Tranexamic Acid Use in Pediatric Craniotomies at a Large Tertiary Care Pediatric Hospital: A Five Year Retrospective Study.

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, has proven efficacy and is recommended for major pediatric surgery to decrease perioperative blood loss. Accumulating evidence suggests that TXA reduces bleeding and transfusion in a variety of adult neurosurgical settings. However, there is a paucity of research regarding TXA indications for pediatric neurosurgery and thus, there are currently no recommendations for its use with this specific population. The objective of this study is to evaluate the existing practice of TXA administration for pediatric neurosurgery at a U.S. tertiary care pediatric hospital over a five-year period. The authors conclude that TXA administration is feasible and should be considered for pediatric neurosurgical cases where potential blood loss is a concern.

Preoperative Tricuspid Regurgitation Is Associated With Long-Term Mortality and Is Graded More Severe Than Intraoperative Tricuspid Regurgitation.

OBJECTIVES: To determine whether preoperative (preop) tricuspid regurgitation (TR) severity grade was associated with postoperative mortality, to examine the correlation between pre-op and intraoperative (intraop) TR grades, and to understand which TR grade had better prognostic predictability in cardiac surgery patients. DESIGN: Retrospective. SETTING: Single institution. PARTICIPANTS: Patients. INTERVENTIONS: Preop and intraop echocardiography TR grades of 4,232 patients who had undergone cardiac surgeries between 2004 and 2014 were examined. MEASUREMENTS AND MAIN RESULTS: Kaplan-Meier curves and Cox proportional hazard models were used to determine the association between TR grades and the primary endpoint of all-cause mortality. The Wilcoxon signed-rank test and Spearman's rank correlation were analyzed to assess the similarity and correlation between preop and intraop-grade pairs. Multivariate logistic regression models of the area under the curve characteristics were compared for prognostic implications. Kaplan-Meier curves demonstrated a strong relationship between preop grades and survival. Multivariate models showed significantly increased mortality starting at mild preop TR (mild TR: hazard ratio [HR] 1.24; 95% CI 1.05-1.46, p = 0.013; moderate TR: HR 1.60; 95% CI 1.05-1.97, p < 0.001; severe TR: HR 2.50; 95% CI 1.74-3.58, p < 0.001). Preop TR grades were mostly higher than intraop grades. Spearman's correlation was 0.55 (p < 0.001). The area under the curves of preop and intraop TR-based models were almost identical (0.704 v 0.702 1-year mortality and 0.704 v 0.700 2-year mortality). CONCLUSIONS: The authors found that echocardiographically-determined preop TR grade at the time of surgical planning was associated with long-term mortality, starting even at a mild grade. Preop grades were higher than intraop grades, with a moderate correlation. Preop and intraop grades exhibited similar prognostic implications.

Postoperative Hearing Loss in a Patient With Crouzon Syndrome: A Case Report.

Sudden postoperative hearing loss is rare, and thought to be caused by a variety of mechanisms. Here we report on a patient with Crouzon syndrome who experienced multiple episodes of postoperative hearing loss, with persistent hearing loss occurring after she received nitrous oxide as part of a general anesthetic. Nitrous oxide is known to cause pressure changes in closed air spaces. Patients with craniofacial syndromes may have acoustic nerve compression from skull base and cartilage anomalies that cause narrowing of the internal acoustic meatus. These anatomic variations may make patients more susceptible to increased middle ear pressure secondary to nitrous oxide, increasing their risk for hearing loss.

Severity of tricuspid regurgitation is associated with long-term mortality.

