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Summary: A 57-year-old male patient with a history of proximal deep vein thrombosis on vitamin K antagonist therapy, suffered a recent hypertensive intracranial hemorrhage without significant neurological deficit. Three weeks later he presented with bilateral central pulmonary embolism. He had witnessed cardiac arrest and was put on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Endovascular thrombectomy with an Aspirex device led to a significant improvement of hemodynamics. VA-ECMO was terminated after one day, an IVC filter was inserted, and he was discharged from ICU after 15 days. In conclusion, VA-ECMO and endovascular therapy are rescue strategies in patients with contraindications for thrombolysis.

Objective: Medical contraindications to estrogen limit women's contraceptive options. This study assessed the association between selected medical contraindications to estrogen on contraceptive use...

Background Os acromiale can be potentially missed or misdiagnosed as acromion fracture, and this can affect treatment determination if it is complicated with an ipsilateral shoulder injury. The clavicle hook plate is a widely used technique for distal clavicle injuries, leading to transacromial erosion, particularly when in the presence of os acromiale. Case presentation A 70-year-old man and a 78-year-old man who had limited mobility and severe pain in their right shoulders following falls attended the emergency center. Both patients were diagnosed with os acromiale with CT or MRI and acute distal clavicle fracture or acromioclavicular joint dislocation. Following a comprehensive evaluation, os acromiale may limit the application of a clavicle hook plate due to potential transacromial erosion. The distal clavicle fracture with ipsilateral os acromiale received treatment with a volar radius locking T plate, and the acromioclavicular joint dislocation with ipsilateral os acromiale was reconstructed using suture anchors. Both yielded satisfactory outcomes and voided transacromial erosion. Conclusions Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate. An axillary lateral radiograph is recommended to detect potential os acromiale in patients using a hook plate.

Background CIEDs have historically restricted the use of MRI due to the potential clinical and configurational risks associated with electromagnetic interference. In this study, the authors investigated the impact of Magnetic Resonance Imaging (MRI) on the functional integrity of non-conditional cardiovascular implantable electronic devices (CIEDs) and their clinical correlates. Methods In this prospective, observational single-center study, we enrolled patients undergoing MRI over a 5-year period. Prior to assessing the impact of MRI on CIEDs, we performed interrogations in sequential duplication to assess the intrinsic variability of devices. Subsequently, we performed interrogations immediately after MRI, and monitored changes in device parameters and clinical events. Results We completed 492 MRI studies, 58% in patients with permanent pacemakers (PPMs) and 42% with implantable cardioverter defibrillators (ICDs). Subsequent MRI exposures occurred in 15% encounters. Accounting for intrinsic variability in CIED leads, there were no significant changes in RA, RV, or LV parameters after MRI, regardless of the region imaged (thoracic vs non-thoracic), type of CIED (PPMs vs ICDs) and among those with serial MRIs. When ranked for % change pre- to post-MRI, the majority of RA, RV and LV metrics for thresholds, sensing, and impedance conformed to ≤20% change from baseline. No significant clinical adverse cardiac events or effect on device microcircuitry occurred during the study. Conclusion Incorporating a novel reproducibility tactic, there were neither clinically meaningful device parameter changes nor adverse clinical events during or following MRIs, suggesting the effects of MRI on non-conditional CIED integrity are far less than previously perceived. This article is protected by copyright. All rights reserved.

Introduction: Use of hydroxychloroquine in patients with coronavirus disease 2019 (COVID-19) was widespread and uncontrolled until recently. Patients vulnerable to severe COVID-19 are at risk of hydroxychloroquine interactions with co-morbidities and co-medications contributing to detrimental, including fatal, adverse treatment effects. Methods: A retrospective survey was undertaken of health conditions and co-medications of patients with COVID-19 who were pre-screened for enrolment in a randomized, double-blind, placebo-controlled hydroxychloroquine multi-centre trial. Results: The survey involved 305 patients [median age 71 (interquartile range 59–81) years]. The majority of patients (n = 279, 92%) considered for inclusion in the clinical trial were not eligible, mainly due to safety concerns caused by health conditions or co-medications. The most common were QT-prolonging drugs (n = 188, 62%) and haematologic/haemato-oncologic diseases (n = 39, 13%) which prohibited the administration of hydroxychloroquine. In addition, 165 (54%) patients had health conditions and 167 (55%) patients were on co-medications that did not prohibit the use of hydroxychloroquine but had a risk of adverse interactions with hydroxychloroquine. The most common were diabetes (n = 86, 28%), renal insufficiency (n = 69, 23%) and heart failure (n = 58, 19%). Conclusion: The majority of hospitalized patients with COVID-19 had health conditions or took co-medications precluding safe treatment with hydroxychloroquine. Therefore, hydroxychloroquine should be administered with extreme caution in elderly patients with COVID-19, and only in clinical trials.

Purpose: Not all patients with stage III non-small cell lung cancer (NSCLC) are suitable for concurrent chemoradiation therapy (CRT). Local failure rate is high for sequential concurrent CRT. As such, there is a rationale for treatment intensification. Methods and Materials: Isotoxic intensity modulated radiation therapy (IMRT) is a multicenter feasibility study that combines different intensification strategies including hyperfractionation, acceleration, and dose escalation facilitated by IMRT. Patients with unresectable stage III NSCLC, Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0 to 2, and unsuitable for concurrent CRT were recruited. A minimum of 2 cycles of platinum-based chemotherapy was compulsory before starting radiation therapy (RT). Radiation dose was increased until a maximum dose of 79.2 Gy was reached or 1 or more of the organs at risk met predefined constraints. RT was delivered in 1.8-Gy fractions twice daily, and an RT quality assurance program was implemented. The primary objective was the delivery of isotoxic IMRT to a dose >60 Gy equivalent dose in 2-Gy fractions (EQD2 assuming an α/β ratio of 10 Gy for acute reacting tissues). Results: Thirty-seven patients were recruited from 7 UK centers. Median age was 69.9 years (range, 46-86 years). The male-to-female ratio was 17:18. ECOG PS was 0 to 5 in 14.2% of patients; PS was 1 to 27 in 77.1% of patients; PS was 2 to 3 in 8.6% of patients. Stage IIIA:IIIB ratio was 22:13 (62.9%:37.1%). Of 37 patients, 2 (5.4%) failed to achieve EQD2 > 60 Gy. Median prescribed tumor dose was 77.4 Gy (range, 61.2-79.2 Gy). A maximum dose of 79.2Gy was achieved in 14 patients (37.8%). Grade 3 esophagitis was reported in 2 patients, and no patients developed grade 3 to 4 pneumonitis. There were 3 grade 5 events: acute radiation pneumonitis, bronchopulmonary hemorrhage, and acute lung infection. Median follow-up at time of analysis was 25.4 months (range, 8.0-44.2) months for 11 of 35 survivors. The median survival was 18.1 months (95% confidence interval [CI], 13.9-30.6), 2-year overall survival was 33.6% (95% CI, 17.9-50.1), and progression-free survival was 23.9% (95% CI, 11.3-39.1). Conclusions: Isotoxic IMRT is a well-tolerated and feasible approach to treatment intensification.

