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Perfusion Jun 2024It is common for patients on venovenous extracorporeal membrane oxygenation (VV ECMO) to require continuous renal replacement therapy (CRRT). This can be done using...
BACKGROUND
It is common for patients on venovenous extracorporeal membrane oxygenation (VV ECMO) to require continuous renal replacement therapy (CRRT). This can be done using separate vascular access for the CRRT circuit, by placing the CRRT hemofilter within the ECMO circuit, or through a separate CRRT circuit connected to the ECMO circuit. When a CRRT circuit is connected to the ECMO circuit, the inflow and outflow CRRT limbs can both be placed pre-ECMO pump or the CRRT circuit can span the ECMO pump, with the CRRT inflow post-ECMO pump and the outflow pre-ECMO pump. Both configurations require the CRRT alarms to be inactivated due to high positive pressure experienced post-pump and low negative pressure pre-pump. We describe a novel technique that does not require separate venous access and still allows the CRRT alarms to be activated.
TECHNIQUE
The CRRT inflow line is connected to the post-oxygenator de-airing port. The CRRT outflow line is connected to the pre-pump side of the ECMO circuit. Pigtails allow for these connections and act as resistors negating the large range of pressures generated by the ECMO centrifugal pump.
RESULTS
We implemented this configuration in 11 patients with 100% success rate allowing for alarms to be maintained in all patients. The median number of interruptions per 100 CRRT days was 11.7. The median CRRT filter lifespan was 2.2 days, and the average blood flow was maintained at 311 mL/min.
CONCLUSIONS
This configuration allows for efficient use of CRRT in ECMO patients while maintaining the safety alarms on the CRRT machine.
PubMed: 38896838
DOI: 10.1177/02676591241263268 -
Nature Reviews. Nephrology Jun 2024Pulmonary hypertension (PH) is common in patients with chronic kidney disease (CKD) or kidney failure, with an estimated prevalence of up to 78% in those referred for... (Review)
Review
Pulmonary hypertension (PH) is common in patients with chronic kidney disease (CKD) or kidney failure, with an estimated prevalence of up to 78% in those referred for right-heart catheterization. PH is independently associated with adverse outcomes in CKD, raising the possibility that early detection and appropriate management of PH might improve outcomes in at-risk patients. Among patients with PH, the prevalence of CKD stages 3 and 4 is estimated to be as high as 36%, and CKD is also independently associated with adverse outcomes. However, the complex, heterogenous pathophysiology and clinical profile of CKD-PH requires further characterization. CKD is often associated with elevated left ventricular filling pressure and volume overload, which presumably leads to pulmonary vascular stiffening and post-capillary PH. By contrast, a distinct subgroup of patients at high risk is characterized by elevated pulmonary vascular resistance and right ventricular dysfunction in the absence of pulmonary venous hypertension, which may represent a right-sided cardiorenal syndrome defined in principle by hypervolaemia, salt avidity, low cardiac output and normal left ventricular function. Current understanding of CKD-PH is limited, despite its potentially important ramifications for clinical decision making. In particular, whether PH should be considered when determining the suitability and timing of kidney replacement therapy or kidney transplantation is unclear. More research is urgently needed to address these knowledge gaps and improve the outcomes of patients with or at risk of CKD-PH.
PubMed: 38890546
DOI: 10.1038/s41581-024-00857-7 -
Acta Neurochirurgica Jun 2024Invasion of the CS is one of the limiting factors for total resection for PitNet tumors with cure rates less than 30%. Extended approaches may be considered in selective...
BACKGROUND
Invasion of the CS is one of the limiting factors for total resection for PitNet tumors with cure rates less than 30%. Extended approaches may be considered in selective and well-studied cases of secreting adenomas.
METHOD
We describe the key steps of the endoscopic transcavernous approach for functional pituitary adenomas with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach.
CONCLUSION
A detailed knowledge of CS anatomy and familiarity with this surgical approach acquired in the laboratory is essential. Proper instrumentation is critical to decrease the risks of vascular injury.
