Subcutaneous bone flap storage after emergency craniectomy: cost-effectiveness and rate of resorption

OBJECTIVEDecompressive craniectomy is used for uncontrolled intracranial pressure in traumatic brain injury and malignant hemispheric stroke. Subcutaneous preservation of the autologous bone flap in the abdomen is a simple, portable technique but has largely been abandoned due to perceived concerns of resorption. The authors sought to characterize their experience with subcutaneous preservation of the bone flap and cranioplasty.METHODSThe authors performed a retrospective single-institution review of subcutaneous preservation of the autologous bone flap after decompressive craniectomy from 2005 to 2015. The primary outcome was clinically significant bone resorption, defined as requiring a complete mesh implant at the time of cranioplasty, or delayed revision. The outcome also combined cases with any minor bone resorption to determine predictors of this outcome. Logistic regression modeling was used to determine the risk factors for predicting resorption. A cost comparison analysis was also used via the 2-sided t-test to compare the cost of cranioplasty using an autologous bone flap with standard custom implant costs.RESULTSA total of 193 patients with craniectomy were identified, 108 of whom received a cranioplasty. The mean time to cranioplasty was 104.31 days. Severe resorption occurred in 10 cases (9.26%): 4 were clinically significant (2 early and 2 late) and 6 demonstrated type II (severe) necrosis on CT, but did not require revision. Early resorption of any kind (mild or severe) occurred in 28 (25.93%) of 108 cases. Of the 108 patients, 26 (24.07%) required supplemental cranioplasty material. Late resorption of any kind (mild or severe) occurred in 6 (5.88%) of 102 cases. Of these, a clinically noticeable but nonoperative deformity was noted in 4 (3.92%) and minor (type I) necrosis on CT in 37 (37%) of 100. Bivariate analysis identified fragmentation of bone (OR 3.90, 95% CI 1.03–14.8), shunt-dependent hydrocephalus (OR 7.97, 95% CI 1.57–40.46), and presence of post-cranioplasty drain (OR 9.39, 95% CI 1.14–1000) to be significant risk factors for bone resorption. A binary logistic regression optimized using Fisher’s scoring determined the optimal multivariable combination of factors. Fragmentation of bone (OR 5.84, 95% CI 1.38–28.78), diabetes (OR 7.61, 95% CI 1.37–44.56), and shunt-dependent hydrocephalus (OR 9.35, 95% CI 1.64–56.21) were found to be most predictive of resorption, with a C value of 0.78. Infections occurred in the subcutaneous pocket in 5 (2.60%) of the 193 cases and after cranioplasty in 10 (9.26%) of the 108 who underwent cranioplasty. The average cost of cranioplasty with autologous bone was $2156.28 ± $1144.60 (n = 15), and of a custom implant was $35,118.60 ± $2067.51 (3 different sizes; p < 0.0001).CONCLUSIONSCraniectomy with autologous bone cranioplasty using subcutaneous pocket storage is safe and compares favorably to cryopreservation in terms of resorption and favorably to a custom synthetic implant in terms of cost. While randomized data are required to definitively prove the superiority of one method, subcutaneous preservation has enough practical advantages with low risk to warrant routine use for most patients.

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Bone Flap Resorption in Pediatric Patients Following Autologous Cranioplasty

Operative Neurosurgery ◽

10.1093/ons/opaa452 ◽

2021 ◽

Author(s):

David S Hersh ◽

Hanna J Anderson ◽

Graeme F Woodworth ◽

Jonathan E Martin ◽

Yusuf M Khan

Keyword(s):

Risk Factors ◽

Bone Resorption ◽

Decompressive Craniectomy ◽

Pediatric Patients ◽

Bone Flap ◽

Calvarial Bone ◽

Advantages And Disadvantages ◽

Bone Flap Resorption ◽

Autologous Bone

Abstract Following a decompressive craniectomy, the autologous bone flap is generally considered the reconstructive material of choice in pediatric patients. Replacement of the original bone flap takes advantage of its natural biocompatibility and the associated low risk of rejection, as well as the potential to reintegrate with the adjacent bone and subsequently grow with the patient. However, despite these advantages and unlike adult patients, the replaced calvarial bone is more likely to undergo delayed bone resorption in pediatric patients, ultimately requiring revision surgery. In this review, we describe the materials that are currently available for pediatric cranioplasty, the advantages and disadvantages of autologous calvarial replacement, the incidence and classification of bone resorption, and the clinical risk factors for bone flap resorption that have been identified to date.