OBJECTIVES: To determine the association between intraoperative/presurgical grade of tricuspid regurgitation (TR) and mortality, and to determine whether surgical correction of TR correlated with an increased chance of survival compared with patients with uncorrected TR. METHODS: The grade of TR assessed by intraoperative transesophageal echocardiography (TEE) before surgical intervention was reviewed for 23,685 cardiac surgery patients between 1990 and 2014. Cox proportional hazard regression models were used to determine association between grade of TR and the primary endpoint of all-cause mortality. Association between tricuspid valve (TV) surgery and survival was determined with Cox proportional hazard regression models after matching for grade of TR. RESULTS: Kaplan-Meier survival curves demonstrated a relationship between all grades of TR. Multivariable analysis of the entire cohort demonstrated significantly increased mortality for moderate (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.1-1.4; P < .0001) and severe TR (HR, 2.02; 95% CI, 1.57-2.6; P < .0001). Mild TR displayed a trend for mortality (HR, 1.07; 95% CI, 0.99-1.16; P = .075). After matching for grade of TR and additional confounders, patients who underwent TV surgery had a statistically significant increased likelihood of survival (HR, 0.74; 95% CI, 0.61-0.91; P = .004). CONCLUSIONS: Our study of more than 20,000 patients demonstrates that grade of TR is associated with increased risk of mortality after cardiac surgery. In addition, all patients who underwent TV surgery had a statistically significantly increased likelihood of survival compared with those with the same degree of TR who did not undergo TV surgery.

Aortic Atheroma Increases the Risk of Long-Term Mortality in 20,000 Patients.

BACKGROUND: The association between long-term survival and aortic atheroma in cardiac surgical patients has not been comprehensively investigated. In this study we determine the relation between grade of atheroma and the risk of long-term mortality in a retrospective cohort of more than 20,000 patients undergoing cardiac operation during a 20-year period. METHODS: We included 22,304 consecutive intraoperative transesophageal and epiaortic ultrasound examinations performed at Brigham and Women's Hospital between 1995 and 2014, with long-term follow-up. The extent of atheromatous disease recorded in each examination was used for analysis. Mortality data were obtained from our institution's data registry. Mortality analyses were done using Cox proportional hazard regression models with follow-up as a time scale. We repeated the analysis in a subgroup of 14,728 patients with more detailed demographic characteristics, including postoperative stroke, queried from the institutional Society of Thoracic Surgeons database. RESULTS: A total of 7,722 mortality events and 872 stroke events occurred. Patients with atheromatous disease demonstrated a significant increase in mortality across all grades of severity, both for the ascending and descending aorta. This relation remained unchanged after adjusting for additional covariates. Adjustments for postoperative stroke resulted in only minimal attenuation in the risk of postoperative mortality related to aortic atheroma. CONCLUSIONS: Aortic atheromatous disease of any grade in the ascending and descending aorta is a significant long-term risk of long-term, all-cause mortality in cardiac operation patients. This association remains independent of other conventional risk factors and is not related to postoperative cerebrovascular accidents.

Adolescent perfectionism: Structural features of the Frost Multidimensional Perfectionism Scale and correlates with attachment and psychopathology.

OBJECTIVES: Perfectionism is recognized as a significant risk factor for psychopathology. Emerging research links attachment to perfectionism in adult and college-age samples. The Frost Multidimensional Perfectionism Scale (FMPS) has been used in adults and adolescents with a variety of factor structures found. This study sought to establish the factor structure in a general adolescent sample prior to testing for associations between perfectionism, attachment, and psychopathology in the same sample. DESIGN: A cross-sectional survey design was used. Confirmatory factor analysis, and correlational and regression analyses were employed. METHODS: A total of 290 adolescents, aged 12-18 years, were recruited from a state secondary school. All completed the FMPS along with brief measures of attachment and psychopathology. RESULT: Exploratory and confirmatory factor analyses failed to replicate previously published models, and a new six-item, 1-factor model representing perfectionism was found instead. This new variable was then used to establish a role for perfectionism and attachment anxiety in predicting internalizing problems. Perfectionism also correlated with conduct problems and hyperactivity. CONCLUSION: This study established a novel factor structure for the FMPS, allowing proof of principle of the role of perfectionism in a relationship with attachment and psychopathology, which after replication, may inform new interventions for perfectionism. Caution is noted about the use of extant perfectionism measures that are not properly developmentally informed and which do not capture the dynamic nature of adolescence and adolescent perfectionism. PRACTITIONER POINTS: Perfectionism is a feature of adolescent psychopathology, including internalizing and externalizing problems. Perfectionism is associated with attachment anxiety and together contributes to internalizing problems. Current conceptualizations of perfectionism may not capture the specific developmental and dynamic aspects of adolescence and should not be regarded as a stable personality trait.