Purpose Current guidelines have no sex‐specific dosage advice for metoprolol. To evaluate whether women and men are prescribed the same dose a cohort analysis was performed in the population‐based Rotterdam Study (RS). Results were replicated in the Integrated Primary Care Information (IPCI) database of automated general practice data. Methods The mean daily starting doses of metoprolol in both sexes were compared with independent‐samples t‐tests and a linear regression analysis was used to adjust in the RS for co‐variables, notably, cardiovascular comorbidity, migraine, age, SBP, DBP, BMI, socioeconomic status, use of other antihypertensive drugs, smoking, and alcohol. In the IPCI‐database, adjustment was for age only. Results The mean daily starting dose was statistically significantly lower in women than in men in both the RS and IPCI database, with a mean difference of 4.8 mg (95%CI −7.8, −1.8) and 4.6 mg (95%CI −5.3,‐4.0), respectively. Statistical significance remained after adjustment in both databases. Conclusions Women received lower starting doses of metoprolol than men in two independent data collections despite non‐sex specific cardiovascular guideline recommendations. This example of real‐life pharmacotherapy can lead to a form of confounding by contraindication in pharmacoepidemiology.

Despite scant evidence, current guidelines indicate that esophageal varices are a relative contraindication to transesophageal echocardiography (TEE). The aim of this study is to compare the risk of gastrointestinal bleeding following TEE among cirrhotic patients with and without endoscopically-documented esophageal varices. This is a retrospective analysis of patients with cirrhosis who underwent upper endoscopy within 4 years of TEE at five institutions between January 2000 and March 2020. Primary outcome was overt gastrointestinal bleeding. Secondary outcomes were hemoglobin decline by at least 2 g/dL or blood transfusion within 48 hours following TEE. Of the 191 patients, 79 (41.4%) had esophageal varices (30.4% large). No patient experienced a primary outcome. Secondary outcomes occurred in 52 (27.2%): 28 (35.4%) with esophageal varices and 24 (21.4%) without varices. After propensity-score covariate adjustment, the odds ratio for a secondary outcome in patients with esophageal varices was 1.49 (95% confidence interval 0.74-2.99). Restricting analysis to those who underwent endoscopy within 1 year of TEE did not significantly alter results. The risk of a secondary outcome was identical between patients who had upper endoscopy prior (27.5%) versus subsequent (26.7%; P = 1.00) to TEE. Conclusions: Among patients with cirrhosis, there was no overt gastrointestinal bleeding after TEE. The likelihood of a 2 g/dL decline in hemoglobin or blood transfusion within 48 hours following TEE was not significantly higher in patients with esophageal varices after controlling for confounders. Patients who underwent upper endoscopy before TEE did not manifest a lower risk of secondary outcomes versus those who had endoscopy after TEE, suggesting that routine preprocedural endoscopy is of marginal utility.

Sleep restriction therapies likely drive improvement in insomnia in middle childhood via increases in homeostatic sleep pressure (e.g., evening sleepiness). Increased evening sleepiness may also dampen comorbid anxiety symptoms; and reduced wakefulness in bed may reduce worry. However, sleep restriction therapies have never been evaluated as a standalone intervention in this population. The mechanism of action needs testing, as do effects on anxiety, and cognitive performance and parasomnias (possible contraindications). This randomised controlled trial evaluated the efficacy of two "doses" of sleep restriction therapy (sleep restriction therapy, bedtime restriction therapy), compared to a control condition (time in bed regularisation). A total of 61 children (mean [SD, range] age 9.1 [2.1, 6-14] years; 54% female) with chronic insomnia disorder received two weekly 60-min treatment sessions with a psychologist. Sleep, sleepiness, anxiety, worry, cognitive performance, and parasomnias were measured pre-treatment, across treatment, and at 4-weeks post-treatment. Both the sleep and bedtime restriction groups experienced reductions in total sleep time (d = 1.38-2.27) and increases in evening sleepiness (d = 1.01-1.47) during the 2-week treatment, and improvements in insomnia (i.e., sleep onset latency; d = 1.10-1.21), relative to the control group. All groups reported improved anxiety and worry, yet there were no differences between the control and restriction groups (all p 0.658). Time in bed increased at the 1-month follow-up, and benefits to sleep and insomnia were maintained. There were no adverse effects on cognitive functioning (all p 0.259), nor parasomnia occurrence (all p 0.740). These results suggest that sleep restriction therapies are brief, yet effective, standalone interventions for insomnia in middle childhood, and improvements are likely due to increased sleepiness, not sleep regularisation.

We aimed to determine pouch function and retention rate for restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) in elderly patients.We identified patients over 50 years old subjected to IPAA for confirmed pathological UC from 1980 until 2016. Patients were grouped according to age: 50-59, 60-69 and 70+ years. Short and long-term outcomes and quality of life (QOL) were compared among the groups.Six hundred and one patients were identified (399 (66.4%) between 50-59 181 (30.1%) between 60-69, and 21 (3.5%) over 70 years of age). More males were in the 70+ arm, and more two-stage procedures were performed in this group. Wound infection increased with age (P = 0.023). There was a trend of more fistula and pouchitis in the 70+ patients (P = 0.052 and P = 0.055, respectively). Pouch failure rate increased with age, and it was statistically significant in the 70+ cohort (P = 0.015). Multivariate stepwise logistic regression showed that pelvic sepsis (HR 4.8 (95% CI 1.5-15.4), P = 0.009), fistula (HR 6.0 (95% CI 1.7-21.5), and mucosectomy with handsewn anastomosis (HR 4.5 (95% CI 1.4-14.7)), were independently associated with pouch failure. No difference was observed in the QOL among the groups, but pouch function was better for patients younger than 60 years.In elderly patients with UC, IPAA may be offered with reasonable functional outcomes, and ileal pouch retention rates, as an alternative to the permanent stoma. Stapled anastomosis increases the chance of pouch retention and should be recommended as long as the distal rectum does not carry dysplasia.

