Disparities in Acute Coronary Syndrome Outcomes in Individuals With Intellectual Disabilities: A Propensity-Matched Analysis of National Inpatient Sample

BACKGROUND

Individuals with intellectual disabilities (IDs) are at similar risk of acute coronary syndrome (ACS) as compared to general population. However, there is a paucity of real-world data evaluating outcomes of ACS in this population. We sought to study ACS outcomes in individuals with IDs using a large national database.

METHODS

Adult admissions with a primary diagnosis of ACS were identified from the national inpatient sample of years 2016-2019. Cohort was stratified according to presence of IDs. A 1 to 1 nearest neighbor propensity score matching using 16 patient variables. Outcomes evaluated were in-hospital mortality, coronary angiography (CA), timing of CA (early [day 0] vs. late [>day0]), and revascularization.

RESULTS

A total of 5110 admissions (2555 in each group) were included in our matched cohort. IDs admissions had higher rates of in-hospital mortality (9 % vs. 4 %, aOR: 2.84, 95 % CI [1.66-4.86], P < 0.001), and were less likely to receive CA (52 % vs. 71 %, aOR: 0.44, 95 % CI [0.34-0.58], P < 0.001) and revascularization (33 % vs. 52 %, aOR: 0.45, 95 % CI [0.35-0.58], P < 0.001). In-Hospital mortality was higher in the ID admissions whether invasive coronary treatment (CA or revascularization) was performed (6 % vs. 3 %, aOR: 2.34, 95 % CI [1.09-5.06], P = 0.03) or not (13 % vs. 5 %, aOR: 2.56, 95 % CI [1.14-5.78], P = 0.023).

CONCLUSION

Significant disparities exist in ACS outcomes and management in individuals with IDs. More research is needed to understand the reasons for these disparities and develop interventions to improve quality of care in this population.

AngioVac for Vegetation Debulking in Right-sided Infective Endocarditis: A Systematic Review and Meta-Analysis

OBJECTIVES

To investigate the utility of AngioVac-assisted vegetation debulking (AVD) in right sided infective endocarditis (RSIE) BACKGROUND: : AngioVac is a vacuum-based device that was approved in 2014 for the percutaneous removal of undesirable materials from the intravascular system. Although there are multiple reports on the use of the AngioVac device to aspirate right-sided heart chamber thrombi, data on its use to treat RSIE is limited.

METHODS

We performed a comprehensive literature search for studies that evaluated the utility of AVD. The primary outcomes of our study were the procedural success, defined as the ability of AngioVac to produce residual vegetation size <50% (RVS<50%) without serious procedural complications, and the clinical success, defined as composite of RVS<50%, in-hospital survival, absence of recurrent bacteremia, and valve function not requiring further intervention. The secondary outcomes included the individual components of the primary outcomes and average length of hospital stay. The pooled means and proportions of our data were analyzed using random effects model, generic inverse variance method, and represented with 95% confidence intervals (CIs).

RESULTS

A total of 44 studies, including 301 patients (mean age: 44.6±18.2 years, 71.6% males) were included. Procedural success was achieved in 89.2% of patients (95% CI:82.3%-93.6%, I²=0%). Clinical success was achieved in 79.1% of patients (95%CI:67.9%-87.2%, I²=15%). Overall survival rate was 89.7% (95% CI:83.1%-93.9%%, I²=9%).

CONCLUSIONS

Our meta-analysis demonstrates that AVD is a promising therapeutic option for RSIE offering a high success rate with an acceptable complication rate across a wide range of patients.

Demographic and Regional Trends of Mortality in Patients With Acute Myocardial Infarction in the United States, 1999 to 2019

Acute myocardial infarction (AMI)-related mortality has been decreasing within the United States because of improvements in management and preventive efforts; however, persistent disparities in demographic subsets such as race may exist. In this study, the nationwide trends in mortality related to AMI in adults in the United States from 1999 to 2019 are described. Trends in mortality related to AMI were assessed through a cross-sectional analysis of the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Age-adjusted mortality rates per 100,000 people and associated annual percentage change and average annual percentage changes with 95% confidence intervals (CIs) were determined. Joinpoint regression was used to assess the trends in the overall, demographic (gender, race/ethnicity, age), and regional groups. Between 1999 and 2019, a total of 3,655,274 deaths related to AMI occurred. In the overall population, age-adjusted mortality rates decreased from 134.7 (95% CI 134.2 to 135.3) in 1999 to 48.5 (95% CI 48.3 to 48.8) in 2019 with an average annual percentage change of -5.0 (95% CI -5.5 to -4.6). Higher mortality rates were seen in Black individuals, men, and those living in the South. Patients older than 85 years experienced substantial decreases in mortality. In addition, rural counties had persistently higher mortality rates in comparison with urban counties. In conclusion, despite decreasing mortality rates in all groups, persistent disparities continued to exist throughout the study period.

