Use of Integra® as a Temporizing Measure Before Definitive Flap Surgery in Mangled Extremities Requiring Revascularization.

Complex palm defects with devascularized digits often require vein grafts. This may need to be followed by a free or pedicled flap to resurface the tissue lost and also cover the vein grafts and the anastomosis. However, if the anastomosis fails, or there is marginal wound necrosis, the existing flap would be redundant and a different flap would be needed for coverage. In such situations, a novel approach would be to temporarily cover the anastomotic site with Integra® (Integra LifeScience Corporation, Plainsboro, NJ), until the digit and skin margin vascularity stabilize. This technique can be used to buy time and potentially lessen the need for pedicled or free flap coverage in the first instance. This should be taken into consideration as a viable alternative during revascularization in such cases. In this case report, we present two cases in which we used Integra® as a temporary cover over exposed vein grafts until vascularization was established and a more definitive flap coverage was done. We were able to place the flap directly over the Integra®. This allowed time to determine additional necrosis of the wound margins and the final size of the defect that required coverage. Other advantages of this technique are that Integra® is readily available, there is no donor site morbidity, and the silicone layer which is not directly in contact with the vein graft can be easily peeled off without any traction. A flap or skin graft can be done directly over the collagen layer of the Integra®. Also, having a collagen layer integrated over the vein graft can potentially obviate the need for a flap.

Effect of Testosterone Treatment on Cardiovascular Events in Men: Protocol for a Systematic Literature Review and Meta-Analysis.

BACKGROUND: Testosterone prescriptions have increased dramatically in recent decades, with increasing usage in men. Despite epidemiological associations reported high circulating concentrations of endogenous androgens and low risk of cardiovascular events and mortality, the effects of exogenous androgens in the form of testosterone therapy for maintaining physiological circulating androgen concentrations on the cardiovascular system remain uncertain with no published meta-analysis on this topic. OBJECTIVE: The aim of this study was to investigate the effects of prescribed testosterone treatment, in all forms and durations, from well-developed randomized controlled trials, on cardiovascular events in men aged 18 years or older. METHODS: Peer-reviewed journal articles published from 1980 to 2019 will be searched from databases (ie CINAHL [Cumulated Index to Nursing and Allied Health Literature], Embase, Medline, Scopus, Cochrane Controlled Register of Trials as well as the Clinical Trial Registry). Randomized controlled trials or cluster randomized controlled trials with at least one intervention arm of testosterone and a control group of usual care or no testosterone treatment will be included in this review and meta-analysis. Studies on men with previous cardiovascular events or cardiac vascularization (coronary bypass surgery or percutaneous coronary intervention) will be excluded. Data related to primary outcomes such as clinical events of any type of stroke or transient ischemic attack, nonfatal myocardial infarction or acute coronary syndrome, emergency coronary artery revascularization, carotid surgery, cardiac mortality, and all-cause mortality will be extracted for analysis. The criteria for PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) will be followed in the evaluation of evidence. RESULTS: Search terms have been piloted and finalized. This study will be completed by the end of 2020. CONCLUSIONS: This protocol will guide a systematic literature review of the evidence around prescribed testosterone and its effect on cardiovascular events in men aged 18 years or older. The findings will inform clinical management of hypogonadal men. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42019134278; https://tinyurl.com/y6t7ggge. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/15163.

Multidisciplinary Management of the Post-Cardiac Arrest Patient.

Cardiac arrest afflicts more than 300,000 persons annually in North America alone. Improving outcomes after cardiac arrest requires an integrated and multidisciplinary approach to postresuscitation intensive care and subsequent recovery. This article reviews components of injury within the post-cardiac arrest syndrome, the salient features of brain-oriented intensive care, best practices in neurologic prognostication, and a rational approach to emergency revascularization and hemodynamic support.

Adverse events while awaiting myocardial revascularization: a systematic review and meta-analysis.

OBJECTIVES: The aim of the current study was to estimate adverse event rates while awaiting myocardial revascularization and review criteria for prioritizing patients. METHODS: A PubMed search was performed on 19 January 2015, to identify English-language, original, observational studies reporting adverse events while awaiting coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Rates of death, non-fatal myocardial infarction (MI) and emergency revascularization were calculated as occurrence rates per 1000 patient-weeks and pooled using random-effects models. RESULTS: The search yielded 1323 articles, of which 22 were included with 66 410 patients and 607 675 patient-weeks on the wait list. When awaiting CABG, rates per 1000 patient-weeks were 1.1 [95% confidence interval 0.9-1.3] for death, 1.0 [0.6-1.6] for non-fatal MI and 1.8 [0.8-4.1] for emergency revascularization. Subgroup analyses demonstrated consistent outcomes, and sensitivity analyses demonstrated comparable event rates with low heterogeneity. Higher urgency of revascularization was based primarily on angiographic complexity, angina severity, left ventricular dysfunction and symptoms on stress testing, and such patients with a semi-urgent status had a higher risk of death than patients awaiting elective revascularization (risk ratio at least 2.8). Individual studies identified angina severity and left ventricular dysfunction as most important predictors of death when awaiting CABG. Adverse rates per 1000 patient-weeks for patients awaiting PCI were 0.1 [95% confidence interval 0.0-0.4] for death, 0.4 [0.1-1.2] for non-fatal MI and 0.7 [0.4-1.4] for emergency revascularization but were based on only a few old studies. CONCLUSIONS: Rates of death, non-fatal MI and emergency revascularization when awaiting myocardial revascularization are infrequent but higher in specific patients. Countries that not yet have treatment recommendations related to waiting times should consider introducing a maximum to limit adverse events, particularly when awaiting CABG.

