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Background: Treatment of cardiogenic shock (CS) often requires the use of vasopressors and inotropic agents, which are associated with an increase in mortality. Data on change in vasopressor and inotrope requirements post Impella 5.0 placement is scarce. Thus, we aimed to study the ability of Impella 5.0 to reduce these requirements. Methods: Retrospective analysis of consecutive patients with CS receiving Impella 5.0 was performed. Vasopressor-Inotrope Score (VIS) and a Modified Catecholamine Equivalent score (MCES) was calculated prior to and up to 72 h post-Impella implantation. Primary outcome was change in MCES from baseline to 48-h post implantation and secondary outcomes included change in VIS, changes in MCES according to SCAI Stage and to underlying etiology, and freedom from mortality at 30-days. Results: Twenty-eight patients with median age of 61 (48, 67) years were included. Impella 5.0 was associated with significant reduction in MCES from baseline [9.7 (5.3, 17)] to 48 h [5.7 (3.8, 7.5), p = 0.001]. VIS was also significantly reduced from baseline [8.3 (3.8, 19.9)] to 48 h [5.0 (2.5, 8), p = 0.003]. MCES at 48 h was significantly reduced in patients with SCAI Stage E versus Stage C ( p = 0.026) and with acute myocardial infarction versus acute decompensated heart ( p = 0.003). Thirty-day survival was 0% in patients that had a baseline MCES ⩾ 10 without a reduction in MCES of at least 5 at 24 h. Conclusion: Impella 5.0 is associated with a significant reduction in MCES and VIS scores in patients presenting with CS with 30-day survival being dependent on MCES.

Purpose:This first-in-human phase I study (NCT 01417546) evaluated the safety profile, optimal immunologic/biological dose (OID/OBD), and immunogenicity of the combination of two peptide B-cell epitope vaccines engineered to represent the trastuzumab- and pertuzumab-binding sites. Although trastuzumab and pertuzumab have been approved for clinical use, patients often develop resistance to these therapies. We have advanced a new paradigm in immunotherapy that focuses on humoral responses based on conformational B-cell epitope vaccines.Patients and Methods:The vaccine is comprised of two chimeric HER-2 B-cell peptide vaccines incorporating a “promiscuous T-cell epitope.” Patients were immunized with the vaccine constructs emulsified with nor-muramyl-dipeptide adjuvant in a water-in-oil Montanide ISA 720VG vehicle. Eligible patients with metastatic and/or recurrent solid tumors received three inoculations every 3 weeks.Results:Forty-nine patients with a median of 4 prior lines of chemotherapy received at least 1 vaccination. Twenty-eight patients completed the 3 vaccination regimens. Six patients received 1 six-month boost after the regimen, and one patient received 7 six-month boosts. No serious adverse reactions or dose-limiting toxicities were observed. The vaccine was well tolerated with dose level 2 as the recommended phase II dose. The most common related toxicity in all patients was injection-site reactions (24%). Two patients had a partial response, 14 had stable disease, and 19 had progressive disease.Conclusions:The study vaccine is safe, exhibits antitumor activity, and shows preliminary indication that peptide vaccination may avoid therapeutic resistance and offer a promising alternative to monoclonal antibody therapies.

This file contains supplemental materials, tables, and figures.

Supplementary Table 2 from Screening for Lynch Syndrome (Hereditary Nonpolyposis Colorectal Cancer) among Endometrial Cancer Patients