Adjunctive Vein of Marshall Ethanol Infusion During Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis

Introduction

Catheter ablation (CA) for atrial fibrillation (AF) can be associated with limited efficacy. Due to its autonomic innervation, the vein of Marshall (VOM) is an attractive target during AF ablation. In this meta-analysis, we aimed to evaluate the efficacy and safety of adjunctive ethanol infusion of VOM (VOM-EI) in AF ablation.

Methods

We performed a comprehensive literature search for studies that evaluated the efficacy and safety of VOM-EI in AF ablation compared to AF catheter ablation alone. The primary outcome of interest was late (≥3 months) AF or atrial tachycardia (AT) recurrence. The secondary outcomes included acute mitral isthmus bidirectional block (MIBB) and procedural complications (pericardial effusion, stroke, or atrio-esophageal fistula). Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model.

Results

A total of four studies, including 804 AF patients (68.2% with persistent AF, the mean age of 63.5±9.9 years, 401 patients underwent VOM-EI plus CA vs. 403 patients who had CA alone), were included in the final analysis. VOM-EI group was associated with a lower risk of late AF/AT recurrence (RR:0.63; 95% CI:0.46-0.87; P = 0.005), and increased probability to achieve acute MIBB (RR:1.39; 95% CI:1.08-1.79; P = 0.009) without an increase in procedural complications (RR:1.05; 95% CI:0.57-1.94; P = 0.87).

Conclusions

Our meta-analysis demonstrated that adjunctive VOM-EI strategy is more effective than conventional catheter ablation with similar safety profiles.

Outcomes of distal versus conventional transradial access for coronary angiography and intervention: An updated systematic review and meta-analysis

INTRODUCTION

Distal transradial artery access (DTRA) has recently gained attention due to potential benefits in terms of local complications. In this meta-analysis, we aimed to evaluate the utility of DTRA compared to conventional transradial artery access (CTRA) for coronary angiography and intervention.

METHOD

Multiple databases were searched from inception through May 2021 for all the studies that evaluated the efficacy and safety of DTRA in the coronary field. The primary outcome was the access success rate. The secondary outcomes were periprocedural local complications (site hematoma, radial artery occlusion, and spasm) and procedural characteristics (cannulation, fluoroscopy, procedure, and radial artery compression times). All meta-analyses were conducted using a random-effect model.

RESULTS

A total of 12 studies (including four randomized control trials) with 1634 patients who underwent DTRA vs. 1657 with CTRA were included in the final analysis. The access success rate was similar between the two groups (odds ratio (OR):0.62; 95% confidence interval (CI):0.30-1.26; P = 0.18; I² = 61%). DTRA was associated with a statistically significant lower rate of radial artery occlusion (OR:0.36; 95% CI: 0.22-0.59; P < 0.001; I² = 0%) but similar rates of radial artery spasm and site hematoma when compared to CTRA. Regarding the procedural characteristics, despite having a longer canulation time (mean difference (min.) [MD] 0.89, 95% CI 0.36-1.42; P < 0.0001), DTRA was associated with shorter compression time and comparable fluoroscopy and procedure times.

CONCLUSIONS

Our meta-analysis demonstrates that the DTRA is effective and safe with superiority in preventing radial artery occlusion when compared to CTRA.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

Background

Sex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (MI). However, type 2 MI is common in contemporary practice with scarce data regarding sex-based differences of clinical outcomes and resource utilization.

Purpose

To examine the association of sex category with clinical outcomes and resource utilization in hospitalizations with type 2 MI.

Methods

The Nationwide Readmission Database 2018 was queried for hospitalizations within the United States with type 2 MI using The International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code I21.A1. Comorbidities and outcomes were identified using the corresponding ICD-10 codes. Complex samples multivariable logistic and linear regression models were used to determine the association between type 2 MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with type 2 MI.

Results

A total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with type 2 MI were more likely to be older (72.8 years vs. 69.7 years; P&lt;0.001), admitted on the weekend (26.5% vs. 25.9%; P=0.02), and have a higher prevalence of chronic pulmonary disease (35.6% vs. 32.0%; P&lt;0.001), obesity (17.9% vs. 15.7%; P&lt;0.001), neurological disorders (22.9% vs. 22.3%; P=0.02), deficiency anemias (7.5% vs. 6.6%; P&lt;0.001), and hypothyroidism (22.1% vs. 10.1%; P&lt;0.001) compared to males with type 2 MI. Female with type 2 MI was associated with lower in-hospital mortality, shorter LOS, less hospital costs, and increased nursing home discharge compared to males with type 2 MI. Females and males with type 2 MI had similar rates of 30-day all-cause readmission [Table 1].

