Perioperative Evaluation and Management of Children with Osteoporosis and Low Bone Mineral Density.

As medical and surgical treatment options for children with osteoporosis expand, multidisciplinary strategies for bone health optimization become more important. Each patient's bone mineral density and fracture history should be interpreted in context. Off-label bisphosphonate use is a standard pharmacologic intervention for children with osteoporosis for optimal bone accrual. It is possible to continue this therapy perioperatively under certain circumstances. The rare side effects (osteonecrosis of the jaw and atypical femur fractures) seem less common in children. Physical therapy, vitamin D supplementation, and other interventions are also important tools for optimal bone health perioperatively and for satisfactory surgical outcomes.

Third-Generation Transcatheter Aortic Heart Valve with Reverse Parachute Sealing Cuff in Patients with Aortic Valve Disease.

BACKGROUND: The Navitor (Abbott Inc, IL, USA) transcatheter heart valve is a novel third-generation self-expanding bioprosthesis with specific features to mitigate paravalvular regurgitation (PVR). Owing to its novelty, there is a paucity of data on its application in clinical practice. METHODS: Consecutive cohort analysis of the use of the Navitor system in an as-treated clinical setting at a quaternary heart hospital. RESULTS: Sixty consecutive non-clinical trial patients treated with Navitor were identified. All patients underwent a successful procedure. The mean age was 79.3 years (±SD 7.82), 56.67% (n=34) were female, and the mean STS score was 4.87 (±SD 5.70). At 30 days post-procedure, all patients were alive with no readmissions for heart failure. One patient had a major vascular complication (1.7%). Four patients (7.14% of patients without a pre-existing pacemaker) received a new permanent pacemaker. Two patients (3.4%) had a non-disabling stroke. PVR at 30 days was trivial or none in 75% of patients, and no patient had worse than mild PVR. CONCLUSIONS: The Navitor system in this as-treated cohort was associated with favourable clinical, haemodynamic, and safety outcomes.

Del Nido cardioplegia in adult cardiac surgery: analysis of myocardial protection and post-operative high-sensitivity Troponin T.

BACKGROUND: del Nido cardioplegia has been adopted for use in adult cardiac surgery, despite a lack of robust randomised evidence supporting equivalence or superiority to conventional hyperkalaemic blood cardioplegia. We investigated the clinical surrogates of myocardial protection, and performed an extensive analysis of post-operative high-sensitivity Troponin T (hs-TnT) values in a general adult cardiac surgery population receiving del Nido, in comparison to a historical hyperkalaemic blood cohort. METHOD: 171 consecutive patients of a single surgeon from between November 2018 and June 2020 received del Nido, and were compared to a historical cohort of 326 patients between January 2016 and November 2018 who received hyperkalaemic blood cardioplegia. Clinical markers of myocardial protection were compared, as were hs-TnT values at 6, 12, 24, and 72-h post-operatively. Equivalence between groups was determined using the two one-sided tests procedure. RESULTS: There was no difference between the groups in the incidence of post-operative low cardiac output state, inotropic support, or myocardial infarction. Del Nido patients had less defibrillation requirement, and more spontaneous resumption of normal sinus rhythm. High-sensitivity Troponin T values were similar at all time-points including in a coronary artery bypass graft subgroup, and in those patients with elevated pre-operative hs-TnT. CONCLUSION: In a broad cohort of adult cardiac surgery patients, including those undergoing coronary artery bypass surgery and those with recent myocardial infarction, del Nido provides equivalent myocardial protection and clinical outcomes when compared to hyperkalemic blood cardioplegia. Post-operative high-sensitivity Troponin T values were also equivalent between the groups.

Postoperative Pain in Thoracic Surgical Patients: An Analysis of Factors Associated With Acute and Chronic Pain.

BACKGROUND: Thoracic surgery is associated with high levels of acute and chronic pain, which is associated with significant morbidity, reduced quality of life, and increased health care expenditure. This study aims to identify patient-care factors associated with higher levels of acute and chronic pain after thoracic surgery. METHODS: The acute pain component of this study retrospectively analysed 53 patients, surgical, anaesthetic, and postoperative factors against an average measure of acute pain during a patient's hospital admission, for 134 individual acute admission episodes. The chronic pain component analysed 58 care factors against a binary chronic pain outcome based on the Neuropathic Pain Scale and the Brief Pain Inventory, for 72 patients, at an average of 7 months postoperatively. RESULTS: Younger age, chronic opioid use, use of talc, and multi-port video-assisted thoracoscopic surgery (VATS) compared to uniport VATS, were all associated with higher levels of acute postoperative pain. Seven (7) months postoperatively, the rate of chronic sensation change or numbness was 31%. The rate of troublesome chronic pain was 8%. History of a mental health condition, chronic opioid use, urgent operation, and the use of tramadol postoperatively were independently associated with a higher risk of chronic pain. CONCLUSIONS: This study identifies several factors associated with higher rates of acute and chronic postoperative pain, and defines the rate of chronic pain in a large tertiary thoracic surgery centre. Consideration should be given to modifying those surgical practices which were identified as being associated with higher levels of pain, including multi-port VATS, and the use of talc. It is important that non-modifiable risk factors for pain, including history of mental health condition, opioid use, age, and urgency of operation, are taken into consideration when informing a patient of the risk of pain postoperatively.

Surgical management of mitral valve infective endocarditis with annular abscess and calcification in the setting of a leaking mycotic infrarenal abdominal aortic aneurysm: a case report.

We present the case of a previously well seventy-four year old male caucasian grazier who presented with mild back pain and was subsequently found to have a large posterior mitral valve leaflet perivalvular abscess associated with mitral annulus calcification and a mycotic infrarenal abdominal aortic aneurysm (AAA) of Staphylococcal origin. He underwent a right axillofemoral bypass with oversewn aorta and a right to left femoral crossover graft, and a subsequent mitral valve repair with decalcification/debridement of the annulus and extensive posterior leaflet reconstruction with pericardium patch. Despite multiple sequelae and an extended intensive care and hospital stay, the patient was discharged home after six months.

Late Cardiotoxicity in Aging Adult Survivors of Childhood Cancer.

The survival rate for childhood cancer is steadily improving, and the current estimate for the prevalence of childhood cancer survivors in the United States is 420,000. With this encouraging trend and the aging of this population, there is an ever-increasing responsibility to identify adult survivors of childhood cancer with adverse health outcomes related to cancer treatment across the span of their lives. To accomplish this, large cohort studies have been developed to follow survivors longitudinally. Compared to siblings, survivors have a higher cumulative incidence of morbidity and mortality, and this gap in incidence only widens with age. One of the most significant late toxicities in survivors is late onset cardiotoxicity, largely due to anthracycline and chest-directed radiation exposure. Survivors also have an increased prevalence of traditional cardiovascular risk factors as they age, which potentiates the risk for major cardiac events. Prevention is essential. Minimizing anthracycline dose exposure in pediatric cancer patients is a primary method of cardioprotection. Dexrazoxane and enalapril have also been studied as primary (pre-exposure) and secondary (post-exposure) cardioprotecant agents, respectively. Additionally, the Children's Oncology Group has published exposure-driven, risk-based screening guidelines for long-term follow-up, which may be a cost-effective way to identify subclinical cardiac disease before progression to clinical presentation. Ongoing research is needed to determine the most effective diagnostic modality for screening (e.g. echocardiography), and the most effective intervention strategies to improve long-term outcomes.