Wheelerhutchison3691

PURPOSE The aim of the present study was to explore the remedial methods for the failure of anterolateral thigh (ALT) flap transplantation and to evaluate the efficacy of these methods in head and neck reconstruction. PATIENTS AND METHODS We performed a retrospective study of 11 patients who experienced intraoperative failure of ALT flap transplantation in head and neck reconstruction that was successfully salvaged with the same donor site. The cause of flap failure, corresponding management, and complications at the donor and recipient sites were recorded. RESULTS All 11 patients were men with an average age of 56.5 years. Of the 11 cases of flap preparation or transplantation failure, 1 was caused by arterial thromboembolism (after vascular anastomosis), 4 by perforator injury, 4 by mistaken perforator ligation, 1 by perforator thromboembolism, and 1 by the perforator deep penetration in muscle. All were successfully rescued with the same donor site, including harvest of another ALT flap with the other perforator in 5 patients, elevation of an anteromedial thigh flap in 4, and perforator anastomosis in 2 patients. CONCLUSIONS With effective remedial methods for the failure of flap transplantation and their great versatility, the use of ALT flaps is a good choice for reconstruction of head and neck defects. The aim of the present study was to evaluate the effectiveness of fixation of the premaxilla to the remaining maxillary stumps using the iliac crest cortical bone and screws in 16 patients with bilateral alveolar clefts. The technique was used in patients who required surgical repositioning of the premaxilla owing to its severe anterior projection and mispositioning. Postoperative follow-up was performed using periapical and occlusal radiographs and clinical examinations at 3 and 6 months after surgery. Subsequently, the patients were referred for resumption of orthodontic treatment. Of the 16 patients evaluated, only 1 patient experienced unilateral loss of the graft, requiring further surgical intervention. PURPOSE To investigate the changes induced by surgically assisted rapid maxillary expansion (SARME) on palate and pharynx morphology as well as the correlation of these changes with the improvement of obstructive sleep apnea (OSA). MATERIALS AND METHODS The study was conducted in 16 patients, seven women and nine men, aged on average 40.23 ± 10.23 years, all of them with OSA confirmed by polysomnography (PSG) and with posterior crossbite. All participants underwent computed tomography (CT) and PSG before and after SARME. The CT scans were used to determine the dimensions of the palate and pharynx before and after surgery. Data were analyzed statistically by the paired t-test, Wilcoxon test and Pearson correlation, with the level of significance set at P  less then  0.05. RESULTS A 56.24% reduction in apnea and hypopnea index was detected (from 33.23 ± 39.54 to 14.54 ± 19.48 P = 0.001). The total airway area increased on average by 23.99% (P = 0.016), although in a more expressive manner in its lower half (28.63%, P = 0.008). A 24% transverse bone increase was observed in the palate in the region of the first premolars and an 18% increase in the region of the first molars (from 2.42 ± 0.31 to 2.99 ± 0.26. P  less then  0.001, and from 3.11 ± 0.32 to 3.70 ± 0.41, P  less then  0.001, respectively), and a mean 15% reduction of its depth (from 1.07 ± 0.33 to 0.89 ± 0.18, P = 0.014). A moderate correlation was detected between palate depth and width and OSA severity, as well as a correlation of the reduction of palate depth and its transverse increase with the improvement of OSA, especially among patients with severe OSA. CONCLUSION It appears that narrowing of the palate, especially in the premolar region, and its greater depth may be related to the severity of OSA. SARME promotes transverse maxillary widening and lowering of palate depth, thus reducing OSA among adults and expanding the airway, especially in its lower half. AIMS Profound left ventricular (LV) hypertrophy with diastolic dysfunction and heart failure is the cardinal manifestation of heart remodelling in chronic kidney disease (CKD). Previous studies related increased T1 mapping values in CKD with diffuse fibrosis. Native T1 is a non-specific readout that may also relate to increased intramyocardial fluid. We examined concomitant T1 and T2 mapping signatures and undertook comparisons with other hypertrophic conditions. METHODS In this prospective multicentre study, consecutive CKD patients (n = 154) undergoing routine clinical cardiac magnetic resonance (CMR) imaging were compared with patients with hypertensive (HTN, n = 163) and hypertrophic cardiomyopathy (HCM, n = 158), and normotensive controls (n = 133). RESULTS Native T1 was significantly higher in all patient groups, whereas native T2 in CKD only (p  less then  0.001 vs. all groups). Native T1 and T2 were interrelated in patient groups and the strength of association was condition-specific (CKD r = 0.558, HTN r = 0.324, both p  less then  0.001; HCM r = 0.157, p = 0.05). Native T1 and T2 were similarly correlated in all CKD stages (S3 r = 0.501, S4 0.586, S5 r = 0.424, p  less then  0.001 for all). Native T1 was the strongest myocardial discriminator between patients and controls (area under the curve, AUC HCM 0.97; CKD 0.97, HTN 0.98), native T2 between CKD vs HCM (AUC 0.90) and native T1 and T2 between CKD vs HTN (AUC 0.83 and 0.80 respectively), p  less then  0.001 for all. CONCLUSIONS Our findings reveal different CMR signatures of common hypertrophic cardiac phenotypes. Native T1 was raised in all conditions, indicating the presence of pathologic hypertrophic remodelling. Markedly raised native T2 was