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Risk factors of aseptic bone resorption: a study after autologous bone flap reinsertion due to decompressive craniotomy

Journal of Neurosurgery ◽

10.3171/2013.1.jns12860 ◽

2013 ◽

Vol 118 (5) ◽

pp. 1141-1147 ◽

Cited By ~ 56

Author(s):

Pedro Dünisch ◽

Jan Walter ◽

Yasser Sakr ◽

Rolf Kalff ◽

Albrecht Waschke ◽

...

Keyword(s):

Risk Factors ◽

Multivariate Analysis ◽

Decompressive Craniectomy ◽

Perioperative Complications ◽

Bone Flap ◽

Type Ii ◽

Flap Necrosis ◽

Bone Necrosis ◽

Increased Risk ◽

Autologous Bone

Object In patients who have undergone decompressive craniectomy, autologous bone flap reinsertion becomes necessary whenever the cerebral situation has consolidated. However, aseptic necrosis of the bone flap remains a concern. The aim of this study was to report possible perioperative complications in patients undergoing autologous bone flap reinsertion and to identify the risk factors that may predispose the bone flap to necrosis. Methods All patients admitted to the authors' neurosurgical department between September 1994 and June 2011 and who received their own cryoconserved bone flap after decompressive craniectomy were studied. The grade of the bone flap necrosis was classified into 2 types. Type II bone necrosis was characterized by aseptic resorption with circumscribed or complete lysis of tabula interna and externa requiring surgical revision. To define predisposing factors, a multivariate analysis was performed using bone necrosis as the dependent variable. Results Among the 372 patients (mean age 48.6 years, 57.4% males) who received 414 bone flaps during the observation period, 134 (36.0%) had a diffuse traumatic brain injury, 69 (18.5%) had subarachnoid hemorrhage, 58 (15.6%) had cerebral infarction, 56 (15.1%) had extraaxial bleeding, 43 (11.6%) had intracerebral bleeding, and 12 (3.2%) had a neoplasm. Surgical relevant Type II bone flap necrosis occurred in 85 patients (22.8%) and 91 bone flaps, after a median time of 15 months (interquartile range [IQR], 10–33 months). In a multivariate analysis with Type II necrosis as the dependent variable, bone flap fragmentation with 2 (OR 3.35, 95% CI 1.59–7.01, p < 0.002) or more fragments (OR 24.00, 95% CI 10.13–56.84, p < 0.001), shunt-dependent hydrocephalus (OR 1.76, 95% CI 0.99–3.12, p = 0.04), and a younger age (OR 0.98, 95% CI 0.96–0.99, p = 0.004) was associated with a higher risk for the development of an aseptic bone flap necrosis. Conclusions In patients undergoing bone flap reinsertion after craniotomy, aseptic bone necrosis is an underestimated problem during long-term follow-up. Especially in younger patients with an expected good neurological recovery and a fragmented bone flap, an initial allograft should be considered because of an increased risk for aseptic bone flap necrosis.

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Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.3.peds17234 ◽

2018 ◽

Vol 22 (3) ◽

pp. 225-232 ◽

Cited By ~ 15

Author(s):

Brandon G. Rocque ◽

Bonita S. Agee ◽

Eric M. Thompson ◽

Mark Piedra ◽

Lissa C. Baird ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Bone Resorption ◽

Bone Graft ◽

Decompressive Craniectomy ◽

Significant Risk ◽

Retrospective Case ◽

Vp Shunt ◽

Selection Of Variables ◽

Cranial Implant

OBJECTIVEIn children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty.METHODSThe authors conducted a multicenter retrospective case study that included all patients who underwent cranioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniectomy and cranioplasty.RESULTSA total of 359 patients met the inclusion criteria. The patients’ mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17–4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03–5.79), and ventilator dependence (OR 8.45, 95% CI 1.10–65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection.Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98–0.99, p < 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts.CONCLUSIONSThis is the largest study of pediatric cranioplasty outcomes performed to date. Analysis included variables found to be significant in previous retrospective reports. Presence of a cranial implant such as VP shunt is the most significant risk factor for cranioplasty infection, whereas younger age at cranioplasty is the dominant risk factor for bone resorption.

