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Objective To characterize current practice patterns of urologists in the management of intravenous (IV) contrast allergy in the setting of endourologic procedures. Methods A survey was administered to all members of the Endourological Society to assess management of IV contrast allergy prior to ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL). Treatment regimens, reports of adverse outcomes, and demographics of respondents were also collected. Data were analyzed using chi-square tests. Results The response rate was 15% (325/2100). A total of 21% and 28% of respondents reported giving prophylaxis prior to URS and PCNL, respectively. Nearly 3% of respondents reported having observed a severe adverse reaction to intraluminal contrast in the past. Approximately half reported giving prophylaxis only 1 hour prior to the procedure. Most respondents (77%) completed a fellowship, the most common being endourology. Chi-square analysis revealed a significant difference between giving prophylaxis for URS or PCNL and the respective case volumes (for URS, X2 = 8.3, P= .004; for PCNL, X2 = 8.5, P= .003) where urologists with the lowest and highest case volumes were more likely to give prophylaxis (Fig. 1). There was no significant difference between giving prophylaxis for URS or PCNL and recency of residency, fellowship training, practice setting, or practice type. Conclusion Most urologists do not give prophylaxis for patients with IV contrast allergy prior to URS and PCNL. Further studies are needed to evaluate the necessity of prophylaxis as well as to establish clear guidelines.

To determine the prevalence, radiographic features and reporting rate of, and the association between the congenital anterior and posterior C1 arch anomalies. The computed tomography (CT) images of the cervical spines of all patients over 18 years who had CT examinations in our hospital during the study period were reviewed to evaluate for congenital anomalies of the anterior and posterior C1 arches. Radiology reports of the corresponding CT examinations were reviewed to determine the reporting rate of these defects. Of 3273 subjects, 185 (5.65%) had congenital atlas anomalies: 169 isolated posterior (5.16%), 15 combined anterior and posterior (bipartite, 0.46%), and one isolated anterior (0.031%) arch defects. Females had a higher prevalence than males (7.46 versus 4.72%, P = 0.0013). Eighty-three cases (44.9%) of C1 arch anomalies were not reported. The Currarino type A, B, C and E posterior arch defects accounted for 81.6, 8.1, 1.1, and 0.5% of all arch anomalies while type D was not observed. Fifteen patients (0.46%) had combined anterior and posterior arch anomalies (bipartite atlas) versus only one with an isolated anterior C1 defect, indicating a significant association between the anterior and posterior arch defects (P

Importance The optimal international normalized ratio (INR) to prevent venous thromboembolism (VTE) in warfarin-treated patients with recent arthroplasty is unknown. Objective To determine the safety and efficacy of a target INR of 1.8 vs 2.5 for VTE prophylaxis after orthopedic surgery. Design, Setting, and Participants The randomized Genetic Informatics Trial (GIFT) of Warfarin to Prevent Deep Vein Thrombosis enrolled 1650 patients aged 65 years or older initiating warfarin for elective hip or knee arthroplasty at 6 US medical centers. Enrollment began in April 2011 and follow-up concluded in October 2016. Interventions In a 2 × 2 factorial design, participants were randomized to a target INR of 1.8 (n = 823) or 2.5 (n = 827) and to either genotype-guided or clinically guided warfarin dosing. For the first 11 days of therapy, open-label warfarin dosing was guided by a web application. Main Outcomes and Measures The primary outcome was the composite of VTE (within 60 days) or death (within 30 days). Participants underwent screening duplex ultrasound postoperatively. The hypothesis was that an INR target of 1.8 would be noninferior to an INR target of 2.5, using a noninferiority margin of 3% for the absolute risk of VTE. Secondary end points were bleeding and INR values of 4 or more. Results Among 1650 patients who were randomized (mean age, 72.1 years; 1049 women [63.6%]; 1502 white [91.0%]), 1597 (96.8%) received at least 1 dose of warfarin and were included in the primary analysis. The rate of the primary composite outcome of VTE or death was 5.1% (41 of 804) in the low-intensity-warfarin group (INR target, 1.8) vs 3.8% (30 of 793) in the standard-treatment-warfarin group (INR target, 2.5), for a difference of 1.3% (1-sided 95% CI, −∞ to 3.05%,P = .06 for noninferiority). Major bleeding occurred in 0.4% of patients in the low-intensity group and 0.9% of patients in the standard-intensity group, for a difference of −0.5% (95% CI, −1.6% to 0.4%). The INR values of 4 or more occurred in 4.5% of patients in the low-intensity group and 12.2% of the standard-intensity group, for a difference of −7.8% (95% CI, −10.5% to −5.1%). Conclusions and Relevance Among older patients undergoing hip or knee arthroplasty and receiving warfarin prophylaxis, an international normalized ratio goal of 1.8 compared with 2.5 did not meet the criterion for noninferiority for risk of the composite outcome of VTE or death. However, the trial may have been underpowered to meet this criterion and further research may be warranted. Trial Registration ClinicalTrials.gov Identifier:NCT01006733

Warfarin-dosing algorithms combine clinical factors and dosing history with the current international normalized ratio (INR) to estimate the therapeutic warfarin dose. Unfortunately, these approaches can result in an overdose if the INR is spuriously low. Our goal was to develop an alert mechanism based on prior INRs in addition to the current INR. Using data from the Genetics InFormatics Trial (GIFT) of Warfarin to Prevent DVT, we analyzed warfarin dose estimates for days 3 through 11 that were ≥10 % higher than an average of the previous two dose estimates. We fit a stepwise mixed model to current and prior dose estimates, and subsequently compared the root-mean-square-error (RMSE) in predicting the final therapeutic dose using the GIFT algorithm versus the mixed model. From 861 dosing records (obtain from 556 patients), 646 dosing records (75 %) were randomly selected for the derivation cohort and 215 dosing records (25 %) for the validation cohort. Using one prior dose estimate improved the accuracy of the warfarin dose estimate. Compared to a dose estimate based on current INR (GIFT algorithm), the mixed model reduced the RMSE in the derivation cohort by 0.0015 mg/day (RMSE 0.2079 vs. 0.2094; p = 0.039). In the validation cohort, the RMSE reduction was not significant. A mixed model of dose estimates based on the current and most recent INRs shows potential to improve the safety of warfarin dosing. Clinicians should be cautious about aggressively escalating the warfarin dose after an INR that is lower than expected.

Because the occurrence of postoperative myocardial ischaemia (MI) predicts subsequent cardiac morbidity and mortality, we determined the prevalence of and risk factors for MI in hip and knee arthroplasty patients. High-sensitivity cardiac troponin T (hs-cTnT) was measured on stored samples from postoperative day two in 394 hip and knee arthroplasty patients ≥ 65 years of age enrolled in the Genetics-InFormatics Trial (GIFT). Fifty-three (13.5 %) participants had MI, of whom only three were diagnosed clinically during their hospitalisation. The risk of MI increased with age [odds ratio (OR) 3.52 per decade, 95 % confidence interval (CI) 2.00–6.19] and diabetes (OR 2.23, 95 % CI 1.04–4.77). MI was rarer with statins (OR 0.74, 95 % CI 0.40–1.35) and more common with hypertension, coronary artery disease and tobacco use, although these were not statistically significant. Subclinical MI occurs frequently after arthroplasty. Diabetic and elderly patients are at highest risk.