Endometrial cancer is the most common cancer in women with Lynch syndrome. The identification of individuals with Lynch syndrome is desirable because they can benefit from increased cancer surveillance. The purpose of this study was to determine the feasibility and desirability of molecular screening for Lynch syndrome in all endometrial cancer patients. Unselected endometrial cancer patients (N = 543) were studied. All tumors underwent microsatellite instability (MSI) testing. Patients with MSI-positive tumors underwent testing for germ line mutations in MLH1, MSH2, MSH6, and PMS2. Of 543 tumors studied, 118 (21.7%) were MSI positive (98 of 118 MSI high and 20 of 118 MSI low). All 118 patients with MSI-positive tumors had mutation testing, and nine of them had deleterious germ line mutations (one MLH1, three MSH2, and five MSH6). In addition, one case with an MSI-negative tumor had abnormal MSH6 immunohistochemical staining and was subsequently found to have a mutation in MSH6. Immunohistochemical staining was consistent with the mutation result in all seven truncating mutation–positive cases but was not consistent in two of the three missense mutation cases. We conclude that in central Ohio, at least 1.8% (95% confidence interval, 0.9-3.5%) of newly diagnosed endometrial cancer patients had Lynch syndrome. Seven of the 10 Lynch syndrome patients did not meet any published criteria for hereditary nonpolyposis colorectal cancer, and six of them were diagnosed at age >50. Studying all endometrial cancer patients for Lynch syndrome using a combination of MSI and immunohistochemistry for molecular prescreening followed by gene sequencing and deletion analysis is feasible and may be desirable. (Cancer Res 2006; 66(15): 7810-7)

We report a case of acute right ventricular failure in a patient with cardiogenic shock on left-sided mechanical circulatory support with Impella 5.0. The patient was successfully bridged to heart transplantation using additional right-sided support with Protek Duo. Key learning points of the case include prompt recognition of acute right ventricular failure in patients on left-sided support, early consideration of right-ventricular mechanical support platforms, and timely deployment of right-sided mechanical support.

BACKGROUND The predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy, PRECISE-DAPT (P-DAPT) score has been validated in large cohorts as an effective tool in predicting bleeding complication after dual antiplatelet therapy (DAPT) as well as in predicting in-hospital mortality. The implication of using this score to predict outcomes, including mortality in patients with atrial fibrillation (AF) undergoing PCI is unknown. OBJECTIVE Role of P-DAPT score to study clinical outcomes, including mortality, hospitalization, and major bleeding, particularly among patients with AF. METHODS This is a retrospective observational study of 18,850 consecutive patients who underwent percutaneous coronary intervention (PCI) across a large multihospital healthcare system from 2010 to 2019. Patients were stratified into four groups depending on the presence or absence of AF and P-DAPT score, with score ≥ 25 defined as high risk. The primary outcome was all-cause mortality. The secondary outcomes evaluated were hospitalization and major bleeding. RESULTS In the unadjusted analyses, a P-DAPT score ≥ 25, in both AF and non-AF population, was associated with increased mortality, hospitalization, and bleeding. After adjusting for baseline covariates, no significant differences in major bleeding risk were found across the four groups. However, a P-DAPT score of ≥25 in AF patients was associated with a higher risk for hospitalizations related to cardiovascular causes (HR: 2.15 95% CI 2.00-2.3, p

The Laparoscopic Approach to Cervical Cancer (LACC) trial changed the surgical management of cervical cancer worldwide. It was a multinational phase III clinical trial that reported lower survival and higher rate of abdominopelvic recurrences in minimally invasive surgery (MIS) than those of open surgery after hysterectomy. It is possible that tumor exposure to the peritoneal cavity in the MIS arm may account for these differences. We propose a novel technique to minimize peritoneal contamination of malignant cells present at the cervical os by placing a vaginal cerclage abdominally to create a seal at the apex of the vagina during MIS radical hysterectomy. The 2 patients in this work remain healthy and disease-free more than 18 months after surgery using this novel technique. We intend this work to serve as a platform both for offering a safe alternative to the open approach supported by the LACC trial and, most importantly, for promoting discussion of the results of the LACC trial and further research on surgical techniques in the treatment of cervical cancer. MIS has repeatedly been shown to have lower rates of infection, fewer complications, and shorter hospital stays while providing oncologic care that is noninferior to open approach.

