year survival of 93%, 72% and 31% in stage I, II, and III patients, respectively. GLS of 17% was identified as the value that best discriminated survivors from nonsurvivors, and the application of this cutoff value provided further mortality risk stratification within each Mayo stage. CONCLUSIONS: GLS is a strong predictor of survival in patients with AL amyloidosis undergoing HCT, potentially providing incremental value over serum cardiac biomarkers for risk stratification. GLS should be considered as a standard parameter along with serum cardiac biomarkers when evaluating eligibility for HCT or other investigational therapies.

Angiographic Embolization in Pediatric Abdominal Trauma.

BACKGROUND: Trauma is the leading cause of childhood morbidity and mortality. Abdominal bleeding is one of the common causes of mortality due to trauma. Angiography and embolization are well recognized as the primary treatments in certain cases of acute traumatic hemorrhage in adults; however, evidence is lacking in the pediatric population. OBJECTIVES: To assess the safety and efficacy of transcatheter arterial embolization (TAE) for blunt and penetrating abdominal and pelvic trauma in the pediatric age group. METHODS: Three children with blunt abdominal trauma and one child with iatrogenic renal injury (age 4-13 years) were managed with TAE for lacerated liver (one patient), pelvic fractures (one patient) and renal injuries (two patients). The first two patients, victims of road accidents, had multisystem injuries and were treated by emergency embolization after fluid resuscitation in the Emergency Department (ED). The other two patients had renal injuries: a 4 year old boy with blunt abdominal trauma was diagnosed on initial computed tomography with an unexpected Wilms tumor and was treated with embolization 1 day after admission due to hemodynamic deterioration caused by active arterial tumor bleeding. The following day he underwent successful nephrectomy. The other patient was 13 year old boy with nephrotic syndrome who underwent renal biopsy and developed hemodynamic instability. After fluid resuscitation, he underwent an initial negative angiography, but second-look angiography the following day revealed active bleeding from an aberrant renal artery, which was then successfully embolized. RESULTS: In all four patients, TAE was diagnostic as well as therapeutic, and no child required surgical intervention for control of bleeding. CONCLUSIONS: We propose that emergency transcatheter angiography and arterial embolization be considered following resuscitation in the ED as initial treatment in children with ongoing bleeding after blunt abdominal trauma or iatrogenic renal injury. Implementation of this policy demands availability and cooperation of the interventional radiology services.

Abnormal placental invasion--a novel approach to treatment case report and review.

The incidence of abnormal placental invasion has increased 10-fold in the past 50 years, reflecting the increased number of cesarean sections performed. Management relies on accurate early diagnosis with appropriate perioperative multidisciplinary planning to anticipate and avoid massive obstetric hemorrhage at delivery. Women at risk should plan to deliver at an institution with appropriate expertise and resources for managing this condition. We report a case of placenta increta management comprising preoperative placement of a pelvic artery balloon catheter, prophylactic balloon occlusion after delivery of the fetus, and embolization-assisted resection of the invaded uterine wall. We review incidence, methods of prenatal diagnosis, risk factors, and management of abnormally invasive placenta.

Cutting balloon angioplasty for primary treatment of hemodialysis fistula venous stenoses: preliminary results.

PURPOSE: To assess the efficacy of the cutting balloon as the primary tool in percutaneous transluminal angioplasty of hemodialysis access stenoses. MATERIALS AND METHODS: A prospective study of symptomatic patients with stenoses of 50% or more in their hemodialysis accesses was undertaken. Provided that no contraindication to the use of cutting balloons existed, the stenoses were treated with the cutting balloon with use of a maximum of a 1:1.1 ratio between expected vessel diameter and balloon diameter. In cases in which dilation to the full diameter of the cutting balloon left a greater than 30% residual stenosis, postprocedural dilation with conventional balloons was carried out. Patient access function was followed. Twenty-nine patients with 42 stenoses have now reached 6 months of follow-up after cutting balloon angioplasty. RESULTS: Technical and clinical success rates were 100%. Slight local extravasation occurred in three cases: two had continued pain after the balloon was deflated and were therefore treated with balloon compression with resolution of symptoms and angiographic findings. In two cases, elastic recoil required stent placement to correct the stenosis. At 6 months, 22 patients (76%) remain in the primary patency category. Inclusion of those with primary assisted patency yields 26 patients (90%), and an additional patient had secondary patency, for a total of 93%. Two patients died of causes not directly related to dialysis. CONCLUSION: The high degree of technical and clinical success likely reflects the lack of major complications. The 6-month follow-up results match those of other series. Further follow-up will show whether this technique produces better results over the long term.

Predictors of relapse during treatment and treatment completion among marijuana-dependent adolescents in an intensive outpatient substance abuse program.

The present study assessed possible predictors of relapse while in treatment and treatment completion among marijuana-dependent adolescents (N = 59) in an intensive outpatient substance abuse treatment program. Comorbid depression was associated with an increased likelihood of relapse and a higher total number of relapses. As expected, relapse while in treatment was associated with a reduced likelihood of successfully completing the treatment program. Comorbid attention deficit hyperactivity disorder (ADHD) was also associated with a lower likelihood of successful program completion. These findings add to a slowly growing literature regarding adolescent substance abuse treatment, and may help clinicians identify marijuana-dependent adolescents at greater risk of relapse or noncompliance.