Background: and Purpose Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. Methods: From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0–1) and independent outcome (mRS 0–2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. Results: Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3–P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79–1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05–2.12), sICH (aOR 2.87, 95% CI 1.23–6.72), and mortality (aOR 1.77, 95% CI 1.07–2.95). Conclusion Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.

Background/Aims: More than 100 million people to date have been affected by the coronavirus disease-2019 (COVID-19) pandemic. Patients with COVID-19 have a higher risk of bleeding complications. We performed a systematic review and meta-analysis to evaluate the outcomes of COVID-19 patients with signs and symptoms of acute gastrointestinal bleeding (GIB). Methods: A systematic literature search was carried out for articles published until until November 11, 2020, in the Embase, MEDLINE, Web of Science, and Cochrane Library databases. We included studies on COVID-19 patients with signs and symptoms of GIB. Results: Our search yielded 49 studies, of which eight with a collective 127 patients (86 males and 41 females) met our inclusion criteria. Conservative management alone was performed in 59% of the patients, endoscopic evaluation in 31.5%, and interventional radiology (IR) embolization in 11%. Peptic ulcer disease was the most common endoscopic finding, diagnosed in 47.5% of the patients. Pooled overall mortality was 19.1% (95% confidence interval [CI]; 12.7%-27.6%) and pooled mortality secondary to GIB was 3.5% (95% CI; 1.3%–9.1%). The pooled risk of rebleeding was 11.3% (95% CI; 6.8%–18.4%). Conclusion The majority of COVID-19 patients with GIB responded to conservative management, with a low mortality rate associated with GIB and the risk of rebleeding. Thus, we suggest limiting endoscopic and IR interventions to those with hemodynamic instability and those for whom conservative management was unsuccessful.

Background: Normal saline solution (NSS) has been the fluid of choice for renal transplant patients, but it can lead to hyperchloremic acidosis and hyperkalemia. This study was performed to compare the safety profile of low-chloride solutions with that of NSS in renal transplant patients. Methods: We conducted a systemic review search on PubMed, Embase, and the Central Cochrane Registry. Randomized clinical trials (RCTs) and matched cohort studies involving NSS as the control arm and low-chloride solutions as an intervention arm were chosen. The standardized mean difference for continuous variables, the odds ratio (OR) for discrete variables, and a 95% confidence interval (CI) for effect sizes were used. A p-value of <0.05 was considered statistically significant. Analysis was performed using a random-effects model irrespective of heterogeneity, which was evaluated using I2 statistics. Results: Nine RCTs and one cohort study with a total of 726 patients were included. After transplantation, serum potassium was significantly lower in the low-chloride group (standardized mean difference compared to NSS group, –0.38 mEq/L; 95% CI, –0.66 to –0.11; p = 0.007). Similarly, postoperative chloride was lower in the low-chloride group (–2.41 mEq/L [–3.34 to –1.48], p < 0.001). No statistically significance was observed in delayed graft function (OR, 0.98 [0.56–1.69], p = 0.93), day 3 creatinine (–0.14 mg/dL [–0.46 to 0.18], p = 0.38), or day 7 urine output (–0.08 L [–0.29 to 0.12], p = 0.43). Conclusion Use of NSS during renal transplant leads to increased incidence of hyperchloremic acidosis with subsequent hyperkalemia, but clinical significance in the form of delayed graft function or postoperative creatinine remains comparable to that of low-chloride solutions.

Background/Aims: More than 100 million people to date have been affected by the coronavirus disease-2019 (COVID-19) pandemic. Patients with COVID-19 have a higher risk of bleeding complications. We performed a systematic review and meta-analysis to evaluate the outcomes of COVID-19 patients with signs and symptoms of acute gastrointestinal bleeding (GIB). Methods: A systematic literature search was carried out for articles published until until November 11, 2020, in the Embase, MEDLINE, Web of Science, and Cochrane Library databases. We included studies on COVID-19 patients with signs and symptoms of GIB. Results: Our search yielded 49 studies, of which eight with a collective 127 patients (86 males and 41 females) met our inclusion criteria. Conservative management alone was performed in 59% of the patients, endoscopic evaluation in 31.5%, and interventional radiology (IR) embolization in 11%. Peptic ulcer disease was the most common endoscopic finding, diagnosed in 47.5% of the patients. Pooled overall mortality was 19.1% (95% confidence interval [CI]; 12.7%-27.6%) and pooled mortality secondary to GIB was 3.5% (95% CI; 1.3%–9.1%). The pooled risk of rebleeding was 11.3% (95% CI; 6.8%–18.4%). Conclusion The majority of COVID-19 patients with GIB responded to conservative management, with a low mortality rate associated with GIB and the risk of rebleeding. Thus, we suggest limiting endoscopic and IR interventions to those with hemodynamic instability and those for whom conservative management was unsuccessful.