Temporary mechanical circulatory support (tMCS) devices are used for the management of cardiogenic shock. The Impella 5.0 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation in IMP5. This single center, retrospective study included patients supported on IMP5 with BIV based AC. The efficacy and safety end points were recovery, bridge to left ventricular assist device (LVAD), cardiac transplant (HTX), or death as well as clinically significant bleeding, incidence of Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure. There were 31 patients included, and 26 (84%) received BIV purge solutions. The median duration of IMP5 was 6 (IQR 4–10) days. Most patients were bridged to LVAD (39%, 12); 16% (5) were bridged to HTX, 16% (5) recovered, and 29% (9) died. One patient (3%) suffered from ischemic stroke and 12% (4) patients developed clinically significant bleeding. tPA was administered to 8 (26%) patients. Logistic regression analysis demonstrated that duration of IMP5 was a significant predictor of tPA use (OR 1.28; 95% Confidence Interval 1.04–1.56). There were no cases of pump failure. Our experience highlights the feasibility of utilizing BIV for routine AC use in IMP5.

We report a case of acute right ventricular failure in a patient with cardiogenic shock on left-sided mechanical circulatory support with Impella 5.0. The patient was successfully bridged to heart transplantation using additional right-sided support with ProtekDuo. Key learning points of the case include prompt recognition of right ventricular failure in patients on left-sided support, early consideration of right-ventricular mechanical support platforms, and timely deployment of right-sided mechanical support.

Objectives: To describe outcomes following wide local excision (WLE) of the vulva for suspected premalignant or benign disease at a tertiary care center over the years 2016 to 2020. To determine differences in the rates of wound complications and positive margins between patients treated by gynecologic oncologists (GO) and those treated by general gynecologic (GYN) surgeons. Methods: Consecutive patients were identified who underwent wide local excision of the vulva for suspected premalignant or benign lesions between June 1, 2016 and February 28, 2020. Institutional Review Board (IRB) approval was obtained and surgical records were reviewed; patients undergoing “wide local excision, vulva,” “simple partial vulvectomy,” or “destruction of vulvar lesion with excision” were considered for inclusion. Demographic, peri- and postoperative, and pathologic data were collected, and patients were separated by surgeon division (GO or GYN). Patients had follow up documented at least through the postoperative appointment. Surface areas of elliptical specimen were calculated using ‘0.25 x length x width x pi.’ Wound complications and other variables were compared between these groups. All eligible patients were included in the analysis of wound complications. Only patients with pathologic diagnoses of vulvar dysplasia were included in the analysis of margin positivity. Fisher's exact tests and Chi squared tests were used to compare categorical variables and logistic regression models were used for continuous variables. P-values Results: Three-hundred thirty-five patients met inclusion criteria over the study period (GO, n=223; GYN, n=112). Patients in the GO group were older (median age 56y versus 40.5y, P 0.5), or hematoma (1% vs 2%, P>0.5). More patients in the GO group had pathology of high-grade vulvar dysplasia (HSIL) with or without occult carcinoma at the time of WLE (77% vs 40%, P Conclusions: There is renewed interest in optimal management of vulvar surgery.[1] WLE is a common procedure done by GO and GYN surgeons. In our study there was a high overall rate (42%) of postoperative wound complication; however, there were no significant differences in complication rates between GO and GYN surgeons. The rate of positive margins following WLE for vulvar dysplasia was also similar between these groups. The trend towards more frequent complications among GO patients may be explained by a population with older age and more comorbidities. It is appropriate for GO or GYN surgeons to perform WLE of the vulva for HSIL, provided the necessary expertise, comfort, and low concern for invasive disease requiring radical excision or lymph node dissection.