Conclusion

Among type 2 MI hospitalizations, females have lower in-hospital mortality, less hospitalization cost, shorter LOS, but increased rates of nursing home discharge compared to males. Thirty-day all-cause readmission was similar between males and females with type 2 MI.

Funding Acknowledgement

Type of funding sources: None.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

BACKGROUND

Sex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (T1MI). However, type 2 myocardial infarction (T2MI) is more common in contemporary practice, with scarce data regarding sex-based differences of outcomes.

METHODS

The Nationwide Readmission Database 2018 was queried for hospitalizations with T2MI as a primary or secondary diagnosis. Complex samples multivariable logistic and linear regression models were used to determine the association between T2MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with T2MI.

RESULTS

A total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with T2MI was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.88-0.96; P < 0.001), shorter LOS (adjusted parameter estimate [aPE] -0.28; 95% CI -0.38-0.17; P < 0.001), less hospital costs (aPE -1510.70; 95% CI -1916.04-1105.37; P < 0.001), and increased nursing home discharges (aOR 1.08; 95% CI 1.05-1.12; P < 0.001) compared to males with T2MI. Females and males with T2MI had similar rates of 30-day all-cause readmission (aOR 1.00; 95% CI 0.97-1.04; P = 0.841).

CONCLUSION

Among T2MI hospitalizations, females have lower in-hospital mortality, hospitalization costs, shorter LOS, and increased rates of nursing home discharge compared to males. Although statistically significant, the clinical significance of these small differences are unknown and require future studies.

Lung ultrasound-guided management to reduce hospitalization in chronic heart failure: a systematic review and meta-analysis

Pulmonary edema is a leading cause of hospital admissions, morbidity, and mortality in heart failure (HF) patients. A point-of-care lung ultrasound (LUS) is a useful tool to detect subclinical pulmonary edema. We performed a comprehensive literature search of multiple databases for studies that evaluated the clinical utility of LUS-guided management versus standard care for HF patients in the outpatient setting. The primary outcome of interest was HF hospitalization. The secondary outcomes were all-cause mortality, urgent visits for HF worsening, acute kidney injury (AKI), and hypokalemia rates. Pooled risk ratio (RR) and corresponding 95% confidence intervals (CIs) were calculated and combined using random-effect model meta-analysis. A total of 3 randomized controlled trials including 493 HF patients managed in the outpatient setting (251 managed with LUS plus physical examination (PE)-guided therapy vs. 242 managed with PE-guided therapy alone) were included in the final analysis. The mean follow-up period was 5 months. There was no significant difference in HF hospitalization rate between the two groups (RR 0.65; 95% CI 0.34-1.22; P = 0.18). Similarly, there was no significant difference in all-cause mortality (RR 1.39; 95% CI 0.68-2.82; P = 0.37), AKI (RR 1.27; 95% CI 0.60-2.69; P = 0.52), and hypokalemia (RR 0.72; 95% CI 0.21-2.44; P = 0.59). However, LUS-guided therapy was associated with a lower rate for urgent care visits (RR 0.32; 95% CI 0.18-0.59; P = 0.0002). Our study demonstrated that outpatient LUS-guided diuretic therapy of pulmonary congestion reduces urgent visits for worsening symptoms of HF. Further studies are needed to evaluate LUS utility in the outpatient treatment of HF.

A meta-analysis of efficacy and safety of genotype-guided versus standard of care treatment strategies in selecting antiplatelet therapy in patients with acute coronary syndrome

BACKGROUND

Previous studies have shown similar rates of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS) patients, treated with P2Y₁₂ inhibitors based on genotype guidance compared to standard treatment. However, given lower than expected event rates, these studies were underpowered to assess hard outcomes. We sought to systematically analyze this evidence using pooled data from multiple studies.

METHODS

Electronic databases were searched for studies of ACS patients that underwent genotype-guided treatment (GGT) with P2Y₁₂ inhibitors versus standard of care treatment (SCT). Studies with a minimum follow-up of 12 months were included. Rate of MACE (defined as a composite of cardiovascular [CV] mortality, nonfatal myocardial infarction [MI], and nonfatal stroke) was the primary outcome. Secondary outcomes were individual components of MI, CV mortality, ischemic stroke, stent thrombosis, and major bleeding. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated and combined using random effects model meta-analysis.