Topics: Humans; Pituitary Neoplasms; Adenoma; Neuroendoscopy; Cavernous Sinus; Endoscopy; Neurosurgical Procedures
PubMed: 38890156
DOI: 10.1007/s00701-024-06168-x -
Journal of Cardiothoracic and Vascular... Apr 2024
PubMed: 38890080
DOI: 10.1053/j.jvca.2024.04.016 -
Phlebology Jun 2024This study compares Endovenous Laser Ablation (EVLA) alone versus combined with ultrasound-guided foam sclerotherapy (UGFS) for Great Saphenous Vein (GSV)...
This study compares Endovenous Laser Ablation (EVLA) alone versus combined with ultrasound-guided foam sclerotherapy (UGFS) for Great Saphenous Vein (GSV) insufficiency. Sixty patients were randomly allocated to EVLA or EVLA-UGFS groups which focused on GSV occlusion rates, complications, additional treatments, and quality of life (QoL) changes. Among 55 participants, the EVLA group had higher 12-month occlusion rates (92.3% vs. 75.8%, = 0.11). Nervous injury (NI) was rarer in EVLA-UGFS (3.4% vs. 23.1%, = 0.04). No significant difference in other complication rates ( > 0.05). QoL improved in both groups ( < 0.001). EVLA-UGFS required more subsequent procedures (24.1% vs. 7.7%, = 0.03). EVLA and EVLA-UGFS effectively treat GSV insufficiency, enhancing QoL. The combined method reduces NI risk but may require more follow-up procedures.
PubMed: 38889758
DOI: 10.1177/02683555241263224 -
Journal of Reconstructive Microsurgery Jun 2024Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the...
BACKGROUND
Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage.
METHODS
A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed.
RESULTS
From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique.
CONCLUSION
Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.
PubMed: 38889744
DOI: 10.1055/s-0044-1787776 -
Critical Reviews in Biomedical... 2024Chronic wounds can be classified as diabetic foot ulcers, pressure ulcers, or venous leg ulcers. Chronic wound management has become a threat to clinicians and... (Review)
Review
Chronic wounds can be classified as diabetic foot ulcers, pressure ulcers, or venous leg ulcers. Chronic wound management has become a threat to clinicians and constitutes a major healthcare burden. The healing process of chronic wounds requires many factors to work in concert to achieve optimal healing. Various treatment options, ranging from hypoxia to infection, have evolved considerably to address the challenges associated with chronic wound healing. The conventional and accelerating treatments for chronic wounds still represent an unmet medical need due to the complex pathophysiology of the chronic wound microenvironment. In clinical settings, traditional chronic wound care practices rely on nonspecific topical treatment, which can reduce pain and alleviate disease progression with varying levels of success but fail to completely cure the wounds. Conventional wound dressings, such as hydrocolloids, gauze, foams, and films, have also shown limited success for the treatment of chronic wounds and only act as a physical barrier and absorb wound exudates. Emerging advances in treatment approaches, including novel therapies (stem cells, microRNAs, and nanocarrier-based delivery systems) and multifunctional biological dressings, have been reported for chronic wound repair. This review summarizes the challenges offered by chronic wounds and discusses recent advancements in chronic wound treatment.
Topics: Humans; Wound Healing; Biological Dressings; Chronic Disease; Animals; Bandages; Diabetic Foot; Wounds and Injuries
PubMed: 38884212
DOI: 10.1615/CritRevBiomedEng.2024053066 -
IScience Jun 2024Endothelial cell (EC) damage or dysfunction serves as the initial event in the pathogenesis of various cardiovascular diseases. Progenitor cells have been postulated to...