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Association of Hypertriglycerideamia with Ischaemic Stroke

Bangladesh Journal of Neuroscience ◽

10.3329/bjn.v32i1.57411 ◽

2016 ◽

Vol 32 (1) ◽

pp. 34-38

Author(s):

Biplob Kumar Das ◽

Kanak Jyoti Mondal

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Ischaemic Stroke ◽

Significant Risk ◽

Serum Triglyceride ◽

Control Group ◽

Case Group ◽

Stepwise Logistic Regression ◽

Serum Triglyceride Level ◽

Analysis Model

Stroke is one of the foremost causes of morbidity, mortality and is a socioeconomic challenge. This is particularly true for developing countries like Bangladesh, where health support system including the rehabilitation system is not within the reach of common people. Hypertriglycerademia has an effective influence in the pathogenesis of Ischaemic Stroke (IS). So, the focus of this study was to evaluate and assess the association of serum triglyceride level in patients of IS. This case control study was carried out in the Department of Neurology in collaboration with Department of Biochemistry, BSMMU, Dhaka from July 2011 to June 2013. In this study, 60 diagnosed cases of ischaemic stroke patients and 60 age and sex matched healthy controls were enrolled. Risk factors of Ischemic Stroke (IS) patients were assessed ( adjusted Odds Ratio) in comparison with healthy adults. In this study, being married [OR. 1.95, 95% CI (0.40-9.42), p=0.409] , smoker [OR.1.65, 95% CI (0.57 - 4.82),p= 0.357], DM [OR. 1.48, 95% CI (0.36-6.06), p=0.582 ], IHD [OR. 1.51, 95% CI (0.29 – 7.89), p=0.624] , HTN [OR. 3.66, 95% CI (1.11–12.12), p=0.033] , overweight [OR.2.31, 95% CI (0.77 – 6.91), 0.135] and obesity [OR. 16.19, 95% CI (1.31–200.6), p=0.030] , increased level of serum TC [OR.8.24, 95% CI (2.07 – 32.83), p=0.003], TG [OR. 9.40, 95% CI (1.17 -75.86), p=0.035], LDL [OR. 0.45, 95% CI (0.10–2.05), p=0.308],and decreased level of HDL [OR. 3.37, 95% CI (1.03 - 12.25), p=0.045] were found as risk factors in developing IS. Independent t-test was done to find out the statistically significant differences of continuous variables like serum lipid profile between case and control group. The mean (SD) value of TG which is focus of this study, was found 237.67 (61.74) in case group, and 169.97 (26.95) in control group which was highly statistically significant (p < 0.0001). All of the significant variables were entered into stepwise logistic regression analysis model. From the logistic regression model, it can be finally concluded that hypertension, obesity, increased level of TC, increased level of TG and decreased level of HDL were statistically significant risk factors for development of IS. Bangladesh Journal of Neuroscience 2016; Vol. 32 (1): 34-38

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Risk factors for hypertensive crisis in children with acute glomerulonephritis

Paediatrica Indonesiana ◽

10.14238/pi56.2.2016.101-6 ◽

2016 ◽

Vol 56 (2) ◽

pp. 101

Author(s):

