Mohammed Firdouse

Thrombosis and thromboembolic complications in fontan patients: a literature review.

Hemodynamic fluctuations and thromboembolic complications are significant areas of concern during the postoperative management of patients with univentricular hearts. The objective of this study is to review the incidence and risk factors associated with thrombosis and thromboembolic complications following total cavopulmonary anastomosis, the third stage of the palliative surgical procedure. A literature search of published evidence was conducted on OvidSP MEDLINE(R) and Embase followed by paired title, abstract, and full-text screening based on specific inclusion criteria. High risks of thromboembolic outcomes were identified across studies, with variable incidences between 3% and 20%, high mortality rates up to 38%, and an inverse relationship with prophylaxis treatment administration. Several risk factors for thrombotic complications, including chronic systemic venous hypertension, protein-losing enteropathy, passive blood flow, atrial arrhythmias, conduit stenosis, prosthetic material use, coagulation factor abnormalities, and several patient characteristics were identified. Based on these findings, a prophylactic anticoagulation algorithm has been proposed.

Distinctive neck swelling in a patient with a vein of Galen arteriovenous malformation

AbstractA vein of Galen arteriovenous malformation (VGAM) is a rare intracranial shunt lacking a capillary bed and resulting in subsequent aneurysmal enlargement. VGAM has been previously reported to present as cardiovascular abnormalities, including increased right-sided cardiac load and pressure, cardiac dilatation, pulmonary hypertension and retrograde flow into the aortic arch. We report the first case of VGAM presenting as a gross right-sided neck swelling in a 39-week-old immediately at birth. Transthoracic echocardiography detected dilatation of the superior vena cava and innominate vein, increased right ventricular and pulmonary arterial pressure, and retrograde flow into the aortic arch. Follow-up neck ultrasound revealed tortuous carotid artery and bilateral dilatation of neck veins. Transcranial ultrasound revealed abnormally dilated vessels posterior to the third ventricle, confirming VGAM. Our case demonstrates that while the differential diagnoses of neck swelling are extensive, such a presentation upon Doppler and echocardiographic investigation, may be suggestive of extracardiac causes such as VGAM. The management of such a condition remains critical due to risk of hemorrhage and extensive cerebral involvement.RiassuntoLa vena di Galeno (VGAM) é una malformazione arterovenosa rara a livello intracranico, caratterizzata da shunt senza un letto capillare e conseguente, successivo, allargamento aneurismatico. La VGAM è stata segnalata in precedenza come anomalia cardiovascolare, con sovraccarico del cuore destro, dilatazione cardiaca, ipertensione polmonare e flusso retrogrado nell’arco aortico. Riportiamo il primo caso di VGAM caratterizzata da gonfiore e tumefazione del lato destro del collo in neonato nato alla 39 settimana di gestazione. L’ecocardiografia transtoracica ha rilevato dilatazione della vena cava superiore e della vena anonima, aumentato di volume del ventricolo destro e della pressione arteriosa polmonare e flusso retrogrado aortico. Il follow-up ecografico del collo ha rivelato tortuosità della carotide e dilatazione bilaterale delle vene del collo. L’ecografia transcranica ha rivelato un’anomala dilatazione dei vasi posteriori al terzo ventricolo, confermando la presenza di VGAM. Il nostro caso dimostra che, anche se le diagnosi differenziali delle tumefazioni del collo sono numerose, una presentazione Doppler ed ecocardiografica come quella riportata, può essere indicativo di causa extracardiaca come la VGAM. La gestione di tale condizione é critica per il rischio di emorragia e di ampio coinvolgimento cerebrale.

Checklist to improve informed consent process in pediatric surgery: A pilot study

PURPOSE The purpose of this study was to develop and validate a checklist to standardize surgical informed consent process. METHODS A checklist was created following a literature search. Consent processes were observed from general surgery (GS) and urology (US) in the pre- and post-intervention phases. Competent patients/guardians were asked to complete a satisfaction questionnaire. All trainees and staff surgeons were interviewed on the checklists utility. RESULTS 73 observations (GS=39, US=34) and 66 observations (GS=30, US=36) were made in the pre- and post-intervention phase, respectively. Our checklist increased the frequency with which surgeons explained alternative treatments (pre-intervention 23.3% vs. post-intervention 81.8%), the role of trainees (15.1% vs. 72.7%), and the potential outcomes of not pursuing surgery (60.3% vs. 87.9%). The patient/guardian average satisfaction score increased between phases within GS (mean[standard deviation] 3.55[0.58] vs. 3.85[0.24]); p=0.002), but not within US (3.53[0.61] vs. 3.52[0.54]); p=0.705) or the overall sample (3.54[0.59] vs. 3.67[0.46]); p=0.329). Interestingly, there was no significant improvement in patient/guardian average anxiety levels in GS (X2=0.069, p=0.793), US (X2=0, p=1) or the overall sample (X2=0.143, p=0.706) following the intervention. CONCLUSION Our checklist aids in standardizing the informed consent process. However, it did not significantly change satisfaction or anxiety levels of patients and guardians. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level III.