Endothelial cell (EC) damage or dysfunction serves as the initial event in the pathogenesis of various cardiovascular diseases. Progenitor cells have been postulated to be able to differentiate into ECs, facilitate endothelial regeneration, and alleviate vascular pathological remodeling. However, the precise cellular origins and underlying mechanisms remain elusive. Through single-cell RNA sequencing (scRNA-seq), we identified an increasing population of progenitors expressing stem cell antigen 1 (Sca1) during vascular remodeling in mice. Using both mouse femoral artery injury and vein graft models, we determined that Sca1 cells differentiate into ECs, restored endothelium in arterial and venous remodeling processes. Notably, we have observed that the differentiation of Sca1 cells into ECs is negatively regulated by the microRNA-145-5p (miR-145-5p)-Erythroblast transformation-specific-related gene (ERG) pathway. Inhibiting miR-145-5p promoted Sca1 cell differentiation and reduced neointimal formation after vascular injury. Finally, a similar downregulation of miR-145-5p in human arteriovenous fistula was observed comparing to healthy veins.
PubMed: 38883819
DOI: 10.1016/j.isci.2024.110080 -
Cureus May 2024Direct oral anticoagulants have simplified the use of anticoagulation for patients and clinicians. These medications now have indications for non-valvular atrial...
Direct oral anticoagulants have simplified the use of anticoagulation for patients and clinicians. These medications now have indications for non-valvular atrial fibrillation and venous thromboembolism and carry a lower risk of bleeding than warfarin. While bleeding complications are common amongst all anticoagulants, spontaneous hemopericardium is a rarely reported side effect of direct oral anticoagulants, previously reported in patients with concomitant malignancy or kidney injury. We present a case of a patient with recently diagnosed renal malignancy and atrial fibrillation on apixaban who developed a spontaneous hemopericardium that required a pericardial window.
PubMed: 38882983
DOI: 10.7759/cureus.60410 -
Injury May 2024Venous thromboembolism following orthopedic trauma surgery remains prevalent despite prophylaxis being a standard of care. Enoxaparin injection is a commonly utilized...
INTRODUCTION
Venous thromboembolism following orthopedic trauma surgery remains prevalent despite prophylaxis being a standard of care. Enoxaparin injection is a commonly utilized prophylaxis regimen among high-risk patients. Patient-reported rates of nonadherence and barriers to enoxaparin use are not described in the literature. A better understanding of these barriers and their impact on adherence to post-discharge prophylaxis regimens may shed light on persistent outcomes gaps.
MATERIALS AND METHODS
Semi-structured interviews were administered to adult patients prescribed prophylactic enoxaparin and presenting to orthopedic surgery outpatient clinic at an urban level 1 trauma center for a post-operative appointment following traumatic injury from April to July 2023. Patients self-reported their age, gender, race, and mobility. Inductive thematic analysis with three-reviewer consensus identified common barriers among responses. Adherence rates were calculated by dividing patients' estimated number of missed doses over total prescribed doses at the point of inquiry.
RESULTS
We identified 154 eligible patients through chart review, and 50 enrolled and interviewed. Participants had a mean age of 37 years. Of 50 participants, 20 identified as female; 25 identified as Black or African American, 16 as White, 5 as Hispanic, 2 as Asian, and 2 as multiracial. Twenty-one participants were non-ambulatory at time of interview. Mean and median patient-reported adherence were 64.5 % (SD 35.5) and 70.5 % (IQR 33-100) respectively. Five patients reported complete nonadherence, while 17 patients reported perfect adherence. Every participant reporting complete nonadherence identified as Black or African American, as compared to 8 out of 17 reporting perfect adherence. Despite acknowledging a twice-daily prescription, 17 patients reported once-daily rather than twice-daily use. Inductive thematic analysis revealed the following six barriers to prophylaxis adherence (number of participants reporting): Inconvenience (18 patients), Pain (16), Fear (12), Acquisition (7), Bruising (7), and Mechanism (7). Altogether, 40 patients endorsed at least one barrier to adherence.
DISCUSSION & CONCLUSIONS
Most patients face barriers to adherence with post-discharge prophylactic enoxaparin, and the resultant rates of adherence are low. This may contribute to persistent outcomes gaps in the orthopedic trauma population despite prophylaxis standards. Changes in prescribing patterns and patient engagement techniques may improve post-operative thromboembolic outcomes.
PubMed: 38878384
DOI: 10.1016/j.injury.2024.111650