Coronary revascularization for multi-vessel coronary artery disease (mvCAD) can be established through PCI or CABG. The benefit of surgical intervention over PCI has been attributed, in part, to more complete revascularization. However, among patients treated with PCI in the present era of drug-eluting stents, it is important to understand whether the completeness of revascularization is associated with mortality. Further, it is important to investigate this relationship in specific patient populations to determine which patients, if any, derive a survival benefit from complete revascularization. Moreover, it is critical to identify which factors are associated with higher mortality in this population to pinpoint potential areas of intervention to mitigate risk. In this propensity-score adjusted analysis, outcomes among 1,580 mvCAD patients who underwent PCI were analyzed and stratified by complete versus incomplete revascularization. The primary outcome was all-cause mortality. Complete revascularization was achieved in 28.4% of the cohort. Complete revascularization was not independently associated with survival compared with incomplete revascularization in the overall cohort (p=0.16). The predictors of increased all-cause mortality included advanced age, chronic lung disease, cardiogenic shock, diabetes, renal insufficiency, reduced left ventricular function, and left main stenosis. Complete revascularization was associated with reduced all-cause mortality in specific patient subsets including those with congestive heart failure and chronic lung disease. Our analysis elucidated numerous clinical predictors of all-cause mortality for mvCAD patients undergoing PCI. Complete revascularization was not among the independent predictors of mortality in the overall population and was associated with reduced mortality in patients with chronic lung disease, history of congestive heart failure and those who did not have previous PCI. While this study was not designed to test whether complete revascularization was superior to incomplete revascularization, the results suggest that when PCI is pursued among patients with mvCAD, achieving complete revascularization does not contribute to increased mortality.

Purpose There has been an emphasis on treating cardiogenic shock (CS) with early mechanical circulatory support (MCS). Yet, algorithmic approaches for the use of specific MCS devices is institutionally dependent. We evaluated the impact of early, upfront Impella 5.0 vs. an alternative MCS device prior to Impella 5.0. Methods Retrospective analysis was performed on 28 consecutive patients at a single center between Jan. '19 - Aug. '20 implanted with Impella 5.0. Patients were separated into those receiving upfront Impella 5.0 and those that had a different MCS device prior to Impella 5.0. Clinical outcomes and hemodynamic data were collected at various time points. Results 16 patients (57%) with a mean age of 60 ± 10.2 years received upfront Impella 5.0, while 12 (43%) with a mean age of 58 ± 12.6 years received an alternative MCS device first (6 IABP, 6 Impella CP). Etiologies of CS in the upfront Impella 5.0 group were decompensated heart failure (HF) in 15 patients (94%) and MI in 1 patient (6%), and in the prior MCS group were decompensated HF in 5 patients (42%) and MI in 7 patients (58%). The mean duration of either IABP or Impella CP use before Impella 5.0 was 0.83 days. The upfront Impella 5.0 cohort had a trend towards higher initial filling pressures shown by elevated RAP, mPAP, PCWP, and reduced CI and CPO prior to implantation. Greater improvements were also seen in each of these variables at 72 hours compared to the alternative MCS group (Figure 1). Complications rates were higher in the alternative MCS group with significant hemolysis in the Impella CP arm with an average plasma free hemoglobin of 324 ± 268 mg/dL, and 1 major vascular complication requiring surgical intervention; and 1 ischemic stroke. Survival in the upfront Impella 5.0 group was 87% and only 56% in the alternative MCS group. Conclusion Early use of Impella 5.0 provides more hemodynamic support and may reduce complications and improve outcomes. It should be considered as initial strategy, when feasible, in patients with CS that require use of MCS.