Purpose: To evaluate the suitability of corneas from septic donors for transplantation by analyzing the discard rate in the eye bank and the clinical outcome of Descemet membrane endothelial keratoplasty (DMEK) using organ-cultured corneal grafts from septic versus nonseptic donors. Methods: This retrospective study included 1554 corneas of which 456 corneas (29%) were from septic and 1072 corneas (69%) from nonseptic donors [for 26 corneas (2%) sepsis status was unknown]. The clinical outcome at 6 months after DMEK was evaluated for 82 grafts (26 from septic and 56 from nonseptic donors). Outcome measures were endothelial cell density, central corneal thickness, and postoperative complications. Results: Primary discard rates were higher for corneas from septic than from nonseptic donors (32.9% vs. 24.5%, P = 0.001). The main discard reason was poor endothelial cell quality for both septic (13.8%) and nonseptic (11.8%) donor corneas. Eye bank contamination rates for septic and nonseptic donor corneas were 1.1% and 1.7%, respectively (P = 0.102). After DMEK, donor endothelial cell density at 6m postoperatively was comparable between grafts from septic and nonseptic donors (1410 +/- 422 cells/mm(2) vs. 1590 +/- 519 cells/mm(2), P = 0.140). No differences in 6m central corneal thickness and in the rebubbling rate were observed between the 2 groups (P = 0.780 and P = 0.396, respectively). None of the cases had graft rejection nor endophthalmitis in both groups. Conclusions: Provided strict adherence to donor screening and evaluation protocols, the use of organ-cultured corneas from septic donors for DMEK does not seem to increase the risk for recipients and allows for expansion of the donor pool for corneal tissue.

BACKGROUND Hemoglobin-Based Oxygen Carriers (HBOCs) can act as an "oxygen bridge" in acute severe anemia when transfusion is indicated, but not possible. We present data on 10 Expanded Access (EA) patients treated with high cumulative doses of Hemopure (HBOC-201), to assess the ability of HBOC-201 to safely treat life threatening anemia in situations where high volumes of product were administered over an extended period of time. STUDY DESIGN AND METHODS Inclusion in this study required that the patient receive at least 10 units of HBOC-201 between 2014 and 2017 under the FDA-sanctioned EA program. Depending on a patient's geographical location, treatment with HBOC-201 was obtained through either a single patient emergency Investigational New Drug (IND) application, or an intermediate size population IND. Of the 41 patients who were treated during this period, 10 patients received 10 or more units of the product. Data were obtained from medical records. RESULTS Treatments with HBOC-201 started within 24 hours of signing consent and were administered at an average rate of 1.99 (SD 0.17) units per day over a mean of 8.2 days (SD 2.9), during which patients received on average 16.2 units (SD 5.7 units) of HBOC-201. The median pre-treatment nadir corpuscular hemoglobin (Hb) concentration was 3.3 (SD 0.9) g/dL and post-treatment Hemoglobin was 7.3 (SD 1.7) g/dL. Common side effects included methemoglobinemia, gastrointestinal symptoms, and hypertension. However, no product-related serious adverse events (SAEs) were noted. All patients survived. CONCLUSIONS Administration of HBOC-201 over an extended period is a feasible and safe oxygen bridge for severely anemic patients who cannot be transfused with RBC.

A radiographic overlap of the lateral femoral condyle and the lateral tibial spine (‘tibial spine sign’) might indicate lateral compartment cartilage damage and might be considered a contraindication for unicompartmental knee arthroplasty (UKA). Therefore, the following research questions were asked: (1) does the presence of a ‘tibial spine sign’ on radiographs correlate with cartilage lesions on the medial aspect of the lateral femoral condyle on corresponding MRIs?; (2) do cartilage lesions on the medial aspect of the lateral femoral condyle indicate cartilage damage in the central area of the distal lateral femur?; and 3) is the ‘tibial spine sign’ impacted by the degree of varus deformity, the amount of coronal tibiofemoral subluxation or the functional status of the ACL? One hundred consecutive knees with varus OA in 84 patients were prospectively included. The relationship of the lateral femoral condyle and the tibial spine was graded from 0 to 2 based on the degree of overlap on AP standing knee radiographs. On MRI, cartilage on the medial aspect of the lateral femoral condyle was assessed. Cartilage in the weight-bearing area of the distal lateral femur was analysed according to the OARSI system. The ‘tibial spine sign’ assessment correlated well with the degree of cartilage damage on the medial aspect of the lateral condyle (rs = 0.7, p

Background: A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. Methods: This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. Results: Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140–720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51–1.73]; P =0.84), death (aHR, 0.78 [95% CI, 0.22–2.76]; P =0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48–1.73]; P =0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15–0.82]; P =0.02). Conclusions: In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.

BACKGROUND: Conventional superior access for cardiac implantable electronic devices (CIEDs) is not always possible and femoral CIEDs (F-CIED) are an alternative option when leadless systems are not suitable. The long-term outcomes and extraction experiences with F-CIEDs, in particular complex F-CIED (ICD/CRT devices), remain poorly understood. METHODS: Patients referred for F-CIEDs implantation between 2002 and 2019 at two tertiary centers were included. Early complications were defined as ≤30 days following implant and late complications >30 days. RESULTS: Thirty-one patients (66% male; age 56 ± 20 years; 35% [11] patients with congenital heart disease) were implanted with F-CIEDs (10 ICD/CRT and 21 pacemakers). Early complications were observed in 6.5% of patients: two lead displacements. Late complications at 6.8 ± 4.4 years occurred in 29.0% of patients. This was higher with complex F-CIED compared to simple F-CIED (60.0% vs. 14.3%, p = .02). Late complications were predominantly generator site related (n = 8, 25.8%) including seven infections/erosions and one generator migration. Eight femoral generators and 14 leads (median duration in situ seven [range 6-11] years) were extracted without complication. CONCLUSIONS: Procedural success with F-CIEDs is high with clinically acceptable early complication rates. There is a notable risk of late complications, particularly involving the generator site of complex devices following repeat femoral procedures. Extraction of chronic F-CIED in experienced centers is feasible and safe.

