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Numerous children born with syndromic craniosynostosis will develop visual impairments. Based on the hypothesis that elevations in intracranial pressure might have greater impacts on vision than development, this review sought to ascertain the prevalence of optic nerve atrophy in syndromic craniosynostosis and to look for potential predictive factors.The authors conducted a retrospective chart review of all children with syndromic craniosynostosis treated at a single center.Of 442 patients with syndromic craniosynostosis, complete ophthalmologic records were available for 253. Although no instances of optic nerve atrophy were noted among those with Saethre-Chotzen or Muenke syndromes, an overall 14.7 percent prevalence was noted among those with Apert (7.8 percent), Crouzon (27.9 percent), and Pfeiffer syndromes (23.1 percent), with initial diagnoses occurring at a mean age of 10 years. The presence of a Chiari malformation was found to significantly correlate with the subsequent diagnosis of optic nerve atrophy (OR, 3.544; p = 0.002); however, the timing of the first cranial vault procedure, presence of a ventriculoperitoneal shunt, degree of brachycephaly, number of vault expansions, and diagnosis of sleep apnea, did not show significant associations.A substantial percentage of children with Apert, Crouzon, and Pfeiffer syndromes were found to develop optic nerve atrophy, with a prevalence likely to trend higher with longer follow-up. Chiari malformations were the only significant potential predictor for optic nerve atrophy. With the goal of preventing visual losses, more frequent monitoring for raised intracranial pressure with ophthalmologic evaluations and magnetic resonance imaging measurements of optic nerve sheath diameters should be considered.Risk, III.

Introduction: Multiple studies have compared coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) to determine the optimal strategy for coronary revascularization (CR). Very few have evaluated the impact of medication history on the relative outcomes. Hypothesis: Evidence-based medical therapy influences outcomes of CABG vs. PCI Methods: All non-STEMI patients (N=3871 PCI, 1181 CABG) undergoing isolated CR in eight community-based hospitals were enrolled. Follow-up (63.5±27.9, median 79.7 months) was obtained at 12, 18 and >60 months by patient/physician contact and Social Security Death Index. Kaplan-Meier curves were used to compare survival free of MACE (nonfatal myocardial infarction, PCI, CABG, mortality) between groups,. Results: Compliance with appropriate anti-platelet therapy improved long-term freedom from MACE in both PCI and CABG patients (Figure 1). Similarly, lipid-lowering therapy improved MACE-free survival in both PCI and CABG patients (Figure 2). Interestingly, treatment with beta blockers appeared to have either a negative (PCI) or marginal (CABG) impact.(Figure 3), most likely representing patient selection. Conclusion: Medication history has a dramatic impact on the long-term outcomes of both PCI and CABG patients and therefore must be included in the evaluation of comparative strategies for revascularization.

To examine whether transcatheter aortic valve replacement (TAVR) is a safe and effective treatment option for aortic stenosis in patients with end-stage renal disease (ESRD).Patients with ESRD undergoing surgical aortic valve replacement have an operative mortality approaching 20% and a 10-year survival of approximately 12%. We investigated whether TAVR is a more reasonable option.This is a multicenter, retrospective study of all patients with ESRD who underwent TAVR in 8 institutions between 12/2011 and 02/2013. Demographic characteristics, mortality, major, and minor complications were evaluated. Outcomes were stratified by operative approach.Forty-three patients with a mean age 76.2 ± 11.0 years and a mean STS predicted risk of mortality of 15.53 ± 8.70% underwent TAVR. Mean duration of dialysis was 45.2 ± 52.3 months (median 29.5 months). Transfemoral (TF) TAVR was performed in 31/43 (72.1%), transapical in 11/43 (25.6%), and transaortic in 1/43 (2.3%). Operative mortality was 14.0% (6/43) with TF mortality 6.5% (2/31) and 33.3% (4/12) in non-TF patients. Six-month mortality was 11/43 (25.6%: 16.1% TF, 50.0% non-TF). Complications included stroke in 2.3% (1/43) and life-threatening or major bleeding in 14.0% (6/43). Discharge to another healthcare facility was 27.0% (10/37). Readmission within 30 days of procedure for any cause was 18.9% (7/37).Patients with ESRD who undergo TAVR are at high risk for mortality and complications. TAVR outcomes are comparable to but not substantially better than those with SAVR. Transfemoral TAVR seems to be at least as safe and effective as the current standard SAVR in patients undergoing aortic valve replacement. © 2016 Wiley Periodicals, Inc.

To compare iliofemoral arterial complications with transfemoral transcatheter aortic valve replacement (TF-TAVR) utilizing surgical cutdown versus percutaneous access with closure devices in a randomized trial.Major vascular complications following TAVR are a significant risk of the procedure. There are no randomized data comparing whether access method in TF-TAVR influences the risk of such complications.From June to December 2011, 30 consecutive patients undergoing TF-TAVR were randomized to either surgical cutdown (C) or percutaneous (P) access. Subjects underwent preoperative CT scans, pre- and post-operative bilateral femoral arterial ultrasound and angiography. The primary endpoint was the composite of major and minor vascular complications at 30 days, as defined by the Valve Academic Research Consortium-2. Multivariate predictors of vascular complications were identified.Of the 30 subjects enrolled, 27 were treated with the randomized method of access as randomized. Iliofemoral complications were observed in eight patients (26.7%; C = 4, P = 4), all of which were dissections and/or stenoses that required percutaneous and/or surgical intervention. There were two (13.3%) major and two (13.3%) minor complications in each group. Two covariates that were significantly associated with vascular complications included female sex and baseline femoral arterial velocity on ultrasound.While surgical cutdown in TF-TAVR is the recommended access for new centers initiating a TAVR program, this small randomized pilot study suggests the lesser invasive percutaneous method in an experienced center is equivalent in safety to the surgical method. Doppler ultrasound may be useful in predicting complications prior to the procedure.