Purpose The Impella 5.0 (IMP5) is a surgically implanted axial flow pump used in cardiogenic shock. Anticoagulation (AC) strategy with unfractionated heparin (UFH) is used for pump patency. Alternative AC strategies have not been well defined. This study examines the outcomes of patients treated with bivalirudin (BIV) for AC during IMP5 utilization. Methods This single center, retrospective study included patients supported on IMP5 with BIV based AC. The primary end points were recovery, bridge to left ventricular assist device (LVAD), cardiac transplant (HTX), or death. Secondary end points included clinically significant bleeding (TIMI major or minor), incidence of tPA (Tissue Plasminogen Activator) use for suspected pump thrombosis, stroke, and device outcomes. Results 31 patients were included with a mean age of 57.4 years and 19.4% female. 26 patients (84%) received BIV purge solution. The median duration of IMP5 was 6 days. Most patients (38.7%) were bridged to LVAD; 16.1% were bridged to HTX, 16.1% recovered, and 29% died. 1 patient (3.2%) suffered ischemic stroke and 12 patients (38.7%) developed TIMI major or minor bleeding. . tPA was administered to 8/31 (25.8%) of patients. There was no difference in time to therapeutic AC between patients given or not given tPA(p=0.18). Of those given tPA, 37.5% had therapeutic aPTTs (61-75 seconds) immediately prior to tPA. 17/23 (73.9%) of patients not given tPA had therapeutic aPTTs (Fig. 1). Overall time to therapeutic range for all subjects is displayed in Figure 2. Logistic regression analysis demonstrated that duration of IMP5 was a significant predictor of tPA use (OR 1.28; 1.04-1.56). There were no cases of pump failure. Conclusion Use of BIV as an alternative to UFH for IMP5 was proven to be feasible with most patients surviving to recovery, LVAD, or HTX.

Objectives: To investigate determinants of wound complication following wide local excision (WLE) of the vulva for suspected premalignant or benign disease at a tertiary care center over the years 2016 to 2020. To determine factors associated with perioperative antibiotic use for WLE of the vulva and whether preoperative intravenous (IV) antibiotics or postoperative topical antimicrobial agents are associated with a decreased risk of wound complication. Methods: Consecutive patients were identified who underwent wide local excision of the vulva for suspected premalignant or benign lesions between June 1, 2016 and February 28, 2020. IRB approval was obtained and surgical records were reviewed; patients undergoing ‘wide local excision, vulva,’ ‘simple partial vulvectomy,’ or ‘destruction of vulvar lesion with excision’ were considered for inclusion. Demographic, peri- and postoperative, and pathologic data were recorded. Dimensions of specimen and elliptical surface areas were recorded. Patient follow up was documented at least through the postoperative appointment. Patients were separated by receipt of preoperative IV antibiotics or postoperative antimicrobial agents and by postoperative wound complications. Fisher's exact tests and Chi squared tests were used to compare categorical variables between groups and logistic regression models were used for continuous variables. P-values Results: Three-hundred thirty-five patients met inclusion criteria over the study period. One-hundred forty-one patients developed a wound complication (42%); this included 134 wound separations (40%), 22 infections (6.6%), and 4 hematomas (1.2%). Thirty-two patients (9.6%) received preoperative IV antibiotics and 42 (12.5%) received postoperative topical antimicrobial agents. Neither IV nor topical antimicrobial agents were associated with a decreased risk of wound complication (RR 0.96, 95% CI 0.62-1.49; RR 0.99, 95% CI 0.66-1.48). Demographics and preoperative characteristics were similar between those who received and did not receive antibiotics. Antibiotic administration was not associated with the maximum length or total surface area of excisions, number of vulvar excisions per surgery, or indication for WLE. Preoperative antibiotic use was similar between the gynecologic oncology and general gynecology divisions (RR 1.23, 95% CI 0.59-2.59). Patients who received IV antibiotics were more likely to be undergoing concurrent hysterectomy or other laparoscopic procedure (RR 12.8, 95% CI 7.87-20.75). Conclusions: WLE of the vulva is a common procedure among gynecologic oncologists and general gynecologists and carries a high rate of wound complication. Recent ERAS guidelines report low-level evidence to consider preoperative antibiotics for WLE and do not comment on topical antimicrobials.[1] In our study neither preoperative antibiotics nor postoperative topical antimicrobials were associated with improved outcomes. Prospective data on this topic is lacking and should be an area of future research. Antibiotic use for WLE-in the absence of concurrent clean-contaminated procedures-appears to be guided by surgeon preference.