The aim of this case–control study is to compare the surgical outcomes of laparoscopic adrenalectomy (LA) for lesions measuring ≥6 cm versus ≤5.9 cm in diameter. Eighty-one patients with adrenal gland lesions ≥6 cm in diameter (intervention group) were identified. Patients were matched to 81 patients with adrenal gland ≤5.9 cm in diameter (control group) based on disease (Conn–Cushing syndrome, pheochromocytoma, primary or secondary adrenal cancer or other disease), lesion side (right, left), surgical technique (anterior transperitoneal approach for right and left LA or anterior transperitoneal submesocolic for left LA) and body mass index class (18–24.9, 25–29.9, 30–34.9, 35–39.9, ≥40 kg/m2). Surgical outcomes were compared between the intervention and control groups. Mean operative time was statistically significantly longer in the interventional arm (101.4 ± 52.4 vs. and 85 ± 31.6 min, p = 0.0174). Eight conversions were observed in the intervention group (9.8%) compared to four in the control group (4.9%) (p = 0.3690). Five (6.1%) and three (3.7%) postoperative complications were observed in the intervention and control groups, respectively (p = 0.7196). Mean postoperative hospital stay was 4.6 ± 2.4 and 4.1 ± 2.3 days in the intervention and control groups, respectively (p = 0.1957). Operative time was statistically significantly longer in adrenal gland lesions ≥6 cm in diameter (vs. ≤5.9 cm). Conversion and complication rates were also higher, but the difference was not statistically significant. Based on the present data, adrenal gland lesions ≥6 cm in diameter are not an absolute contraindication to the laparoscopic approach.

Background & aim Active abdominal compression-decompression cardiopulmonary resuscitation (AACD-CPR), which applies to cardiac arrests with contraindication of standard chest compressions (SCC) CPR, has been utilized in cardiac arrest. However, the efficacy and safety of AACD-CPR still remained controversy. This analysis was designed to comprehensively compare AACD versus SCC-CPR in patients with cardiac arrest. Methods We searched the Cochrane Library, PubMed, EMBASE, Web of Science and CNKI up to April 22, 2019. Mean difference (MD) and risk ratio (RR) with its 95% confidence intervals (CIs) were estimated to compare outcomes of the groups. Our primary outcomes were restoration of spontaneous circulation (ROSC) and short-term survival. Two reviewers assessed trial quality and extracted data independently. All statistical analyses were performed using standard statistical procedures provided in Review Manager 5.2 and Stata 12.0. Results A total of seventeen studies (N = 1647 patients) were identified for the present analysis. Compared with standard CPR, AACD-CPR was superior in restoration of spontaneous circulation (ROSC) and short-term survival, with pooled RRs of 1.38 (95% CI 1.23–1.55; P Conclusions Generally, in this combined analysis we found a statistically significant improvement in survival and ROSC with the use of AACD-CPR as compared with the use of standard CPR. There was also significant improvement in incidence of fracture, long-term survival, PETCO2 and CPP with AACD-CPR in comparison with standard CPR; results were not statistically different between the groups regarding to vomiting rate and adverse events. The standardized, diversified and individualized methods of clinical operation of AACD-CPR need exploration and expectingly serve as a guideline for clinical application of AACD-CPR in the future.

Background Percutaneous pulmonary valve implantation (PPVI) numbers are rising but are still minor compared to surgery due to several contraindications. We sought to analyze the impact of PPVI compared to standard surgery in an unselected cohort with dysfunctional right ventricular outflow tract (RVOT). Reasons for PPVI failure and possible contraindications were explored. Methods Between 2010 and 2015 all consecutive patients who underwent surgery or intervention for a dysfunctional RVOT were investigated. Results A total of 382 cases was identified – 246 patients underwent successful valve insertion: 166 surgeries (166/246 = 67.4%) with 55/166 homografts (33.1%), 106 Contegra ® grafts (63.8%), 5 Hancock valves (3.0%). Overall, 70/246 patients presented a priori with an enlarged RVOT > 28 mm (28.5%) not appropriate for PPVI and 14/246 (5.7%) had additional defects necessitating surgery. Some 31/246 patients had surgery for initial repair of congenital defects or were too small ( ® valves (63.7%), 29 Melody valves (36.3%)]. The RVOT was too large for PPVI in 22/246 patients (8.9%). A total 20/246 patients (8.1%) showed coronary compression after balloon interrogation. In 4/246 patients PPVI was not possible due to technical issues (1.4%). Conclusion PPVI could be performed successfully in 80/382 patients (20.9%). An enlarged RVOT, small patient size, and coronary compression were the major obstacles for interventional management. Future developments for larger RVOTs and smaller body weight may expand the indication for PPVI.

Hepatic steatosis carries a risk of postoperative liver dysfunction in donors and graft nonfunction in recipients. This article discusses the evaluation of fatty infiltration in donor liver parenchyma on multidetector computed tomography.The methods of hepatic fat estimation include measurement of hepatic attenuation in HU and calculation of the liver attenuation index (LAI). Liver attenuation values reflect the degree of steatosis. Average attenuation of liver parenchyma is calculated by placing the circular region of interest of at least 1 cmA total of 52 donors were evaluated as potential recipients (34 men, 18 women; mean age, 33.2 years; range, 23-55 years). In 34 donors liver attenuation index (LAI) values were from 2 HU to 22 HU. An LAI5 HU correctly predicted the absence of significant macrovesicular steatosis. These donors were acceptable for a liver transplant. The LAI values of -10 to 5 HU were suggestive of mild to moderate steatosis (6%-30%); 18 (34.6%) volunteers did not proceed to donation because of negative LAI -5 HU. In 2 cases with LAI of -7 and LAI of -8 liver biopsy was performed, and 30% steatosis was confirmed in the pathohistologic examination. Unacceptable liver biopsy result was considered as contraindication for donation. The LAI values of -10 HU were suggestive of moderate to severe hepatic steatosis of 30% or greater. In these cases liver biopsy is not needed, as such donors are not acceptable for liver transplant.Computed tomography imaging provides a detailed evaluation of fatty infiltration in donor liver parenchyma.

