Comparison of Local Injection of Fresh Frozen Plasma to Traditional Methods of Hemostasis in Minimally Invasive Procedures.

RATIONALE AND OBJECTIVES: To evaluate different techniques for reducing hemorrhagic complications in coagulopathic patients with elevated international normalized ratio having an image-guided percutaneous invasive procedure; techniques included systemic transfusion of fresh frozen plasma (FFP), local injection of FFP, percutaneous injection of gelatin sponge, and percutaneous placements of angiographic coils. MATERIALS AND METHODS: Retrospective review of 232 consecutive patients with known coagulopathy undergoing image-guided minimally invasive procedures were selected. Ninety-one patients had local FFP injected, 40 patients underwent local synthetic gelatin injection, 16 patients had percutaneous coil embolization, and 85 patients received systemic FFP. The number of bleeds, complications related to bleeds, and systemic complications were recorded. A 30 cc threshold was used to delineate significant bleeding. RESULTS: No patients experienced clinically significant or insignificant bleeding with local FFP injection (P value <.05). Other local hemostatic methods (Gelfoam, systemic FFP, and coil embolization) were associated with higher levels of bleeding (12.5%, 17.1%, 37.5%, respectively) and complications (7.5%, 31.4%, 37.5%, respectively). Systemic FFP infusion was associated with respiratory, infectious, and mortal complications. CONCLUSIONS: Local injection of blood products provides a safe and efficacious hemostatic agent to reduce the incidence of postprocedural bleeding. The technique is associated with lower rates of bleeding and systemic complications when compared to other local and systemic techniques. Further randomized prospective studies with a larger patient cohort need to be performed to corroborate these initial findings.

Does Sleeve Shape Make a Difference in Outcomes?

INTRODUCTION: Sleeve gastrectomy (SG) is one of the most common procedures performed for weight loss. Many seek the "perfect sleeve" with the notion that the type of calibrating device affects sleeve shape, and this in turn will affect outcomes and complications. Two major concerns after SG are amount of weight loss and acid reflux. Our aim was to determine if the various calibration methods could impact sleeve shape and thereby allow for better outcomes of weight loss and reflux. METHODS: A retrospective chart review was performed of 210 patients who underwent SG and had postoperative upper gastrointestinal (UGI) study from 2011 to 2015 in a single center by a single (fellowship-trained) bariatric surgeon. Data regarding demographics, calibrating devices and clinical outcomes at 1 year (weight loss and de novo acid reflux) were collected. UGIs were reviewed by two radiologists blinded to the clinical outcomes. Sleeve shape was classified according to a previously described classification as tubular, dumbbell, upper pouch, or lower pouch. The types of calibrating devices used to guide the sleeve size intraoperatively were endoscopy, large-bore orogastric tube, and fenestrated suction tube. RESULTS: One hundred ninety-nine patients met inclusion criteria (11 had no esophagram). Demographics revealed age 45.76 ± 10.6 years, BMI 47 ± 8.6 kg/m2, and 82% female. Calibration devices used were endoscopic guidance (7.6%), large bore orogastric tube (41.4%), and fenestrated suction tube (50.5%). Sleeve shape was reported as 32.6% tubular, 20.6% dumbbell, 39.2% lower pouch, and 7.5% upper pouch (100% interrater reliability). No correlation was seen with type of calibration used. Of patients, 62.0% had > 50% excess weight loss at 1 year. Twenty-three percent of patients remained on PPI at 1 year (of which 43.3% did not have reflux preoperatively). The lower pouch shape showed a trend toward less reflux and more weight loss. CONCLUSION: This study showed no clear association between uniformity of sleeve shape and the type of calibration device used. The study showed a trend toward decreased reflux and improved weight loss with the lower pouch shape, regardless of calibration device.

Direct Injection of Blood Products Versus Gelatin Sponge as a Technique for Local Hemostasis.

PURPOSE: To provide a method of reducing risk of minimally invasive procedures on patients with abnormal hemostasis and evaluate efficacy of direct fresh frozen plasma injection through a procedure needle tract compared to Gelfoam (gelatin sponge) administration. MATERIALS AND METHODS: Eighty patients with elevated international standardized ratio (INR) undergoing minimally invasive procedures using imaging guidance were selected retrospectively. Forty patients had received Gelfoam as a means of tract embolization during the procedure. The other 40 received local fresh frozen plasma (FFP) through the needle tract. The number of complications and clinically significant bleeding events were recorded. A threshold of 30 cc of blood loss after a procedure was used to identify excess bleeding. RESULTS: No patients experienced clinically significant bleeding after administration of FFP. Five patients experienced postoperative drops in hemoglobin or hematomas after administration of Gelfoam. CONCLUSION: Local injection of blood products can reduce postprocedure bleeding in patients undergoing minimally invasive procedures and provides a safe alternative to the use of synthetic fibrin plugs.