RESULTS

A total of 4,095 patients (2007 in the GGT and 2088 in the SCT group were analyzed from three studies). Significantly lower odds of MACE (6.0 vs. 9.2%; OR: 0.63, 95% CI: 0.50-0.80, p < .001, I² = 0%) and MI (3.3 vs. 5.45%; OR: 0.63; CI 0.41-0.96; p = .03; I² = 46%) were noted in the GGT group compared to SCT. No significant difference was noted with respect to CV and other secondary outcomes.

CONCLUSION

In patients with ACS, genotype-guided initiation of P2Y₁₂ inhibitors was associated with lower odds of MACE and similar bleeding risk in comparison to SCT.

Patent foramen ovale closure in the management of cryptogenic stroke: a review of current literature and guideline statements

OBJECTIVE

The management recommendations for patent foramen ovale (PFO) closure in cryptogenic stroke are rapidly evolving. The data has expanded recently with four major trials demonstrating superiority of percutaneous device closure over medical management in preventing cryptogenic stroke recurrence. This paper aims to review the current literature for referring physicians who may encounter patients with patent foramen ovale before referring these patients to stroke specialists and/or interventional cardiologists.

METHOD

For this Narrative review, we conducted a broad literature search with expert selection of relevant data. Our search included a review of the currently available trials, guideline statements, position papers, cost-effectiveness of device closure data, as well as the impact of device closure on quality of life.

RESULTS

Most European societies are now in favor of evaluating all patients aged 60 years or younger with recent cryptogenic stroke in the setting of a PFO after careful consideration of the patient's echocardiographic and clinical risk factors. On the other hand, American societies, except for the American Academy of Neurology, have not yet passed official updated recommendations.

CONCLUSION

PFO closure can be considered for the prevention of recurrent cryptogenic stroke in patients aged ≤60 years after a thorough evaluation and discussion about benefits and potential risks (including but not limited to atrial fibrillation) of the procedure. Accumulating evidence supports prognostic, quality of life, and economic benefit from percutaneous PFO closure with newer generation closure devices in the right subset of patients.

HIGHLIGHTS

Data from 4 major trials (RESPECT, CLOSE, DEFENSE-PFO, REDUCE) demonstrates the superiority of PFO closure over medical management alone in preventing cryptogenic stroke recurrence. Trials investigated mostly patients ≤60 years old, and therefore results may not be generalizable to the entire population. Further randomized trials evaluating the safety and efficacy of PFO closure in patients older than 60 years are warranted.Atrial fibrillation is one of the most common "occult" causes of cryptogenic stroke and should be excluded by ambulatory electrocardiographic monitoring. It is important to also rule out other causes of stroke, including hypercoagulable states, atherosclerotic lesions, other cardioembolic sources, and arterial dissection.Complications of PFO procedure include new-onset AF, development of scar tissue, risk of aortic root dilation and subsequent erosions, and potential thrombi formation on the device.PFO closure with medical therapy is more cost-effective than medical therapy alone.Patients who underwent PFO closure had lower rates of depression, anxiety, and stress compared to those who did undergo closure.Development of the RoPE score has helped clinicians identify patients with cryptogenic stroke and PFO who might be a candidate for PFO closure. A score of 7, 8, and 9-10 corresponds to a causal risk of 72%, 84%, and 88%, respectively, and defines a subset of patients who may benefit from PFO closure.Current guidelines recommend determining the need for PFO closure on a case-by-case basis, depending on risk factors, in patients age 60 or less with recent cryptogenic stroke in the setting of PFO.

Takotsubo syndrome: Does "Diabetes Paradox" exist?

BACKGROUND

Previous small-scale studies have reported conflicting findings regarding the prevalence of diabetes mellitus (DM) and its association with outcomes in patients with takotsubo syndrome (TTS) OBJECTIVE: We sought to assess the prevalence of DM and its association with outcomes in TTS patients.

METHODS

Nationwide inpatient sample (NIS) was queried to extract patient information from January 1, 2009 to September 30, 2015. Propensity score matching (PSM) was done to compare mortality and other in-hospital outcomes.

RESULTS

A total of 40,327 hospitalizations for TTS were included. The prevalence of DM in TTS was 19.3% vs 23.1% (p-value < 0.01) in patients without TTS in the NIS from 2009 to 2015. In the PSM cohort, there was no difference in in-hospital mortality (1.1% vs 1.4%; p = 0.76), stroke (1.2% vs 0.9%; p = 0.09), cardiogenic shock (3.7% vs 3.9%; p = 0.61), cardiac arrest (1.2% vs 1.2%; p = 0.94), ventricular arrhythmias (3.7% vs 3.3%; p = 0.23), circulatory support (2.1% vs 1.8%; p = 0.17), and invasive mechanical ventilation (4.9% vs 4.7%; p = 0.54) in TTS patients with versus without diabetes. In sub-group analysis, diabetes with chronic complications patients were found to have lower mortality (0.7% vs 2.0%; p = 0.04) compared to patients without diabetes and those with uncomplicated diabetes (0.6% vs 2.6%; p = 0.002).