Background The Fecal Occult Blood Test (FOBT) is one of the diagnostic modalities indicated for screening patients for Colorectal Cancer (CRC). Despite being approved only for screening for CRC, numerous studies in the past have illustrated misuse of the FOBT. We examined utilization of the FOBT for patients admitted to a community teaching hospital. Methods The study was conducted at Saint Joseph Hospital, Chicago USA. A retrospective review of Electronic Medical Records (EMRs) of patients admitted from January 2016 to December 2017 was performed. Results We reviewed the EMRs of 729 patients who received the stool testing for occult blood (FOBT). All tests (100%) were carried out for purposes other than CRC screening. Anemia (38%) was the most common reason documented for carrying out the FOBT. Further, 88% of the tests were ordered on patients who either did not fulfill CRC screening criteria or had other contraindications for testing. Usage of contraindicated medication was the most important factor (58% of patients) that made the candidates ineligible for testing. A total 73 Colonoscopies were ordered for patients who received the test inappropriately with a resulting low yield (0.47%) of CRC diagnosis. Conclusion The stool occult blood test continues to be utilized for reasons other than CRC screening. Majority of patients who underwent the test were not suitable candidates due to the presence of contraindications for testing. Unsuitable FOBT testing led to further unnecessary investigations.

This study sought to identify knowledge gaps and attitudinal barriers to prescribing intrauterine contraception (IUC).A national, Web-based survey of Canadian gynaecology (GYN) and family medicine (FM) physicians was conducted. The survey was distributed through several channels, including physicians' databases, invitations through a commercial email aggregating service, and contacting residency programs. For knowledge-based questions, correct answers were those consistent with Canadian practice guidelines. Ethics approval was granted through Queen's Health Sciences Research Ethics Board. Project funding was through a research grant from Bayer, Inc. (Canadian Task Force Classification III).A total of 600 responses were received. GYN physicians' knowledge about IUC (number correct / 40) was better than that of the FM and FM with additional women's health training (FMWH) groups (median [interquartile range] 39 [37-40], 36 [32-38], and 37 [35-39]; P 0.0001). Factors associated with lower scores included rural practice location, lack of affiliation with medical trainees, extremes of practice duration, and self-perceived lack of knowledge about IUC. Most respondents prescribed IUC (93.7%). Among prescribers, 97.0% inserted IUC. The most common reasons for not prescribing or inserting IUC included lack of training, lack of comfort, and referral to other physicians to provide this service. Respondents indicated that they would be more likely to prescribe and/or insert IUC if cost barriers were removed, patient interest was increased, or if there was improved access to patient-centred educational materials and hands-on training modules.This study suggests that although many GYN and FM physicians are offering IUC, misconceptions regarding contraindications still exist, and several barriers are related to deficiencies in providers' knowledge. Therefore, educational efforts should be prioritized to increase the usage of IUC.

Listing practices for solid organ transplantation are variable across programs in the USA. To better characterize this variability, we performed a survey of psychosocial listing criteria for pediatric and adult heart, lung, liver, and kidney programs in the USA. In this manuscript, we report our results regarding listing practices with respect to obesity, advanced age, and HIV seropositivity. We performed an online, forced-choice survey of adult and pediatric heart, kidney, liver, and lung transplant programs in the USA. Of 650 programs contacted, 343 submitted complete responses (response rate = 52.8%). Most programs have absolute contraindications to listing for BMI > 45 (adult: 67.5%; pediatric: 88.0%) and age > 80 (adult: 55.4%; pediatric: not relevant). Only 29.5% of adult programs and 25.7% of pediatric programs consider HIV seropositivity an absolute contraindication to listing. We found that there is variation in absolute contraindications to listing in adult programs among organ types for BMI > 45 (heart 89.8%, lung 92.3%, liver 49.1%, kidney 71.9%), age > 80 (heart 83.7%, lung 76.9%, liver 68.4%, kidney 29.2%), and HIV seropositivity (heart 30.6%, lung 59.0%, kidney 16.9%, liver 28.1%). We argue that variability in listing enhances access to transplantation for potential recipients who have the ability to pursue workup at different centers by allowing different programs to have different risk thresholds. Programs should remain independent in listing practices, but because these practices differ, we recommend transparency in listing policies and informing patients of reasons for listing denial and alternative opportunities to seek listing at another program.

The aim of this study was to evaluate the safety and efficacy of the EkoSonic Endovascular System (EKOS) in patients with acute pulmonary embolism (APE) at high or intermediate-high risk and contraindication to systemic fibrinolysis.This is a retrospective study including consecutive patients admitted due to high-risk or intermediate-high-risk APE and treated by EKOS because of an absolute or relative contraindication to systemic fibrinolysis. The primary efficacy end-point was the change from baseline to 72 h in right to left ventricular dimension ratio [right ventricular/left ventricular (RV/LV) ratio]; pulmonary embolic burden using the Qanadli Index; and systolic pulmonary arterial pressure (SPAP). The primary safety end-point was the occurrence of bleeding (GUSTO classification) within 72 h.Eighteen patients (5 men, 13 women; mean age 74 ± 12.7 years) affected by high-risk APE (n = 5; 27.8%) or intermediate-high-risk APE (n = 13; 72.2%) were included. A significant reduction of mean RV/LV ratio (1.38 ± 0.3 vs. 0.97 ± 0.16; P 0.0005); Qanadli Index [27.06 ± 2.6 vs. 18.8 ± 7.8 (P 0.001) and SPAP (71.1 ± 12 vs. 45.2 ± 16 mmHg; P 0.001)] was observed within 72 h after EKOS. Five bleeding events occurred: one fatal and four moderates; three out of them led to the access site hematoma, two due to pre-existing active bleeding.EKOS is an effective tool to treat patients with APE at high or intermediate-high risk and contraindication to fibrinolysis. It is a relatively safe therapy considering the critical conditions and high bleeding risk of the receiving population.