Sherly Yuniarchan ◽

Risky Vitria Prasetyo ◽

Ninik Asmaningsih Soemyarso ◽

Mohammad Sjaifullah Noer

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Risk Factor ◽

Pediatric Population ◽

Hypertensive Crisis ◽

Significant Risk ◽

Significant Risk Factor ◽

P Value ◽

Acute Glomerulonephritis ◽

Female Ratio

Background Hypertensive crisis occurs in 1-4% of the hypertensive pediatric population, mostly due to acute glomerulonephritis (AGN). Some factors have been suggested to affect blood pressure (BP) in children, such as age, sex, race/ethnicity, obesity, and socioeconomic status, but little is known for risk factors for hypertensive crisis in AGN.Objective To analyze the risk factors for hypertensive crisis in children with AGN.Methods Retrospectively, we studied possible risk factors for hypertensive crisis in children with AGN at Dr. Soetomo Hospital from 2007 to 2011. Hypertensive crisis was defined as systolic BP ≥180 mmHg or diastolic BP ≥120 mmHg (for children ≥ 6 years of age); and systolic and/or diastolic BP >50% above the 95th percentile (for children aged <6 years). We evaluated the demographic and clinical characteristics as potential risk factors. Statistical analysis was done with Chi-square, Fisher’s exact, and logistic regression tests. Variables with P <0.25 in the univariable analysis were further analyzed by the multivariable logistic regression model. A P value of < 0.05 was considered statistically significant.Results There were 101 children included (mean age 9.7 (SD 2.17) years), with a male-to-female ratio of 2.7:1. Hypertensive crisis occurred in 42 (41.6%) children, of whom 8 had hypertensive urgency and 34 had hypertensive emergency. Proteinuria was seen in 53 children with AGN (52.5%) and was the significant risk factor for hypertensive crisis in our subjects (OR=2.75; 95%CI 1.16 to 6.52; P=0.021). Gender, clinical profiles, ethnicity, nutritional status, blood urea nitrogen (BUN), and glomerular filtration rate (GFR) were not significant risk factors for hypertensive crisis.Conclusion Proteinuria is the significant risk factor for hypertensive crisis in children with AGN.

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Study of Risk Factors Associated with Suicide Attempt in Patients with Bipolar Disorder Type I

Journal of Neurosciences in Rural Practice ◽

10.1055/s-0040-1709347 ◽

2020 ◽

Vol 11 (02) ◽

pp. 291-298

Author(s):

Karthick Subramanian ◽

Vikas Menon ◽

Siddharth Sarkar ◽

Vigneshvar Chandrasekaran ◽

Nivedhitha Selvakumar

Keyword(s):

Risk Factors ◽

Bipolar Disorder ◽

Logistic Regression ◽

Family History ◽

Suicide Attempt ◽

Coping Strategies ◽

Binary Logistic Regression ◽

Type I ◽

Factors Associated ◽

History Of

Abstract Background Suicide is the leading contributor to mortality in bipolar disorder (BD). A history of suicidal attempt is a robust predictive marker for future suicide attempts. Personality profiles and coping strategies are the areas of contemporary research in bipolar suicides apart from clinical and demographic risk factors. However, similar research in developing countries is rarer. Objectives The present study aimed to identify the risk factors associated with suicidal attempts in BD type I (BD-I). Materials and Methods Patients with BD-I currently in clinical remission (N = 102) were recruited. Sociodemographic details and the clinical data were collected using a semistructured pro forma. The psychiatric diagnoses were confirmed using the Mini-International Neuropsychiatric Interview 5.0. The National Institute of Mental Health–Life Chart Methodology Clinician Retrospective Chart was used to chart the illness course. Presumptive Stressful Life Events Scale, Coping Strategies Inventory Short Form, Buss–Perry aggression questionnaire, Past Feelings and Acts of Violence, and Barratt Impulsivity scale were used to assess the patient’s stress scores, coping skills, aggression, violence, and impulsivity, respectively. Statistical Analysis Descriptive statistics were used for demographic details and characteristics of the illness course. Binary logistic regression analyses were performed to identify the predictors for lifetime suicide attempt in BD-I. Results A total of 102 patients (males = 49 and females = 53) with BD-I were included. Thirty-seven subjects (36.3%) had a history of suicide attempt. The illness course in suicide attempters more frequently had an index episode of depression, was encumbered with frequent mood episodes, especially in depression, and had a higher propensity for psychiatric comorbidities. On binary logistic regression analysis, the odds ratios (ORs) for predicting a suicide attempt were highest for positive family history of suicide (OR: 13.65, 95% confidence interval [CI]: 1.28–145.38, p = 0.030), followed by the presence of an index depressive episode (OR: 6.88, 95% CI: 1.70–27.91, p = 0.007), and lower scores on problem-focused disengagement (OR: 0.72, 95% CI: 0.56–0.92, p = 0.009). Conclusion BD-I patients with lifetime suicide attempt differ from non-attempters on various course-related and temperamental factors. However, an index episode depression, family history of suicide, and lower problem-focused engagement can predict lifetime suicide attempt in patients with BD-I.