Application of SYNTAX score in emergency PCI strategy for STEMI patients with multivessel diseases / 重庆医学

Objective To evaluate the effect of SYNTAX score in the emergency revascularization strategy selection in ST‐segment elevation myocardial infarction patients with multi‐vessel disease(MVD) and to analyze the patient′s prognosis and influen‐cing factors .Methods A total of 144 patients with STEMI complicating MVD verified by coronary arterial angiography in the Xin‐qiao Hospital of Third Military Medical University from August 2010 to March 2012 were collected and divided into the once com‐plete revascularization group (CR group) ,staged complete revascularization group (SR group) and incomplete revascularization group (IR group) according to different emergency PCI strategies .The basic clinical conditions and coronary arterial SYNTAX score were recorded .The occurrence rate of major adverse cardiovascular events (MACCE) during 12 months follow up period was performed the statistics .The results of coronary arterial angiography were collected .The effect of different strategy on prognosis and the risk factors affecting prognosis were analyzed .Results There was no statistically significant difference in the all‐cause mor‐tality between the IR group with the CR and SR groups (P>0 .05) ,while the cerebrovascular event ,repeat revascularization during hospitalization ,AMI and total MACCE occurrence rate had statistical difference between the IR group with the CR and SR groups (P 0 .05) ,while which in moderate lesion had statistical difference among 3 groups(P<0 .05) ,the CR group had the highest occurrence rate of MACCE . Conclusion For the patients with STEMI complicating MVD ,the SYNTAX score can be used as the evidence for selecting reperfu‐sion strategies and applied in emergency PCI .

Predictive factors predicting inadequate ST-segment resolution in patients with acute ST-segment elevation myocardial infarction after percutaneous coronary intervention / 中华急诊医学杂志

Objective To survey ST-segment resolution in STEMI patients undergoing emergency percutaneous coronary intervention (PCI) and to find the specific clinical features of patients with inadequate ST-segment resolution.Methods A total of 198 patients were divided into two groups according to the ratio of ST-segment resolution:relatively adequate ST-segment resolution group (＞ 50％) and inadequate STsegment resolution group (＜ 50％).The clinical features,infarct-related artery and PCI-related evants were evaluated,and major adverse cardiovascular events (MACE including target vessel revascularization,recurrent myocardial infarction,or death) were recorded during hospitalization and follow-up period.Multivariate logistic analysis was used to identify relevant factors influencing ST-segment resolution of STEMI patients after treatment with PCI.The Statistical analyses of data were carried out using SPSS 10.0 software.Results (1) There were 156 patients with relativey adequate ST-segment resolution and 42 patients with inadequate ST-segment resolution.Of them,there were higher percentage of patients aged over 75years in the inadequate ST-segment resolution group than those in the relatively adequate ST-segment resolution group (9 cases,21.4％ vs.14 cases,9.0％ ; P ＜0.05).(2) In inadequate ST-segment resolution group,thetotal ischemic time was significant longer [(5.2 ±2.2) h vs.(3.0 ± 1.6) h,P ＜0.01].The infarctrelated artery (IRA) was more common at left anterior descending coronary artery (LAD) (27 cases,64.3％ vs.69 cases,44.2％; P ＜ 0.05) and there were fewer patients with TIM grade 3 of IRA in inadequate ST-segment resolution group after primary PCI than that in relative adequate ST-segment resolution group (32 cases,76.2％ vs.140 cases,89.7％ ; P ＜ 0.05).There was a lower rate of using GP Ⅱ b/Ⅲ a receptor antagonist and a higher rate of prescribing IABP in inadequate ST-segment resolution group.(3) There is a higher incidence of MACE during hospitalization and follow-up period in patients with inadequate ST-segment resolution.(4) Multivariate logistic analysis indicated that age over 75 years,LAD occlusion,the total ischemic time were related to ST-segment resolution.Conclusions The patients with age over 75 years,LAD occlusion,longer ischemia time,and unemployment GP Ⅱ b/Ⅲ a receptor antagonist before PCI were prone to get inadequate ST-segment resolution and poor prognosis.Age over 75 years,LAD occlusion,and longer ischemic time were independent risk factors of the inadequate ST-segment resolution in STEMI patients after emergency PCI.