Per-oral pyloromyotomy (POP or G-POEM) provides significant short-term improvements in symptoms and objective emptying for patients with medically refractory gastroparesis, but it is unclear if patients with gastroparesis and co-existing dysmotility (small bowel or colonic delay) also benefit. In this study, we used wireless motility capsule (WMC) data to measure outcomes in patients with isolated gastroparesis (GP) and gastroparesis with co-existing dysmotility (GP + Dys) who underwent POP. We retrospectively analyzed patients who had POP and completed WMC data during their evaluation of intestinal dysmotility. WMC data were reviewed to identify patients who demonstrated isolated GP or GP + Dys. Each patient's pre-op and post-op Gastroparesis Cardinal Symptom Index (GCSI) and 4-h solid-phase scintigraphy gastric emptying studies (GES) scores were compared to evaluate improvement. Of the entire cohort (n = 73), 89% were female with a mean age of 47.0 ± 15.0 years old. Gastroparesis etiologies were divided among idiopathic (54.8%), diabetic (26%), postsurgical (8.2%), autoimmune (5.5%), and multifactorial (5.5%). Forty-one patients (56%) had GP and 32 patients (44%) had GP + Dys. GCSI improved after POP whether the patient had isolated GP (− 12.31, p

BACKGROUND/AIM Melanoma incidence has increased in the United States over the past few decades, and disparities in patient treatment have been described. Although most patients with melanoma are good candidates for curative treatment, some are considered poor candidates for treatment because of comorbid conditions. We examined whether patient demographics influence treatment contraindication in melanoma. PATIENTS AND METHODS The National Cancer Database (NCDB) was used to identify patients with melanoma from 2004 through 2015. Multivariate logistic regression was used to determine independent associations, adjusted for confounders. We excluded patients who did not receive treatment for reasons and patients with unknown treatment status. RESULTS A total of 499,092 patients met the inclusion criteria. Of these, 525 (0.1%) had Treatment contraindicated because of comorbid conditions (TCBC) and 498,567 (99.9%) received treatment. Multivariate logistic regression showed higher odds of TCBC in patients with government insurance (OR=1.34, 95%CI=03-1.73; p=0.03) and patients without insurance (OR=2.75, 95%CI=1.76-4.29; p

Objectives In a conventional hospital ward, we used high-flow nasal oxygen (HFNO) to treat elderly COVID-19 patients noneligible for intensive care unit transfer. Methods This study was conducted in the Institut Hospitalo-Universitaire Mediterranee Infection, Assistance Publique-Hopitaux de Marseille (AP-HM), France. We used high-flow nasal oxygen (HFNO) in our conventional infectious disease ward from 15 September 2020 for elderly patients noneligible for intensive care unit transfer. Results Of the 44 patients (median age 83 years (57–94), mean: 80.25), 61.4% (27/44) were men. The median Charlson score was 7 (1–15). The median of the NEWS-2 score upon admission was 8 (3–11) and was 10 at the time of initiation of HFNO. The median PaO2/FiO2 ratio was 103 (71–151) prior to HNFO initiation. Among the 44 patients, 16 patients (36.4%) had been weaned from HFNO, and 28 patients had died (63.6%). Conclusions In this preliminary report, we observed that HFNO saved the lives of one-third of elderly COVID-19 patients who would have systematically died.

For high-risk classified patients, patients with superobesity and in cases of contraindication to abdominal surgery, traditional bariatric surgery might lead to potential morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a novel and effective bariatric therapy for morbidly obese patients. Our research group initially evaluated the safety, feasibility, and efficacy of ESG for high-risk, high body mass index (BMI) patients, and patients contraindicated to abdominal surgeries.Eligible patients characterized as high-risk for bariatric surgery due to high-BMI, severe comorbidities, or impenetrable abdomen were prospectively documented. ESG was performed by using Overstich® (Apollo Endosurgery, Austin, TX, USA). Primary outcomes included technical success, post-procedure adverse events and mortality, and the change of weight and BMI.ESG was successfully performed for all patients (N = 24, mean age was 55.6 (± 9.2) years old, 75% male). Baseline weight and BMI were 157.9 (± 49.1) kg and 49.9 (± 14.4) kg/mESG can be used as a safe, feasible, and effective option for the therapy of patients with superobesity, high-risk patients, and patients contraindicated to abdominal surgery. Graphical Abstract.

Doxorubicin is a first-line therapy for patients with unresectable advanced soft tissue sarcoma (STS). However, because of cardiotoxicities, it is not used for patients with cardiac problems. Eribulin has exhibited efficacy for advanced STS in second- or later-line treatments. In the present study, we retrospectively analyzed the efficacy and safety of first-line eribulin therapy for patients with advanced STS unable to receive doxorubicin. Six of 28 patients who received eribulin as any line treatment received eribulin as a first-line treatment. The reasons for avoiding doxorubicin were as follows: cardiac problems for four patients and advanced age for two. Median progression-free survival (PFS) of the patients who received eribulin as first-line and, second or later-line therapy were 9.7 months (95% CI: 1.0-not reached) and 3.9 months (95% CI: 2.7–5.9), which were not significantly different. The reasons for discontinuation of eribulin were disease progression and adverse events (2 fatigue and 1 neuropathy) for three patients each. No treatment-related cardiotoxicity was observed. The findings of this study indicated that eribulin exhibits meaningful efficacy for the patients with contraindications for doxorubicin as a first-line treatment without cardiac adverse events. However, appropriate safety management is necessary because older patients are typically among those intolerable of doxorubicin.