Moving Away From Spoon-Feeding as a Teaching Style in Radiology.

OBJECTIVE: Medical education has been an important topic in the literature, with many new attempts to revitalize and improve efforts to teach physicians and students. As a unique subspecialty that incorporates visual learning, knowledge of clinical management and presentation, basic science topics such as physics and mechanics, and procedural skills, radiology affords itself to new and more effective methods of teaching. CONCLUSION: Much of radiology education has currently focused on the concept of spoon-feeding information from the teacher to the learners. This article outlines the dangers of this approach in radiology and offers solutions for educators to improve their teaching skills and use the potential afforded by the diversity of the field.

Time trends in gastroparesis treatment.

INTRODUCTION: While delayed emptying is the defining criterion for gastroparesis, prokinetics often only have a limited impact on symptoms and have been associated with potentially serious adverse effects. The goal of this study was to determine how this information and regulatory changes affected gastroparesis management. METHODS: The electronic medical records of patients seen between 2003 and 2012 in the outpatient clinic of a large tertiary center were retrieved based on the billing diagnosis of gastroparesis. Demographic, clinical, and survival data were abstracted. RESULTS: A total of 709 patients were identified, with diabetes (21.2 %) and prior surgery (9.8 %) being the most common identifiable causes. The majority of patients (56 %) had idiopathic gastroparesis. The cohort was female predominant (79.5 %) with an average age of 45.4 ± 0.6 years. At the index encounter, 61.8 % received prokinetics. About one-third (37.7 %) used antiemetics at least intermittently. Between 2003 and 2012, prokinetic use dropped from 81 to 43 %, while the use of antiemetics increased from 14 to 41 %. Similarly, there was a significant increase in prescribed opioids and antidepressants. During the period of the study, 44 patients (6.2 %) died. Increasing age, a higher comorbidity burden, anxiety, and medication use were associated with higher mortality risks. CONCLUSION: This large outpatient cohort suggests that treatment trends move away from prokinetics and focus on symptom-oriented therapy and/or confounding mood disorders.

Long-term outcome of defibrillator recipients included in the federal audit conducted by the Department of Justice.

Institutions across the United States have been subjected to a federal audit for defibrillator implantable cardioverter defibrillator [ICD] implantations that violated the Centers for Medicare and Medicaid payment policy. We examined the long-term outcome of ICD recipients whose implantation procedures were audited by the Department of Justice (DOJ). Patients (n = 225) included in the DOJ audit at the University of Pittsburgh Medical Center between the years 2003 and 2010 were followed to the end point of all-cause mortality. A cohort of 206 consecutive and contemporary ICD recipients not included in the federal audit served as controls. Compared with the controls, the audited cases were older (p <0.001), had more preserved ejection fraction (p <0.001), and were less likely to be implanted for a primary prevention indication (p = 0.001). They also had significantly shorter time from myocardial infarction (p <0.001) or revascularization (p <0.001) to ICD implantation. Over a median follow-up of 3.6 years, 187 patients died and 71 received ICD therapy for ventricular arrhythmias. Patients whose cases were audited had worse survival compared with controls (hazard ratio 1.41, 95% confidence interval 1.05 to 1.90, p = 0.023) even after correcting for differences in baseline characteristics (hazard ratio 1.46, 95% confidence interval 1.05 to 2.02, p = 0.023). Rates of appropriate and inappropriate ICD therapies were similar between the audited cases and controls. In conclusion, patients whose ICD implantations were audited by the DOJ have worse long-term survival compared with nonaudited control patients. These data support compliance with the Centers for Medicare and Medicaid guidelines when the individual patient's clinical condition allows it.

Heart failure readmissions.

OPINION STATEMENT: Heart failure readmissions (HFR) represent a personal burden for patients and a large financial burden for the healthcare system. As such, strategies to decrease HFR are avidly sought and studied. There are many reasons for HFR that challenge programs aimed to reduce the frequency of HFR. Large pharmacological and device trials often incorporate hospital admission as an endpoint, and many programs have been developed in varied settings to address HFR. Some of the most successful programs use a multidisciplinary team approach, intensive patient education and system commitment. Many risk factors for HFR have been identified although prediction tools are limited. The reduction of HFR should incorporate a multidisciplinary approach with 1) evidenced-based physician-guided medical and device therapy; 2) institutional programs for effective care transitions; 3) strategies aimed to improve disease management; and 4) engage patients in self-care.