Incidence and Management of Thrombotic and Thromboembolic Complications Following the Norwood Procedure: A Systematic Review:

Background: The stage 1 Norwood procedure and its variants represent the first step of palliation for hypoplastic left heart syndrome. Although appropriate postoperative thromboprophylaxis is integral, significant variance remains across institutional practices. The purpose of this systematic review is to estimate the incidence of thrombosis and thromboembolism following the Norwood or modified Blalock-Taussig shunt procedure and examine current thromboprophylaxis regimens. Methods: Ovid MEDLINE and Embase were searched from January 2000 to June 2016 for primary studies explicitly reporting incidence of thrombosis, thromboembolism (strokes and pulmonary embolisms), or shunt occlusion in neonates, infants, and children undergoing the Norwood procedure or any variant. All-cause mortality was a secondary outcome of interest. Results: Of 887 identified articles, 15 cohort studies were deemed eligible, the majority including modified Blalock-Taussig shunt patients. Reported incidence of thrombosis ranged from 0% to 40%; thromboembolic events were rarely reported. Overall mortality ranged from 4.5% to 31.3% across studies. Although most studies involved the long-term acetylsalicylic acid use, thromboprophylaxis strategies varied across studies. Due to substantial variability in event rates, no correlation was identified with thrombotic complications. Discussion: Clinical practice guidelines recommend that patients receive intraoperative unfractionated heparin therapy and either aspirin or no antithrombotic therapy postoperatively. Our findings suggest a substantial risk of thrombosis and thromboembolism and demonstrate substantial variation in thromboprophylaxis practices. Conclusion: Although postoperative thromboprophylaxis seems optimal, it remains controversial whether the long-term aspirin use is most effective. Our findings highlight the lack of a gold-standard thromboprophylaxis strategy and emphasize the need for more consistency.

Using Texting for Clinical Communication in Surgery: A Survey of Academic Staff Surgeons:

Background. Text messaging has become ubiquitous and is being increasingly used within the health care system. The purpose of this study was to understand texting practices for clinical communication among staff surgeons at a large academic institution. Methods. Staff surgeons in 4 subspecialties (vascular, plastics, urology, and general surgery) were surveyed electronically. Results. A total of 62 surgeons from general surgery (n = 33), vascular surgery (n = 6), plastic surgery (n = 13), and urology (n = 10) completed the study (response rate 30%). When conveying urgent patient-related information, staff surgeons preferred directly calling other staff surgeons (61.5%) and trainees (58.8%). When discussing routine patient information, staff surgeons used email to reach other staff surgeons (54.9%) but preferred texting (62.7%) for trainees. The majority of participants used texting because it is fast (65.4%), convenient (69.2%) and allows transmitting information to multiple recipients simultaneously (63.5%). Most felt that texting enhances patient care (71.5%); however, only half believed that it enhanced trainees’ educational experiences. The majority believed that texting identifiable patient information breaches patient confidentiality. Conclusions. Our data showed high adoption of text messaging for clinical communication among surgeons, particularly with trainees. The majority of surgeons acknowledge security concerns inherent in texting for patient care. Existing mobile communication platforms fail to meet the needs of academic surgeons. Further research should include guidelines related to texting in clinical practice, educational implications of texting, and technologies to better meet the needs of clinicians working in an academic surgical settings.

Incidence and Management of Thrombotic and Thromboembolic Complications Following the Superior Cavopulmonary Anastomosis Procedure: A Literature Review

The objective of this literature review was to estimate the incidence of thrombosis and thromboembolism associated with the superior cavopulmonary anastomosis (SCPA) procedure and its variants and to examine current thromboprophylaxis regimens utilized. MEDLINE and EMBASE were searched from inception to August 2017 for all prospective and retrospective cohort studies explicitly reporting incidence of thrombosis, thromboembolism, or shunt occlusion in neonates, infants, and children undergoing 1 or more variants of the SCPA procedure. End points included thrombotic events and thromboembolic events (strokes and pulmonary embolisms) as primary outcomes, and overall mortality as a secondary outcome, at the last available follow-up time point. Of 1303 unique references identified, 13 cohort studies were deemed eligible. Reported incidence of thrombosis and thromboembolic events ranged from 0% to 28.0% and from 0% to 12.5%, respectively. Reported incidence of major bleeding events ranged from 0% to 2.9%. Reported overall mortality ranged from 2.5% to 50.5% across studies. Thromboprophylaxis protocols varied across institutions and studies, most commonly involving unfractionated heparin (UFH), warfarin, enoxaparin, acetylsalicylic acid (ASA), or combinations of ASA and warfarin, ASA and low-molecular-weight heparin (LMWH), UFH and LMWH, and UFH and ASA; several studies did not specify a protocol. Due to substantial variability in reported event rates, no clear correlation was identified between prophylaxis protocols and postoperative thrombotic complications. Despite guidance recommending postoperative UFH as standard practice, thromboprophylaxis protocols varied across institutions and studies. More robust trials evaluating different thromboprophylaxis regimens for the management of these patients are warranted.