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A Comparison between Pediatric and Adult Patients after Cranioplasty: Aseptic Bone Resorption Causes Earlier Revision in Children

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1698391 ◽

2019 ◽

Vol 81 (03) ◽

pp. 227-232 ◽

Cited By ~ 2

Author(s):

Jennifer Göttsche ◽

Friederike Fritzsche ◽

Gertrud Kammler ◽

Thomas Sauvigny ◽

Manfred Westphal ◽

...

Keyword(s):

Risk Factor ◽

Bone Resorption ◽

Pediatric Patients ◽

Young Age ◽

Adult Patients ◽

Bone Flap ◽

Complication Rates ◽

Bone Flap Resorption ◽

Number Of Patients ◽

Autologous Bone

Abstract Background and Study Aims/Objective Cranioplasty, a common neurosurgical intervention following decompressive craniectomy (DC), is associated with high complication rates. Bone flap resorption in particular leads to a considerable number of patients requiring further surgery. The aim of this study was to investigate the frequency and time of occurrence of complications following cranioplastic procedures in children and adults. Material and Methods Data of children and adults who underwent cranioplasty between July 2010 and March 2018 were analyzed retrospectively. Clinical data, complications, and risk factors regarding aseptic bone resorption (ABR) were evaluated including patient age, occurrence of shunt-dependent hydrocephalus, and number of fragments in autologous bone flaps. Results Severe traumatic brain injury (TBI) was the leading cause for DC among children (66.7%), associated with a significantly higher number of fragments (p = 0.002). In the adult population, the most common cause was malignant infarction (55.9%) followed by TBI (24.6%). Pediatric patients in our institution received autologous bone flaps less frequently than adult patients (61.1% and 83.1%, respectively). Young age and a higher number of fragments in autologous bone flaps were associated with the occurrence of ABR. Children and adolescents showed significantly higher rates of aseptic bone necrosis (p = 0.007) and revision cranioplasty (p = 0.036). Kaplan-Meier estimates were used to further analyze bone flap resorption in children and adults, showing that revision surgery due to ABR was performed earlier in children (p = 0.001, log-rank test). Conclusion Pediatric patients demand specific care when cranioplasty is performed following DC. We identified age as an independent risk factor. The higher number of fragments appears to be a correlation due to the higher number of TBIs in children. Our data indicate that young age is the most important risk factor for the development of ABR as a frequent and early complication with a shorter revision-free time interval in children. Consequently, the uncritical use of cryopreserved autologous bone flaps should be questioned in this population.

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Associations between risk factors and developmental dysplasia of the hip and ultrasonographic hip type: a retrospective case control study

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.13.180174 ◽

2019 ◽

Vol 13 (2) ◽

pp. 161-166 ◽

Cited By ~ 5

Author(s):

H. Ömeroğlu ◽

A. Akceylan ◽

N. Köse

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Family History ◽

Hip Dysplasia ◽

Positive Family History ◽

Significant Risk ◽

Breech Presentation ◽

Developmental Dysplasia ◽

Type I ◽

Dysplasia Of The Hip

Purpose We aimed to revisit the correlation between the previously defined risk factors and the occurrence of developmental dysplasia of the hip (DDH) and to assess the influence of these factors on the ultrasonographic type of hip dysplasia according to the Graf’s classification in patients with DDH. Methods Data of healthy infants (mean age 33 days) who had bilateral mature (normal) hips (Graf type I) were compared with the data of infants (mean age 105 days) who were treated by abduction brace due to unilateral or bilateral DDH (Graf type IIa- and worse hips). Results Infants with at least one risk factor had a significantly higher rate of DDH than those with no risk factors (p < 0.001). Likewise, infants with more than one risk factor had a significantly higher rate of DDH than those with only one risk factor (p = 0.008). Family history, breech presentation and swaddling were found to be the three significant risk factors related to the development of DDH. Family history, swaddling and oligohydramnios were found to be the three significant risk factors correlated with a higher rate of unstable/decentred hip(s) (Graf types D/III/IV) in patients with DDH. Conclusion The risk of DDH significantly increases in infants who have more than one risk factor for DDH. Positive family history and postnatal traditional swaddling are the two main factors both in the aetiology of DDH and in development of a more severe hip dysplasia in patients with DDH. Besides, breech presentation increases the risk of development of DDH and oligohydramnios leads to development of a more severe hip dysplasia in patients with DDH. By introducing these four variables as ‘absolute risk factors for DDH’ to the selective newborn hip screening programmes, the sensitivity and specificity of these programmes may be optimized and the risk of delayed diagnosis may be lessened. Level of Evidence Level III prognostic study