CONCLUSIONS

Prevalence of DM was lower in TTS in comparison to patients without TTS. In addition, complicated DM patients were found to have lower in-hospital mortality. Further studies are needed to assess the mid and long-term outcomes of DM with and without chronic complications in TTS.

Meta-Analysis of the Efficacy and Safety of P2Y12 Inhibitor Monotherapy After Short Course of Dual-Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Guidelines recommend dual antiplatelet therapy (DAPT) following drug-eluting stent (DES) placement for ≥12 months in acute coronary syndrome or 6 months in stable coronary artery disease. However, with the advent of newer-generation stents, the optimal duration of DAPT to balance bleeding and thrombotic risks has been debated.

OBJECTIVES

We aimed to perform a meta-analysis of randomized controlled trials (RCT) comparing P2Y₁₂ monotherapy in short-duration group (SDG) vs. standard treatment group (STG) course of DAPT in patients undergoing PCI.

METHODS

Electronic databases were searched for RCTs of patients undergoing percutaneous coronary intervention (PCI) with DES placement who received short (≤ 3 months) vs. standard DAPT course (≥12 months) and were followed for ≥12-months. Rates of major adverse cardiovascular events (a composite of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal stroke) were the primary outcome. Study-specific odds ratios (OR) and corresponding 95% confidence intervals were calculated using random-effects model.

RESULTS

A total of 20,706 patients (10,344 in the SDG and 10,362 in the STG) were analysed from four studies. There was no significant difference observed for MACE (OR = 0.95, 95% CI: 0.81-1.08, P = .92, I² = 0%) myocardial infarction or stent thrombosis. However, lower rates of major bleeding were noted in the SDG (1.20 vs. 1.80%; OR: 0.61; 95% CI: 0.37-0.99; P = .04; I² = 71%) albeit with increased heterogeneity.

CONCLUSION

A short duration of DAPT followed by P2Y₁₂ inhibitor monotherapy was comparable to 12 months of DAPT with respect to MACE and thrombotic events, with lower rates of major bleeding events in select group of patients undergoing PCI. More data is needed to assess efficacy in patients with complex lesions and high risk ACS population including those with STEMI presentation.

Bladder Stone in Pregnancy: A Case Report and Review of the Literature

BACKGROUND Bladder stones are rare in pregnancy, and can be associated with adverse outcomes such as recurrent urinary tract infection and obstruction of labor. Management of bladder stones discovered in pregnancy has traditionally been done via open techniques such as cystolithotomy or with percutaneous removal. Our objective was to present a case of bladder stone in pregnancy and review prior reports on bladder stones and management in pregnancy. CASE REPORT A 28-year-old gravida 4 para 3 at 10 weeks gestation presented with dysuria, bladder spasm, weak urinary stream, and positional voiding. On first trimester ultrasound, a bladder stone (sized 3.7 cm) was identified and was confirmed by x-ray (KUB). Urology was consulted and removed the stone via cystolitholapaxy with holmium laser. Her symptoms subsequently resolved, and she went on to have an uncomplicated term spontaneous vaginal delivery. The removal of the stone enabled her to have a subsequent vaginal delivery without the potential for obstruction of labor. CONCLUSIONS Based on our review of the literature and this case report, laser cystolitholapaxy is a safe alternative to open surgery for the management of bladder stones in pregnancy. When discovered at the time of delivery, vaginal delivery is feasible if the stone is small or can be displaced. If encountered at time of cesarean delivery, then cystotomy with stone removal is recommended provided inflammation is not present.

Simulation-based training in urology residency programmes in the USA: Results of a nationwide survey

Objective

To evaluate the current usage of simulation in urological education in the USA and the barriers to incorporating a simulation-based educational curriculum, as the shift towards competency-based medical education has necessitated the introduction of simulation for training and assessing both non-technical and technical skills.

Materials and methods

Residency programme directors at Accreditation Council for Graduate Medical Education (ACGME)-accredited urology training programmes in the USA were invited to respond to an anonymous electronic survey. The study evaluated the programme directors’ experiences and opinions for the current usage of existing urology simulators. The survey also elicited receptiveness and the barriers for incorporating simulation-based training curricula within urology training programmes.