BACKGROUND: The objevctive of the present study was to explore the potential influence of blood markers and patient factors such as risk factors, kidney function profile, coagulation profile, lipid profile, body mass index, blood pressure, and vein diameter on the maturation of arteriovenous fistula (AVF) in patients with end-stage renal disease. METHODS: Retrospective data from 300 patients who had undergone AVF creation at the Royal Infirmary of Edinburgh were examined. A predictive logistic regression model was developed using a backward stepwise procedure. Model performance, discrimination, and calibration were assessed using the receiver operating characteristic (ROC) curve and Hosmer–Lemeshow goodness-of-fit test. The final model was externally validated by 100 prospective patients who received a new fistula at the Royal Infirmary of Edinburgh. RESULTS: A total of 400 (300 retrospective and 100 prospective) patients were recruited for this study, with a mean age of 60.14 ± 15.9 years (development set) and 58 ± 15 years (validation set), respectively (P = 0.208). Study results showed that males were twice as likely to undergo fistula maturation as females, while patients with no evidence of peripheral vascular disease (PVD) were three times more likely to mature their fistula and a preoperative vein diameter > 2.5 mm resulted in a fivefold increase in fistula maturation as compared with a vein size of less than 2.5 mm. The model for fistula maturation had fair discrimination, as indicated by the area under the ROC curve (0.68), but good calibration as indicated by the Hosmer–Lemeshow test (P = 0.79). The area under the receiver operating curve for the validation model in the validation set was 0.59. Similarly, in the validation set, the Hosmer–Lemeshow statistic indicated an agreement between the observed and predicted probabilities of maturation (P > 0.05). CONCLUSION: Gender, PVD, and vein size are independent predictors of AVF maturation. The clinical utility of these risk categories in the maturation of AVF requires further evaluation in longer follow-up.
Arteriovenous Fistula* ; Blood Pressure ; Body Mass Index ; Calibration ; Discrimination (Psychology) ; Female ; Fistula ; Follow-Up Studies ; Humans ; Kidney ; Kidney Failure, Chronic* ; Logistic Models ; Male ; Peripheral Vascular Diseases ; Prospective Studies ; Renal Dialysis ; Retrospective Studies ; Risk Factors ; ROC Curve ; Veins

The growing proportion of individuals suffering from chronic kidney disease has considerable repercussions for both kidney specialists and primary care. Progressive and permanent renal failure is most frequently treated with hemodialysis. The efficiency of hemodialysis treatment relies on the functional status of vascular access. Determining the type of vascular access has prime significance for maximizing successful maturation of a fistula and avoiding surgical revision. Despite the frequency of arteriovenous fistula procedures, there are no consistent criteria applied before creation of arteriovenous fistulae. Increased prevalence and use of arteriovenous fistulae would result if there were reliable criteria to assess which arteriovenous fistulae are more likely to reach maturity without additional procedures. Published studies assessing the predictive markers of fistula maturation vary to a great extent with regard to definitions, design, study size, patient sample, and clinical factors. As a result, surgeons and specialists must decide which possible risk factors are most likely to occur, as well as which parameters to employ when evaluating the success rate of fistula development in patients awaiting the creation of permanent access. The purpose of this literature review is to discuss the role of patient factors and blood markers in the development of arteriovenous fistulae.
Arteriovenous Fistula* ; Fistula ; Humans ; Kidney ; Prevalence ; Primary Health Care ; Renal Dialysis ; Renal Insufficiency ; Renal Insufficiency, Chronic ; Reoperation ; Risk Factors ; Specialization ; Surgeons

The growing proportion of individuals suffering from chronic kidney disease has considerable repercussions for both kidney specialists and primary care. Progressive and permanent renal failure is most frequently treated with hemodialysis. The efficiency of hemodialysis treatment relies on the functional status of vascular access. Determining the type of vascular access has prime significance for maximizing successful maturation of a fistula and avoiding surgical revision. Despite the frequency of arteriovenous fistula procedures, there are no consistent criteria applied before creation of arteriovenous fistulae. Increased prevalence and use of arteriovenous fistulae would result if there were reliable criteria to assess which arteriovenous fistulae are more likely to reach maturity without additional procedures. Published studies assessing the predictive markers of fistula maturation vary to a great extent with regard to definitions, design, study size, patient sample, and clinical factors. As a result, surgeons and specialists must decide which possible risk factors are most likely to occur, as well as which parameters to employ when evaluating the success rate of fistula development in patients awaiting the creation of permanent access. The purpose of this literature review is to discuss the role of patient factors and blood markers in the development of arteriovenous fistulae.
Arteriovenous Fistula* ; Fistula ; Humans ; Kidney ; Prevalence ; Primary Health Care ; Renal Dialysis ; Renal Insufficiency ; Renal Insufficiency, Chronic ; Reoperation ; Risk Factors ; Specialization ; Surgeons