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Serious Symptomatic Thromboembolic Complications in Patients Undergoing Total Hip Replacement - A Prospective Study.

Blood ◽

10.1182/blood.v108.11.630.630 ◽

2006 ◽

Vol 108 (11) ◽

pp. 630-630

Author(s):

Camilla Ryge ◽

Michael Rud Lassen ◽

Soeren Solgaard ◽

Stig Sonne-Holm

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Regression Analysis ◽

Total Hip Replacement ◽

Logistic Regression Analysis ◽

Hip Replacement ◽

Significant Risk ◽

Vascular Events ◽

Total Hip ◽

Vein Thrombosis

Abstract Purpose: To describe the rate and time of onset of serious thromboembolic (TE) complications within the first 90 postoperative days in an unselected population of THR patients. Secondary to analyse the data base for possible risk factors of TE. Material and method: Five hundred (430 primary THR and 70 revision THR) consecutive patients undergoing THR in Frederiksborg County, Denmark from January 2004 until May 2005 participated. The patients were interviewed the day before surgery for medical history. On the 5th postoperative day and at a telephone interview 90 days postoperatively patients were asked about signs and symptoms of acute myocardial infarction (AMI), pulmonary embolism (PE), deep vein thrombosis (DVT), transitory cerebral ischemia (TCI)/stroke, retinal vein thrombosis (RVT) and other cardio vascular events. All events were validated in hospital and/or the general practitioners files, using international criteria. All patients except 1 had chemical thromboprophylaxis during hospitalization. No patients had extended thromboprophylaxis after discharge. 498 patients had 90 days follow-up. Two patients withdrew their consent. Results: 24 patients (4.8%) experienced at least one serious TE complication during the first 90 days after the operation. Two (0.4%) patients died in relation to the operation (no autopsy was performed). Five patients (1.0%) had PE. One patient (0.2%) had AMI, 10 (2.0%) had DVT, two (0.4%) had RVT and four (0.8%) had TCI. Two patients experienced two events - one had AMI and later on a TCI, another had PE and TCI on the same day. Nine patients had their first event during the first five postoperative days - 15 patients had their first event after the 5th postoperative day. The only significant risk factor found in a backward logistic regression analysis including interaction (test for confounder/bias) was the length of the operation P=0.003 OR= 1.016 (1.005–1.026). This study has not been able to show any significant correlation between age, gender, co-morbidities, preoperative hemoglobin value ore platelet count, high ASA-score, kind of anesthesia, indication for operation or use of cement or interactions between the above in the logistic regression analysis, but individually all these factors were significant risk factors in the introductory bivariate analysis. Discussion: This study shows that venous and arterial thrombotic complications persist to be a major contribution to postoperative morbidity and mortality after elective total hip replacement, despite of rigorous early mobilization and optimized regimens of prevention of thromboembolism. After this study has been performed ACCP has recommended extend prophylaxis by LMWH, pentasaccharide or warfarin up to 4–5 weeks after total hip replacement. Further research to identify patients at risk is warranted to optimize risk/benefit of total hip replacement and prevention of venous and arterial thromboembolism. The majority of events occurred after discharge calling for improvement of the post-discharge period to reduce the risk of serious thromboembolism.

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Risk Factors for Silent Cerebral Infarcts in a Pediatric Sickle Cell Anemia (SCA) Cohort

Blood ◽

10.1182/blood.v112.11.2487.2487 ◽

2008 ◽

Vol 112 (11) ◽

pp. 2487-2487 ◽

Cited By ~ 1

Author(s):

Francoise Bernaudin ◽

Suzanne Verlhac ◽

Annie Kamdem ◽

Cécile Arnaud ◽

Lena Coïc ◽

...