PURPOSE: The goal of this study was to determine if the US adult population with nocturia (waking from sleep at night to void) can easily take medications (desmopressin acetate) approved by the US Food and Drug Administration for nocturia. The study examined: (1) the prevalence of comorbid conditions, laboratory abnormalities, and concomitant medications that increase risk of desmopressin use; and (2) whether these factors are associated with age or nocturia frequency. METHODS: Using a cross-sectional analysis of four US National Health and Nutrition Examination Survey (NHANES) waves (2005–2012), a total of 4111 participants aged ≥50 years who reported ≥2 nightly episodes of nocturia were identified. The main outcome was frequency of contraindications and drug interactions as described in US Food and Drug Administration–approved prescribing information. These prescribing concerns were matched to examination findings, medical conditions, concomitant medications, and laboratory results of NHANES participants. The associations between prescribing concerns and nocturia severity and age groups were examined. FINDINGS: The mean participant age was 65.7 years (95% CI, 65.3–66.1), and 45.5% were male. Desmopressin prescribing concerns were present in 80.5% (95% CI, 78.0–82.9) of those ≥50 years of age with nocturia; 50.0% (95% CI, 47.0–53.0) had contraindications, and 41.6% (95% CI, 39.3–44.0) took a concomitant drug that could increase risk of low serum sodium. Desmopressin contraindications were higher with older age (P < 0.001) and present in 73.2% (95% CI, 69.3–77.1) of those ≥80 years of age. IMPLICATIONS: Using NHANES data, this study showed that older US adults with nocturia have a high prevalence of medical conditions, concomitant medications, and baseline laboratory abnormalities that likely increase the risk of potentially severe adverse side effects from desmopressin use. A medication designed and approved for a clinical symptom that is most common in older adults could not be taken by most of the older adults with the symptom.

Sometimes there is doubt as to whether or not anticoagulants should be initiated, and if so which ones, in patients with atrial fibrillation and advanced age, increased frailty, or fall risk, kidney, or liver impairment, alcohol abuse, uncontrolled hypertension, or a history of major bleeding. These subgroups have increased risk of haemorrhage as well as thromboembolism. Treatment with anticoagulants is indicated in the vital elderly, preferably with direct oral anticoagulants as demonstrated by robust data. The available study results for the other subgroups may not be (fully) generalisable to clinical practice. In such patients, a comprehensive risk assessment is therefore advised; as is discussing the pros and cons of (not) using anticoagulants and of both type of anticoagulants. Only in exceptional cases is it justified not to use anticoagulants.

Patients aged ≥75 years with the diagnosis of atrial fibrillation (AF) are at a higher risk of stroke and, according to recent recommendations, should receive oral anticoagulant (OAC) therapy. This study aimed to assess the recommended prophylactic antithrombotic therapy among patients with AF aged ≥ 75 years and its compliance with current guidelines. We also aimed to identify predisposing factors associated with the administration of non-vitamin K antagonist oral anticoagulants (NOACs) in elderly patients with AF. This was a retrospective, single-center observational study. Patients with AF aged ≥75 years hospitalized at a reference cardiology center from 2014 to 2017 were included in the analysis. Among the 1236 eligible patients (43.4% male; mean age, 82 years), OACs were recommended in 90.1% of cases. Of these, 59.8% of patients used NOACs and 40.2% used vitamin K antagonists. Additionally, 3.3% of patients received antiplatelet (AP) therapy and 2.5% were administered low molecular weight heparin. Only 4.5% of patients did not receive any anticoagulant treatment. The majority (89.9%) of patients received relevant prophylactic antithrombotic therapy according to current guidelines; only 1.4% were overtreated and 8.7% were undertreated. The significant predictors of NOAC therapy among patients treated with anticoagulants were non-permanent AF (odds ratio [OR] = 1.68, 95% confidence interval [CI] = 1.30–2.18, P = .0001), age-by 5 years (OR = 1.33, 95% CI = 1.16–1.52, P = .0001), and glomerular filtration rate-by 5 units (OR = 1.06, 95% CI = 1.02–1.10, P = .0066). A high percentage of AF patients aged ≥75 years receive OACs, mainly NOACs. Most patients are treated according to the current guidelines; under treatment is primarily observed in patients receiving AP therapy. Non-permanent AF, age, and preservation of renal function are significant predictors of NOAC use.

Summary Introduction and Objective 50–80% of term newborns develop jaundice, or hyperbilirubinemia (HB), in their first week. The vast majority have benign etiologies, including physiologic jaundice of the newborn and breast milk/breastfeeding jaundice, which do not affect the synthetic capacity of the liver, thus conferring a low risk of peri-procedural bleeding. Though uncommon, HB in the setting of sepsis, biliary obstruction, or metabolic disease, may increase procedural bleeding risk. Circumcision of neonates with HB has not been well studied. We sought to characterize practice patterns among Society of Pediatric Urology (SPU) members and to explore whether HB confers increased bleeding risk for newborn circumcision. Methods An anonymous survey of 14 multiple-choice questions was sent to members of the SPU listserv. Questions regarding circumcision and HB were presented. We performed a literature review regarding whether HB confers increased surgical bleeding risk. Results 100/234 (43%) SPU members completed the survey. The majority (79/100) perform neonatal circumcision and use the Gomco© clamp (68%). 24/79 (30%) factor total bilirubin (Tbili) level in their decision prior to performing circumcision. Of those who consider HB a factor, 11/24 (46%) had cutoff Tbili levels at which they await improvement prior to proceeding. The most common cutoff level was Tbili level of 10–15 mg/dL (6/11, 55%). Discussion Existing data suggest a possible increased bleeding risk isolated to cases of HB in the setting of biliary obstruction or other associated relevant findings (ill infant, recent infection, congenital syndromes) or known personal/family history (fulminant liver disease, familial bleeding diatheses). While literature from Jewish Mohels and Talmudic discussion suggest that elevated Tbili may be a contraindication to circumcision, no scientific studies exist directly assessing the impact of HB on bleeding risk with circumcision. A review of the scientific literature suggests that isolated HB in otherwise healthy newborns does not increase bleeding risk. Conclusions 30% of pediatric urologists survey respondents consider HB a potential contraindication to neonatal circumcision. Despite varied practices in circumcising jaundiced babies, neonatal jaundice rarely confers increased bleeding risks. While deferring circumcision is appropriate in an ill infant with HB, or in those with a genetic/congenital syndrome or with family history of coagulopathic, review of the scientific literature suggests that in otherwise healthy neonates, elevated Tbili likely represents benign causes and is unlikely to increase bleeding risk. Download : Download high-res image (116KB) Download : Download full-size image Summary Figure . Total bilirubin level at which respondents with a cutoff level would defer circumcision (n=11).

Acute ischemic stroke (AIS) and acute ST-elevation myocardial infarction (STEMI) are leading causes of mortality worldwide. Concurrent AIS presentation with STEMI is rare and potentially fatal. Most importantly to date many centres in Malaysia are still not aware on how to treat this condition. We report a case of AIS, which was treated with intravenous tenecteplase (TNK) according to ischemic stroke dosage and lead to improvement of neurological deficit.