Results

In all, 43 completed surveys were received (35% response rate). Amongst responders, 97% (42/43) reported having access to a simulation education centre, and 60% (25/42) have incorporated simulation into their curriculum. A total of 87% (37/43) agreed that there is a role for a standardised simulator training curriculum, and 75% (30/40) agreed that simulators would improve operating room performance. A total of 64% (27/42) agreed that cost was a limiting factor, 12% (5/42) agreed on the cost-effectiveness of simulators, 35% (17/41) agreed there was an increased need for simulator education within work-hour limitations, and 38% (16/42) agreed a simulation programme would reduce patient risks and complications.

Conclusions

The majority of urology programme directors consider that there is a role for incorporating a simulation-based curriculum into urology training. Barriers to implementation include cost burden, need for constant technology updates, need for advanced planning, and willingness of faculty to participate in administration.

Postthrombotic Syndrome: Long-Term Sequela of Deep Venous Thrombosis

Postthrombotic syndrome is a common long-term complication of proximal lower extremity deep venous thrombosis, which not only significantly affects the quality of life of patients but also imposes a substantial financial burden on our healthcare system. Due to limited awareness and inability of physicians to recognize and treat this condition early, its prevalence is steadily increasing. In this article, we review the pathophysiology, the risk factors involved, diagnostic workup, and the various management options available to treat this condition.

Post-Chemotherapy Robotic Retroperitoneal Lymph Node Dissection: Institutional Experience

PURPOSE

There is little literature on robotic retroperitoneal lymph node dissection (RRPLND) in the difficult post-chemotherapy (PC) setting. We report on the outcome of RRPLND in patients with PC-residual masses.

MATERIALS AND METHODS

Between 2011 and 2015, we performed 12 PC-RRPLND. Mean patient age was 37.8 years. Mean body mass index was 30.78. Nine (75%) patients had nonseminomatus germ cell tumor (NSGCT) and three (25%) patients had seminoma tumors. Cancer stage was III in six (50%), II-C in three (25%), II-B in two (16.7%), and II-A in one (8.03%). International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic classification in the NSGCT was good in six, intermediate in two, and poor in one, and was good in the three seminoma patients.

RESULTS

The procedure was completed effectively in 11 (91.7%) patients. Mean operative time was 312 minutes. The mean estimated blood loss was 475 mL. Mean hospital stay was 3.2 days. Mean number of lymph node excised was 12. Six of the excised masses were ≥5 cm (N3), largest was 7.5 cm. Pathology showed teratoma in five (45.5%), benign/necrosis in five (45.5%), and viable germ cells in one (9%). Major complication (Clavien ≥3) occurred in one patient and minor (Clavien ≤2) in two. Antegrade ejaculation was preserved in eight patients and in one could not be assessed. At a median follow-up of 31 months, no infield or outfield relapses occurred.

CONCLUSIONS

Robotic PC-retroperitoneal lymph node dissection (RPLND) is technically feasible and with acceptable morbidity. It is associated with low blood loss and short hospital stay. More research is needed to assess the long-term outcome and to compare standard open RPLND.

Left dominant circulation increases mortality in acute coronary syndrome: A systematic review and meta-analysis of observational studies involving 255,718 patients

BACKGROUND

The effect of coronary dominance on mortality in patients with acute coronary syndrome (ACS) remains unclear. We performed a meta-analysis to evaluate the effect of coronary dominance in patients with ACS.

METHODS

Several data sources were searched for studies which compared studies that compared outcomes between right and left dominant coronary circulation in patients with ACS. The measured outcomes were in-hospital, 30-day or long-term mortality as reported in individual studies. The Generic inverse variance method was used in a random-effects model to pool mortality as an outcome. Odds ratio (OR) was calculated for mortality in the left dominant circulation relative to a right dominant one. Sub-group analysis was performed after stratification of mortality by duration.

RESULTS

A total of 5 studies with 8 comparisons and 255,718 participants revealed an increased risk mortality (OR = 1.27 (95% CI: 1.13 - 1.42; P < 0.0001; I(2)  = 34%). Sub-group analysis revealed that the increased risk was evident at all time periods after the ACS; in-hospital (OR = 1.37; 95% CI: 1.07 - 1.76; P = 0.01; I(2)  = 50%), at 30 days (OR = 1.69; 95% CI: 1.14 - 2.52; P = 0.009; I(2)  = 18%) and long-term (OR = 1.15; 95% CI: 1.03 - 1.28; P = 0.01; I(2)  = 0%).