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Regression Analysis ◽

Risk Factor ◽

Logistic Regression Analysis ◽

G6pd Deficiency ◽

Significant Risk ◽

Significant Risk Factor ◽

History Of ◽

Independent Risk Factors

Abstract Background Silent infarcts are associated with impaired cognitive functioning and have been shown to be predictors of stroke (Miller ST J Pediatr 2001). Until now, reported risk factors for silent infarcts were low pain event rate, history of seizures, high leukocyte count and Sen bS haplotype (Kinney TR Pediatrics 1999). Here, we seek to define the prevalence and risk factors of silent infarcts in the Créteil SCA pediatric cohort comprising patients assessed at least yearly by transcranial doppler (TCD) since 1992, and by MRI/MRA. Methods This study retrospectively analyzed data from the Créteil cohort stroke-free SS/Sb0 children (280; 134 F, 146 M), according to institutional review board. Time-averaged mean of maximum velocities higher than 200 cm/sec were considered as abnormal, resulting in initiation of a transfusion program (TP). A switch to hydroxyurea was proposed to patients with normalized velocities (< 170 cm/sec) and normal MRA on TP, although TP was re-initiated in case of abnormal velocities recurrence. Patients with “conditional” velocities (170–199 cm/sec) were assessed by TCD 4 times yearly. Alpha genes and beta-globin haplotypes were determined. Baseline biological parameters (G6PD activity; WBC, PMN, Reticulocytes, Platelets counts; Hemoglobin, Hematocrit, HbF, LDH levels; MCV; SpO2) were obtained a minimum of 3 months away from a transfusion, one month from a painful episode, after 12 months of age, before the first TCD, and always before therapy intensification. Results. Patients were followed for a total of 2139 patient-years. Alpha-Thal was present in 114/254 patients (45%) and 27/241 (11.2%) had G6PD deficiency. Beta genotype, available in 240 patients, was BaBa in 102 (42.5%), BeBe in 54 (22.5%), SeSe in 19 (7.9%) and “other” in 65 (27.1%); TCD was abnormal in 52 of 280 patients (18.6%). MRA showed stenoses in 30 of 226 evaluated patients (13.3%) while MRI demonstrated presence of silent infarcts in 81/280 patients (28.9%). Abnormal TCD (p<0.001), G6PD deficiency (p=0.008), high LDH (p=0.03), and low Hb (p=0.026) were significant risk factors for stenoses by univariate analysis while multivariate analysis retained only abnormal TCD as a significant risk factor for stenoses ([OR= 10.6, 95% CI (4.6–24.4)]; p<0.001). Univariate logistic regression analysis showed that the risk of silent infarcts was not related to alpha-Thal, beta genotype, abnormal TCD, WBC, PMN, platelets, reticulocyte counts, MCV, LDH level, HbF %, pain or ACS rates but was significantly associated with stenoses detected by MRA (p<0.001), gender (male; p=0.04), G6PD deficiency (p=0.05), low Hb (p=0.016) and Hct (p=0.012). Multivariate logistic regression analysis showed that gender ([OR= 2.1, 95% CI (1.03–4.27)]; p=0.042), low Hb ([OR= 1.4, 95% CI (1.0–1.1)]; p=0.05) and stenoses ([OR= 4.8, 95% CI (1.88–12.28)]; p=0.001) were all significant independent risk factors for silent infarcts. The presence of stenoses was the only significant risk factor for silent infarcts in patients with a history of abnormal TCD ([OR= 5.9, 95% CI (1.6–21.7)]; p=0.008). Conclusion We recently showed that G6PD deficiency, absence of alpha-Thal, and hemolysis are independent significant risk factors for abnormal TCD in stroke-free SCA patients (Bernaudin et al, Blood, 2008, in press). Here, we report that an abnormal TCD is the most significant risk factor for stenoses and, expanding previous studies, we demonstrate that stenoses, low Hb and gender are significant independent risk factors for silent infarcts.

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