Introduction Mortality remains high in cardiogenic shock (CS) despite recent emphasis on multidisciplinary approach with early identification and initiation of mechanical circulatory support (MCS). The microaxial ventricular assist device (VAD), Impella 5.0® (Abiomed, Danvers, MA), is an acute MCS device effective in unloading the left ventricle and providing circulatory support to facilitate cardiac recovery or bridge to durable therapies. Escalation in pharmacologic support of CS with vasopressors and inotropes have been associated with increased mortality. We evaluated the impact of the early use of Impella 5.0 in CS with respect to vasoactive agent requirements and clinical outcomes. Methods Retrospective analysis was performed on 14 consecutive patients in CS admitted to the University of Pittsburgh Medical Center between Jan. 2019 - March 2020 implanted with Impella 5.0. Hemodynamic data was collected pre-implantation and up to 72 hours post-implantation. The Vasoactive-Inotropic Score (VIS) and an adjusted Catecholamine Equivalent (CE) score were used to quantify vasopressor and inotrope use for cardiovascular support. Results Most patients were male (86%) with a mean age of 55 ± 11.0 years. Etiologies of CS were acute myocardial infarction (29%) and decompensated heart failure (71%). Use of Impella 5.0 was associated with a reduction in RAP, mPAP, and PCWP that was apparent after 4 hours and continued up to 72 hours post-implantation (RAP: 18 [12, 23], 9 [7, 14], 12 [7, 15]; mPAP: 40 [37, 48], 29 [26, 34], 30 [25, 31]; PCWP: 32 [28, 37], 23 [15, 26], 21 [18, 23] at pre-implantation, 4, and 72 hours after implantation respectively). An immediate and sustained increase in CI, CPO, and PAPi was also demonstrated up to 72 hours (CI: 1.79 [1.38, 2.09], 2.31 [1.93, 2.83], 2.5 [2.04, 2.75]; CPO: 0.54 [0.44, 0.81], 0.8 [0.66, 1.08], 0.80 [0.69, 0.92]; PAPi: 1.26 [0.90, 1.73], 2.145 [1.32, 2.81], 2.0 [1.23, 2.57] at pre-implantation, 4, and 72 hours after implantation respectively). The mean number of vasopressor and inotropes at 72 hours were reduced from 1.92 to 1, along with a sustained reduction in the VIS and CE scores up to 72 hours (Figure 1). The burden of ventricular arrhythmias also decreased post-implantation. Survival occurred in 11 patients (78.6%), with all being discharged from the hospital. Two patients received heart transplants, six received durable LVADs, and three recovered. Conclusions Early initiation of acute MCS with Impella 5.0 in CS is associated with an improvement in hemodynamic parameters and a reduction in vasoactive agents as demonstrated by the VIS and CE score, with favorable clinical outcomes.

The PRECISE-DAPT (P-DAPT) score has been validated in large cohorts as an effective tool in predicting bleeding complication after dual antiplatelet therapy as well as in predicting in-hospital mortality. The implication of using this score to predict outcomes including mortality in patients with

Dose-related effects of atrial overdrive pacing (AOP) on sleep-related breathing disorder (SRBD) were studied. Fourteen patients with pacemakers with moderate to severe SRBD (mean screening apnea-hypopnea index [AHI] 35.2 +/- 21.9 events/hour) were randomized to 3 levels of pacing (50, 10, and 20 beats/min greater than the mean nocturnal heart rate) and studied by polysomnography, observing for changes in AHI. At the 2 AOP levels, no significant change was observed in the primary end point of reduction in AHI. Additionally, there was no observed impact on secondary end points of the study. Cyclic variation of heart rate was progressively abolished with higher levels of AOP without affecting AHI. Large variations were observed between the screening and control studies in SRBD indexes in a number of patients. In conclusion, AOP demonstrated no benefit to predominantly obstructive SRBD disorder of at least moderate severity.