CONCLUSIONS

In this meta-analysis we found that there is an increased risk of mortality with LD coronary circulation in patients with ACS. The knowledge of coronary dominance may not only be helpful as an incremental prognostic factor beyond pre-procedural risk scores in all patients with ACS, but may also aid in clinical decision making in a subset of these patients. © 2015 Wiley Periodicals, Inc.

Recurrent myocardial infarctions in a young football player secondary to thrombophilia, associated with elevated factor VIII activity

Myocardial infarction (MI) due to coronary atherosclerosis in young adults is uncommon; rare causes such as cocaine abuse, arterial dissection, and thromboembolism should be considered. A 21-year-old football player, and otherwise healthy African American man, developed chest pain during exercise while bench-pressing 400 lbs. Acute MI was diagnosed based on physical examination, electrocardiography findings, and elevated cardiac enzymes. Coronary arteriography showed a thrombus occluding the proximal left anterior descending artery (LAD). Aggressive antiplatelet therapy with aspirin, clopidogrel, and eptifibatide was pursued, in addition to standard post-MI care. This led to the successful resolution of symptoms and dissolution of the thrombus, demonstrated by repeat coronary arteriography. Five months later, he presented with similar symptoms during exercise after lifting heavy weights, and was found to have another acute MI. Coronary arteriography again showed a thrombus occluding the LAD. No evidence of coronary artery dissection or vasospasm was found. Only mild atherosclerotic plaque burden was observed on both occasions by intravascular ultrasound. A bare metal stent was placed at the site as it was thought this site had acted as a nidus for small plaque rupture and thrombus formation. Elevated serum factor VIII activity at 205% (reference range 60%–140%) was found, a rare cause of hypercoagulability. Further workup revealed a patent foramen ovale during a Valsalva maneuver by transesophageal echocardiography. Both events occurred during weight lifting, which can transiently increase right heart pressure in a similar way to the Valsalva maneuver. In light of all the findings, we concluded that an exercise-related increase in factor VIII activity led to coronary arterial thrombosis in the presence of a small ruptured plaque. Alternatively, venous clots may have traversed the patent foramen ovale and occluded the LAD. In addition to continuing aggressive risk factor modification, anticoagulation therapy with warfarin was initiated with close follow-up.

Vaginal repair of ureterovaginal fistula may be suitable for selected cases

Ureterovaginal fistula (UVF) is an uncommon but devastating complication of gynecologic surgery. Management includes ureteral stenting for 6-8 weeks. For stent failure, ureteroneocystostomy (UNC) through an open, laparoscopic, or robotic abdominal approach is the classic alternative. Originally pioneered for repair of vesicovaginal fistulas (VVF), the use of the vaginal approach in UVF is scarcely reported in the literature. We report the successful repair of UVF performed exclusively through the vaginal approach in two women after robotic hysterectomy. In select clinical scenarios, this approach may be applied, as it provides a minimally invasive option for managing UVF after failure of ureteral stenting.

Neurocardiogenic syncope: mechanisms, evaluation and treatment

Syncope is the abrupt and transient loss of consciousness due to a temporary reduction in cerebral blood flow, associated with an absence of postural tone, followed by a rapid and usually complete recovery. It may result from several possible etiologies, ranging from the benign to the potentially fatal. Neurocardiogenic (vasovagal) syncope is the most common of a group of neurally mediated syncopes, characterized by a sudden failure of autonomic regulatory mechanisms to maintain adequate blood pressure and, occasionally, heart rate, to sustain cerebral perfusion and consciousness. The diagnosis may be suggested by a characteristic history and by exclusion of other causes of syncope; however, in some cases, upright tilt table testing may be required to provoke typical hemodynamic responses. Cardiologists and cardiac electrophysiologists are frequently expected to manage patients with suspected neurocardiogenic syncope. The following review aims to provide a basic framework for understanding its pathophysiology, clinical presentations, diagnosis and treatment.

Long-term follow-up for reconstruction of strictures of the fossa navicularis with a single technique

OBJECTIVE

To retrospectively review our experience with the ventral transverse skin island elevated on a dartos fascia flap.

PATIENTS AND METHODS

In all, 45 patients were consecutively operated by the senior author using this technique from March 1987 to January 2006. The files of 35 patients were assessed for the study. Success was defined as a patent urethral calibre of >/=16 F that did not require further procedures. Follow-up consisted of, endoscopy with calibration, office visits, and telephone calls. This procedure was described in 1987 by Jordan. The overall outcome as well as indications after the follow-up period are presented.

RESULTS

The overall success rate was 83% with a mean long-term follow-up of 10.2 years. All of the patients with a non-lichen sclerosus (LS)/balanitis xerotica obliterans (BXO) diagnosis had excellent results (23/23) with a mean follow-up of 10.2 years. LS/BXO recurred at the fossa or meatus in six of 12 patients. Seventeen patients (48%) were lost to follow-up, and three patients (9%) died from other causes.