BACKGROUND: We assessed whether the paediatric-appropriate facilities were available at Emergency Departments (ED) in community hospitals in a Canadian province. METHODS: We conducted a cross-sectional survey of EDs in community hospitals in Ontario, Canada that had inpatient paediatric facilities and a neonatal intensive care unit. Key informants were ED chiefs, clinical educators, or managers. The survey included questions about paediatric facilities related to environment, triage, training, and staff in EDs. RESULTS: Of 52 hospitals, 69% (n=36) responded to our survey. Of them, 14% EDs (n=5) had some separated spaces available for paediatric patients. About 53% (n=19) of EDs lacked children activities, e.g., toys. Only 11% (n=4) EDs were using paediatric triage scales and 42% (n=15) had a designated paediatric resuscitation bay. Only half of the ED (n=18) required from their staff to update paediatric life support training. Only 31% (n=11) had a designated liaison paediatrician for the ED. Paediatric social worker was present in only 8% (n=3) of EDs in community hospitals. CONCLUSION: Most of the Ontario community hospital EDs included in this survey had inadequate facilities for paediatric patients such as specific waiting and treatment areas.

BACKGROUND: Spinal anesthesia with bupivacaine, typically used for elective and emergency cesarean section, is associated with a significant incidence of hypotension resulting from sympathetic blockade. A variety of dosing regimens have been used to administer spinal anesthesia for cesarean section. The objective of this study was to compare the incidence of hypotension following two different fixed dosing regimens. METHODS: This was a randomized double-blind clinical trial with a two-sided design, 5% significance level and 80% power. After approval of the hospital ethics review committee, 60 patients were divided randomly into two groups. In one group, the local anesthetic dose was adjusted according to height and weight, and in the other, the dose was adjusted according to height only. RESULTS: Sixty women with a singleton pregnancy were included. Of the factors that could affect dose and blood pressure, including age, weight, height, and dose, only height differed between the groups. Mean heart rate was similar between the groups. Hypotension was significantly more frequent with dosage based on height alone than with two-factor dose calculation (56.7% vs. 26.7%; P = 0.018). CONCLUSIONS: Adjusting the dose of isobaric bupivacaine to a patient's height and weight provides adequate anesthesia for elective cesarean section and is associated with a decreased incidence and severity of maternal hypotension and less use of ephedrine.
Advisory Committees ; Anesthesia ; Anesthesia, Spinal* ; Anesthetics, Local ; Blood Pressure ; Body Height ; Body Weight ; Bupivacaine ; Cesarean Section* ; Emergencies ; Ephedrine ; Ethics, Institutional ; Female ; Heart Rate ; Humans ; Hypotension ; Incidence ; Pregnancy

Objective: To determine antibiotic resistance patterns and virulence potential of Campylobacter jejuni (. C. jejuni) isolates from clinical human diarrheal infections, cattle and healthy broilers. Methods: Antibiotic sensitivity patterns of C. jejuni isolates were determined by Kirby Bauer Disc Diffusion assay. These isolates were then subjected to virulence profiling for the detection of mapA (membrane-associated protein), cadF (fibronectin binding protein), wlaN (beta-l,3-galactosyltransferase) and neuAB (sialic acid biosynthesis gene). Further C. jejuni isolates were grouped by random amplification of polymorphic DNA (RAPD) profiling. Results: A total of 436 samples from poultry (. n=88), cattle (. n=216) and humans (. n=132) from different locations were collected. Results revealed percentage of C. jejuni isolates were 35.2% (31/88), 25.0% (54/216) and 11.3% (15/132) among poultry, cattle and clinical human samples respectively. Antibiotic susceptibility results showed that similar resistance patterns to cephalothin was ie. 87.0%, 87.1% and 89%among humans, poultry and cattle respectively, followed by sulfamethoxazole+trimethoprim 40.0%, 38.7% and 31.0% in humans, poultry and cattle and Ampicillin 40%, 32% and 20% in humans, poultry and cattle respectively. Beta-lactamase activity was detected in 40.00% humans, 20.37% cattle and 32.25% in poultry C. jejuni isolates. CadF and mapA were present in all poultry, cattle and human C. jejuni isolates, wlaN was not detected in any isolate and neuAB was found in 9/31 (36%) poultry isolates. RAPD profiling results suggested high diversity of C. jejuni isolates. Conclusions: Detection of multidrug resistant C. jejuni strains from poultry and cattle is alarming as they can be potential hazard to humans. Moreover, predominant association of virulence factors, cadF and mapA (100% each) in C. jejuni isolates from all sources and neuAB (36%) with poultry isolates suggest the potential source of transmission of diverse types of C. jejuni to humans.