With the rapid uptake of the robotic approach in gynecologic surgery, a thorough understanding of the technology, including its uses and limitations, is critical to maximize patient outcomes and safety. This review discusses the role of training modalities and development of curricula for robotic surgery. Furthermore, methods for incorporating the entire surgical team and the process of credentialing/maintaining privileges are described.

The increasing popularity of reptile ownership has been paralleled with an increasing incidence of human Salmonella infections. Antimicrobial agents have been suggested for the elimination of Salmonella carriage by reptiles. Nine green iguanas, Iguana iguana, with naturally acquired Salmonella were isolated from each other, and treated with 10 mg/kg enrofloxacin for 14 d. Salmonella was not detected in follow-up cultures of eight of the nine iguanas obtained up to 32 wk after treatment, but was detected repeatedly in the feces of one treated iguana. Antimicrobial agents cannot be relied upon to eliminate carriage of Salmonella with absolute certainty.

Catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE) has emerged as an alternative to systemic thrombolysis (ST) in patients with massive and submassive PE. ST in patients with submassive PE is effective at reducing PE related morbidity compared to heparin alone, however the net

Background and Purpose— Antiplatelet therapy nonresponse is associated with worse clinical outcomes. We studied the clinical outcomes associated with platelet function-guided modifications in antiplatelet therapy in patients with ischemic stroke or transient ischemic attack. Methods— From January 2005 to August 2007, 324 patients with ischemic stroke underwent platelet function testing using platelet aggregometry. Aspirin nonresponse was defined as a mean platelet aggregation ≥20% with 0.5 mg/mL arachidonic acid and/or ≥70% with 5 μmol/L adenosine diphosphate. Clopidogrel nonresponse was defined as a mean platelet aggregation ≥40% with 5 μmol/L adenosine diphosphate. A modification was any increase in antiplatelet therapy occurring after testing. Clinical outcomes were compared between patients with and without platelet function-guided antiplatelet therapy modifications using univariate and propensity score-adjusted analyses. Results— In patients with ischemic stroke or transient ischemic attack, 43% (n=128) and 35% (n=54) were nonresponders to aspirin and clopidogrel, respectively. After platelet function testing, antiplatelet therapy was increased in 23% of patients (n=73). After propensity score matching (n=61 in each group), antiplatelet therapy modification was associated with significantly increased rates of death, ischemic events, or bleeding (hazard ratio, 2.24; 95% CI, 1.12–4.47; P =0.02) compared with no modification in antiplatelet therapy and a trend toward increased bleeding (hazard ratio, 3.56; 95% CI, 0.98–12.95; P =0.05). No differences in ischemic events were observed. Conclusions— Platelet function-guided modification in antiplatelet therapy after an ischemic stroke or transient ischemic attack was associated with significantly higher rates of adverse clinical outcomes.

The objective of this study was to describe in detail the technique of total pelvic exenteration. Total pelvic exenteration (TPE) was first described in 1948 by Brunschwig. Since its description, complications of the procedure and surgical innovations have changed the approach to this radical surgery. We have described our institutional approach and outcomes of TPE. Fifty-four patients underwent TPE between 2004 and 2010 by the Division of Surgical Oncology at the Ohio State University Medical Center. Fifty-three patients have complete medical records available for review. Outcomes are described and have shaped these techniques. Patients were divided into various groups based on their histology: colorectal (n = 36), gynecologic (n = 6), urologic (n = 5), squamous cell (n = 2), sarcomatous disease (n = 3), and severe infections (n = 1). These were divided into two groups-colorectal (n = 36) and noncolorectal (n = 17)-for analysis. Demographics, operative time, length of stay, and complication rates were similar between the two groups. The median survival was 21.4 months for the colorectal group and 6.9 months for the noncolorectal group. Total pelvic exenteration for colorectal tumors has improved survival when compared with patients undergoing exenteration for pelvic malignancies of other origins. Total pelvic exenteration continues to be associated with high morbidity; however, with appropriate patient selection and proper operative technique, a perioperative mortality of 0 per cent can be achieved.