Nonserious infections (NSIE) as colds, flu syndromes, and urinary tract infection, are the most common infections seen in patients with immune mediated inflammatory diseases. Yet, little is known about the impact of immunosuppression, particularly with tumor necrosis factor inhibitors (TNFi), on these infections. A systemic review of large, randomized controlled trials was conducted to identify incidence, types, and outcomes of NSIE associated with the most commonly prescribed TNFi: adalimumab, etanercept, and infliximab.

This study was designed to evaluate the bone regeneration potential of the dura mater and dura mater substitute (Durepair) in the presence of recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered in a collagen sponge-collagen-ceramic matrix (CCM; MasterGraft Matrix) in a large skull defect in growing canines.Forty immature male beagles were used to create two 2.5 x 4-cm cranial defects on each side of the sagittal suture. The dura mater on the left side was cut to make a 1 x 3-cm defect and replaced with bovine skin collagen (Durepair). The dura mater on the right side remained intact. Different doses of rhBMP-2 (none [8 animals], 0.11 mg/ml [4 animals], 0.21 mg/ml [4 animals], and 0.43 mg/ml [8 animals]) were infused on 2 Type I bovine absorbable collagen sponge (ACS) strips. The strips were layered with the CCM (15% hydroxyapatite [HA]/85% tricalcium phosphate [TCP]) to reconstruct both cranial defects. In a fifth group (8 animals), 0.43 mg/ml rhBMP-2 was directly infused into the CCM. Demineralized canine cancellous freeze-dried demineralized bone matrix (DBM; 8 animals) was used as a control in a sixth group. All materials were fixed under 2 resorbable protective sheets (MacroPore). Skulls were resected 16 weeks after operation. Histological and histomorphometric analyses on the percentage of the defect spanned by bone, and the percentage of residual HA-TCP granules and collagen were analyzed.Calcified seroma was the only complication observed and only occurred in the 0.43-mg/ml rhBMP-2 groups (Groups 4 and 5). Dura mater repair appeared complete at 4 months in all animals. New bone was formed sporadically throughout the skull defect in the ACS+CCM and DBM groups without rhBMP-2. In all rhBMP-2 groups, mature new bone (compact and trabecular) was uniformly formed across the defect on both the repaired and intact dura mater sides. There was significant new compact bone formation on top of the repaired dura mater, which did not appear in the ACS+CCM and DBM groups lacking rhBMP-2. Greater HA-TCP and collagen scaffold resorption was noted in rhBMP-2 groups compared with non-rhBMP-2 groups. Statistical analysis showed there was a significantly lower percentage of bone spanning the defect in the ACS+CCM group compared with groups with rhBMP-2, with more residual HA-TCP and collagen on the repaired dura mater side than the intact dura mater side (p0.05). In all rhBMP-2 groups, there were no significant differences in new bone formation between the repaired and intact dura mater sides (p0.05).The ACS+CCM combination had an effect similar to demineralized bone-on-bone regeneration in craniofacial reconstruction. The addition of rhBMP-2 to CCM directly or with ACS induces mature new bone formation in large cranial defects both in the presence of intact dura mater and repaired dura mater.

Study design An in vitro study to determine the intradiscal pressure changes during flexion in levels above a simulated fusion was performed. Objectives To determine if intradiscal pressure increases more during flexion in discs above an instrumented spinal segment compared to an uninstrumented segment. Summary of background data The progressive degeneration of intervertebral discs adjacent to a fused or fixed segment is a phenomenon that is noted but poorly understood. Intuitively, the degeneration appears to be a function of altered biomechanics of the motion segments in the spine. Methods Two intervertebral disc levels were evaluated, L3-L4 and L4-L5 from each of six fresh frozen cadaver spines. Pressure measurements were taken with the spine uninstrumented, with bilateral pedicle screw-rod instrumentation from L5 to S1, and with bilateral pedicle screw-rod instrumentation from L4 to S1. Pressure measurements were accomplished with Millar Mikro-Tip pressure transducers. The transducers were placed within the nucleus pulposus of L3-L4 and L4-L5 intervertebral discs. Pressure data were recorded by computer data acquisition. The pressure data were compared by intervertebral level and by the effects of added instrumentation. Results In general, the addition of instrumentation significantly affected the intradiscal pressure in the levels above a simulated fusion. The intradiscal pressure increased as the amount of levels involved in the simulated fusion increased. The intradiscal pressure increased as flexion motion increased. A greater increase was seen at the L4-L5 level than the L3-L4 level. When L5-S1 fixation was added, the intradiscal pressure increased. When L4-S1 fixation was added, the intradiscal pressure further increased. Conclusion This study demonstrated increasing intradiscal pressures during flexion.