CME: Hormonal Therapy for Gender Incongruence and Gender Dysphoria

Background Percutaneous Endoscopic Gastrostomy (PEG) can involve some complications, despite the good safety of its track record. The Buried Bumper Syndrome (BBS) is a rare, late and dangerous complication that consists in the erosion of the internal bumper through the gastric wall. Case presentation We report the development of BBS in a man with chronic obstructive pulmonary disease (COPD) who had a persistent chronic cough which was prevalently but not solely in the morning and required placement of a PEG tube for continuous infusion of Levodopa/carbidopa intestinal gel for advanced Parkinson's disease. Conclusion We believe that COPD with chronic cough while not representing an absolute contraindication to PEG placement, may potentially cause BBS and therefore an appropriate regimen of tube care by expert personnel is mandatory in this setting.

'No abstract'

Background: In February 2016, a pharmacy-to-dose (PTD) pneumococcal vaccination protocol was implemented to aid in the appropriate selection of pneumococcal vaccines. Objective: The primary objective was to compare the rate of appropriate vaccine ordering with the PTD protocol. Secondary objectives were to assess vaccine administration rate and determine factors preventing patients from receiving the vaccine after appropriate selection. Methods: This was a single-center, retrospective cohort study of adult patients admitted to an inpatient service. Eligible patients were 19 years of age or older and had either a PTD pneumococcal vaccination order placed or an alert triggered indicating that the patient was a candidate for a vaccination. Patients were excluded if they had contraindications to receiving either pneumococcal vaccine. The Fisher exact test was used to evaluate the primary objective, and descriptive statistics were used to evaluate the secondary objectives. Results: A total of 327 patients were included in the analysis: 167 in the preprotocol cohort and 160 in the postprotocol cohort. The correct vaccine ordering rates were found to be 26.9% (45/167) and 83.1% (133/160) in the preprotocol and postprotocol cohorts, respectively ( P < 0.001). In the postprotocol cohort, 17.5% (28/160) of patients did not have a vaccine administered. Reasons for vaccine administration failure were identified as patient refusal, patient expired during admission, vaccine not dispensed by pharmacy, and vaccine dispensed by pharmacy but returned. Conclusions: The PTD pneumococcal vaccination protocol significantly improved correct vaccine ordering rates.

Background Despite widespread implementation, limited data exists relating morbidity or adverse outcomes to Car Seat Tolerance Screen (CSTS) result in preterm and low birth weight (LBW) neonates. The objective of this study was to determine longer term post-discharge outcomes of infants who failed a CSTS. Methods We performed a case control study evaluating outcomes of infants born over one year who failed vs. passed an initial CSTS, utilizing both retrospective medical record review and parental survey data 2-3 years after discharge. Subjects were matched one case of failed CSTS to two controls who passed CSTS based on sex, gestational age, and BW. We performed bivariate analysis of clinical and demographic risk factors comparing those who passed vs. failed CSTS. Results We identified 19 subjects who failed and matched to 37 controls. Cases were significantly more likely to be diagnosed with obstructive sleep apnea (p = 0.027), asthma (p = 0.016), and be treated with albuterol (p = 0.008). We did not find differences in frequency of urgent care visits or hospital admissions between the groups. Although more of the cases were noted to have developmental delays, the difference was not statistically significant. Conclusion This is the first study to evaluate longer term post-discharge outcomes of subjects having undergone CSTS. Subjects who failed CSTS had significantly increased incidence of respiratory diagnoses such as OSA and asthma than matched controls by 2-3 years after discharge. Larger studies are necessary to further evaluate these findings, but this does provide data that CSTS may be useful in identifying at risk neonates.

OBJECTIVECraniopharyngiomas arise from the pituitary stalk, and in adults they are generally located posterior to the chiasm extending up into the third ventricle. The extended endonasal approach (EEA) can provide an ideal corridor between the bottom of the optic chiasm and the top of the pituitary gland (chiasm-pituitary corridor [CPC]) for their removal. A narrow CPC in patients with a prefixed chiasm and a large tumor extending up and behind the chiasm has been considered a contraindication to EEA, with a high risk of visual deterioration and subtotal resection.METHODSA database of all patients treated in the authors’ center (Weill Cornell Medical College, NewYork-Presbyterian Hospital) between July 2004 and August 2016 was reviewed. Patients with craniopharyngiomas who underwent EEA with the goal of gross-total resection (GTR) were included in the study. Patients with postfixed chiasm or limited available preoperative imaging were excluded. Using preoperative contrast-enhanced T1-weighted sagittal midline MR images, the authors calculated the CPC as well as the distance from the chiasm to the top of the tumor (CTOT). From these numbers, they calculated a ratio of the CPC to the CTOT as a measure of difficulty in removing the tumors through the EEA and called this ratio the corridor index (CI). The relationship between the CI and the ability to achieve GTR and visual outcome were measured.RESULTSThirty-four patients were included in the study. The mean CPC was 10.1 mm (range 5.2–19.1 mm). The mean CTOT was 12.8 mm (range 0–28.3 mm). The median CI was 0.8; the CI ranged from 0.4 to infinity (for tumors with a CTOT of 0). Thirty-two patients had GTR (94.1%) and 2 had subtotal resection. The CPC value had no relationship with our ability to achieve GTR and no effect on visual or endocrine outcome.CONCLUSIONSEEA for craniopharyngioma is generally considered the first-line surgical approach. Although a narrow corridor between the top of the pituitary gland and the bottom of the chiasm may seem to be a relative contraindication to surgery for larger tumors, the authors’ data do not bear this out. EEA appears to be a successful technique for the majority of midline craniopharyngiomas.

Magnetic resonance imaging (MRI) is a widely used diagnostic tool with great benefits but has been considered contraindicated in people with cardiac implantable electronic devices (CIED). We investigated the occurrence of MRI in people with CIEDs and associated adverse events in a national cohort. Of 17,848 people included, 56 (0.3%) had at least one MRI; 16 of 16,102 (0.1%) with MRI non-compatible CIEDs and 40 of 1746 (2%) with MRI compatible CIEDs. Following MRI exposure, hospitalisations for potential serious adverse events were rare. Refereed/Peer-reviewed