CONCLUSIONS

The ventral transverse penile skin island flap has proven to be effective, reliable, reproducible, and with good functional and aesthetic results in all fossa navicularis strictures with the exception of those strictures resulting from LS/BXO.

The technique of vessel sparing excision and primary anastomosis for proximal bulbous urethral reconstruction

PURPOSE

We present a technique not previously described for proximal bulbous or bulbomembranous urethral reconstruction of excision and primary anastomosis. The technique has the potential advantages of preserving the proximal urethral blood supply.

MATERIALS AND METHODS

From June 2003 to October 2006, 10 patients underwent vessel sparing urethral reconstruction including 3 after radical prostatectomy, 6 following straddle trauma and 1 potentially with a congenital stricture. A plane was developed between the urethra and the proximal blood supply at the bulbospongiosum, allowing for division of the urethra without dividing the spongy tissue of the corpus spongiosum or the arteries to the bulb. Only 7 patients are presented for data analysis because the other 3 have not had sufficient followup to date.

RESULTS

Patient age range was 15 to 72 years (mean 47). The patient with a congenital stricture was 2 years old. Stricture length ranged from 0.5 to 2.5 cm (mean 1.5). The patients who had undergone radical prostatectomy were either incontinent or were believed to be possibly rendered incontinent after the urethral reconstruction. At a mean followup of 12.5 months (range 6 to 38) all 7 patients had patent urethras, 2 were incontinent and 1 underwent implantation with an AMS 800 sphincter using a transcorporal approach. As of this writing all 10 patients are apparently stricture-free.

CONCLUSIONS

Preservation of blood supply is always a noble achievement in surgery. However, it technically often requires significant effort. In patients after radical prostatectomy with proximal anterior urethral or bulbomembranous strictures, preserving the blood supply possibly decreases cuff erosion when undergoing later implantation Many patients (approximately 12% lifetime risk of prostate cancer) will require radical prostatectomy and may later require a sphincter. Further studies are warranted to evaluate the benefit of applying this technique in all suitable patients.

Long-term followup for excision and primary anastomosis for anterior urethral strictures

PURPOSE

We report our experience and long-term followup of patients undergoing excision and primary anastomotic reconstruction for anterior urethral strictures.

MATERIALS AND METHODS

From July 1986 to May 2006 the charts of 260 patients who underwent excision with primary anastomosis at our center for bulbar urethral stricture were reviewed. Patient age ranged from 14 to 78 years (mean 38.4), stricture length ranged 0.5 to 4.5 cm (mean 1.9). Patients who had surgery within the last 5 years were contacted by telephone if their 6-month postoperative cystoscopic evaluation was patent and they had not visited the clinic afterward.

RESULTS

After a mean followup of 50.2 months 257 patients (98.8%) were symptom-free and required no further procedures. Recurrent stricture occurred early in 2 patients and late in 1 patient. Two patients opted for intermittent dilations, and a single direct visual internal urethrotomy was performed in 1 patient 4 years postoperatively. One of the patients who elected dilation subsequently elected urethral reconstruction, which was done successfully. Complications encountered were position related neuropraxia in 9 (3.4%), early urinary tract infection in 13 (5%), chest related in 5 (1.9%), scrotalgia in 4 (1.5%) and wound related in 4 (1.5%). All resolved within the early postoperative period. Erectile dysfunction was encountered in 6 (2.3%) patients, of whom 4 had a history of significant straddle trauma, 4 responded well to oral pharmacotherapy and 1 elected to not have the erectile dysfunction treated.

CONCLUSIONS

Excision with primary anastomosis for anterior urethral stricture has a high success rate of 98.8% with durable long-term results in most patients. Complications are few, of short duration and self-limited. Where applicable, we believe that the procedure clearly is the choice for short anterior urethral strictures.

Reconstruction and Management of Posterior Urethral and Straddle Injuries of the Urethra

Urethral stricture disease, once associated mainly with gonococcal urethritis, is now most frequently a consequence of trauma, such as a fall-astride injury or a pelvic fracture. This article discusses issues and approaches related to the treatment of strictures associated with perineal straddle trauma and pelvic fracture urethral distraction defects. The authors emphasize that endoscopic procedures seldom cure these strictures and in-dwelling stents are seldom useful in treatment. Primary anastomotic techniques are associated with success rates in the high 90% range and appear to be remarkably durable in most cases. In contrast, tubed reconstruction of the urethra is inevitably associated with diminished success rates and with problems of durability.