CKD-specific, suggesting a prominent role of intramyocardial fluid. V.BACKGROUND Cardiac implanted electronic devices (CIEDs) can detect short durations of previously unrecognised atrial fibrillation (AF). The prognostic significance of device-detected subclinical AF, in the context of contemporary heart failure (HF) therapy, is unclear. METHODS Amongst patients enrolled in the Remote Monitoring in HF with implanted devices (REM-HF) trial, three categories were defined based on total AF duration in the first year of follow-up no AF, subclinical AF (≥6 min to ≤24 h), and AF >24 h. All-cause mortality, stroke, and cardiovascular hospitalisation were assessed. RESULTS 1561 patients (94.6%) had rhythm data 71 (4.6%) had subclinical AF (median of 4 episodes, total duration 3.1 h) and 279 (17.9%) had AF >24 h. During 2.8 ± 0.8 years' follow-up, 39 (2.5%) patients had a stroke. Stroke rate was highest amongst patients with subclinical AF (2.0 per 100-person years) versus no AF or AF >24 h (0.8 and 1.0 per 100-person years, respectively). In the overall cohort, AF >24 h was not an independent predictor of stroke. Quizartinib concentration However, amongst patients with no history of AF (n = 932), new-onset subclinical AF conferred a three-fold higher stroke risk (adjusted HR 3.35, 95%CI 1.15-9.77, p = 0.027). AF >24 h was associated with more frequent emergency cardiovascular hospitalisation (adjusted HR 1.46, 95%CI 1.19-1.79, p  less then  0.0005). Neither AF classification was associated with mortality. CONCLUSIONS In patients with HF and a CIED, subclinical AF was infrequent but, as a new finding, was associated with an increased risk of stroke. Anticoagulation remains an important consideration in this population, particularly when the clinical profile indicates a high stroke risk. V.BACKGROUND Children requiring gastrostomy tubes (GT) have high resource utilization. In addition, wide variation exists in the decision to perform concurrent fundoplication, which can increase the morbidity of enteral access surgery. We implemented a hospital-wide standardized pathway for GT placement. METHODS The standardized pathway included mandatory preoperative nasogastric feeding tube (FT) trial, identification of FT medical home, and standardized postoperative order set, including feeding regimen and parent education. An algorithm to determine whether concurrent fundoplication was indicated was also created. We identified children referred for GT placement from 2015 to 2018 and compared concurrent fundoplication rates and outcomes pre- and postimplementation. RESULTS We identified 332 patients who were referred for GT. Of these, 15 avoided placement. Concurrent fundoplication decreased postpathway (48% vs 22%, p  less then  0.0001). After adjusting for reflux and cardiac disease, prepathway patients were 3.5 times more likely to undergo concurrent fundoplication. ED visits (46% vs 27%, p = 0.001) and postoperative LOS (median (IQR) 10 days (5-36) to 5.5 days (1-19), p = 0.0002) decreased. CONCLUSIONS A standardized pathway for GT placement prevented unnecessary GT placement and fundoplication with reduction in postoperative LOS and ED visits. This approach can significantly reduce resource utilization while improving outcomes. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level II. BACKGROUND Although longer ECMO run times for patients with congenital diaphragmatic hernia (CDH) have been associated with worse outcomes, a large study has not been conducted to examine the risk factors for long ECMO runs. METHODS The Extracorporeal Life Support Organization (ELSO) Registry from 2000 to 2015 was used to identify predictors of long ECMO runs in CDH patients. A long run was any duration of ≥14 days. Multivariable logistic regression models were used to examine the association between demographics, pre-ECMO blood gas/ventilator settings, comorbid conditions, and therapies on long ECMO runs. RESULTS There were 4730 CDH-infants examined. The largest association with long ECMO runs was on-ECMO repair (OR 3.72, 95% CI 3.013-4.602, p  less then  0.001) and the use of THAM (OR 1.463, 95% CI 1.062-2.016, p = 0.02). Each drop in pH quartile was associated with an increased risk of long ECMO run pH ≥ 7.3 (reference), pH 7.2-7.9 (OR 1.24, 95% CI 0.98-1.57, p = 0.07), pH 7.08-7.19 (OR 1.46, 95% CI 1.17-1.84, p = 0.001), pH ≤ 7.07 (OR 1.64, 95% CI 1.29-2.07, p  less then  0.001). CONCLUSIONS We found a correlation between both pre-ECMO demographics/timing of repair and the subsequent risk of long ECMO runs, providing insight for both providers and parents about the risk factors for longer runs. TYPE OF STUDY Treatment Study. LEVEL OF EVIDENCE Level III. PURPOSE Testicular torsion is one of the most common causes of acute scrotum in pediatric age. The present study aimed to evaluate the role of preoperative manual detorsion in the management of testicular torsion. METHODS Retrospective data analysis of pediatric patients treated for acute testicular torsion at a tertiary center over the last 5 years. Manual detorsion was attempted by surgeon's preference. Successful manual detorsion was defined as complete pain resolution with a normal color Doppler ultrasound. All patients underwent surgical exploration. Patient data analyzed included age, pain duration, site of onset, attempt of manual detorsion, pain relief after manual detorsion, color Doppler ultrasound results, surgical findings and outcome. RESULTS One hundred twenty-two patients were included. Manual detorsion was attempted in 48% (58/122) cases. Manual detorsion was successful in 26% (15/58) patients. In the unsuccessful, residual cord torsion was found at surgery in 27.5% (16/58); in the remaining 27, there was no cord torsion at surgery.