Use of percutaneous cholecystostomy for complicated acute lithiasic cholecystitis: solving or deferring the problem?

Objective: Percutaneous cholecystostomies are not infrequently used as an adjunct in the treatment of severe lithiasic cholecystitis, particularly in unstable and comorbid patients. However, their out of proportion liberal use tends to substitute the performance of emergency cholecystectomy, which the definitive treatment. Our aim was to assess the short and long-term outcomes of patients who had percutaneous cholecystostomy insertion due to severe lithiasic cholecystitis, aiming to define areas for improvement of our institutional practice. Materials and Methods: Retrospective review of our institutional practice including all patients who had a percutaneous cholecystostomy for complex lithiasic cholecystitis, over a 5-year period, allowing for an additional 1-year follow up. Results: A total of 34 patients were included in our final analysis. Percutaneous cholecystostomy insertion enabled quick and efficient control of the source of biliary sepsis without major procedural complications in all cases. In 14 (41.2%) patients, cholecystostomy alone served as definitive treatment, while in 20 (58.9%) cases it was used as bridging strategy for delayed elective cholecystectomy. In the delayed cholecystectomy group of patients, we noted a high conversion rate from laparoscopic to open surgery rate of 70%, with an overall subtotal cholecystectomy rate of 60%. Conclusion: Percutaneous cholecystostomies should be reserved only for complex lithiasic cholecystitis patients who are unwilling and/or unfit for surgery. We advocate the performance of upfront emergency cholecystectomy in any other case with liberal use of operative bail-out strategies, as a delayed elective operation is anyway likely to be converted to open and/or subtotal cholecystectomy.

Exploring the Effects of Instructional Message Strategies on Risk Perceptions and Behavioral Intentions: The Case of a Substandard Vaccine Incident

Extending the recent theorizing of the message-centric approach to instructional risk and crisis communication, this study identifies two distinct instructional strategies used by regulatory authorities and adopts a goal-attainment approach to measuring the effectiveness of both strategies in instructing nonscientific publics about impending risks. Specifically, we conducted a quasi-experiment immediately after a substandard vaccine incident in China to examine the differential effects of regulators’ instructional press releases on stakeholders’ risk perceptions and behavioral intentions. We found that the explanation-focused buffering strategy is significantly more effective in both heightening individuals’ cognitive risk perception and reducing their affective risk perception, while the personalization-focused bridging strategy shows more effectiveness in sustaining individuals’ intention to consume and positively evaluate domestic vaccines. Additionally, the findings highlight the need to tailor instructional message strategies to regulatory organizations’ ultimate goals of communication activities. Practical implications for government regulators and risk communicators are also discussed.

Assessing the Bus Bridging Effectiveness on the Operational Resilience of the Subway Service in Toronto

Unplanned rail disruptions result in substantial delays to passengers and severe effects on the economy of a large city like Toronto. While bus bridging has been a widely adopted method to replace the subway service in such events, its effect on the operational resilience of the subway service is less often studied. This study assesses the resilience of the subway network of Toronto employing an optimal bus bridging strategy. First, subway incidents are categorized based on their characteristics using K-mean clustering analysis. The incidents are then grouped based on the performance of optimal bus bridging plans. Classification and regression tree analysis is used for this task, employing two metrics: the total user delay and total number of shuttle buses under the optimal bridging scenario. Queueing and optimization models developed previously by the University of Toronto are used to determine and simulate the optimal bus bridging plans of a sample of incidents. The severity of unplanned disruptions is finally demonstrated using a severity scale and the effect of incident duration uncertainty is analyzed. The results show that along the congested city alignments, where the capacity of the roads and stations is limited, the bus bridging service is often insufficient to replace the train service. However, it could be a good alternative in uncongested subway segments where the available street capacity is relatively high, allowing large bus volumes to serve the corridor. This model is easily applicable to different rail systems and it could assess other systems to produce better bridging plans.

A Novel Bridging Strategy Using Central Extracorporeal Membrane Oxygenation in Post-Myocardial Infarction Ventricular Septal Defect

Ventricular septal defect (VSD) is a fatal mechanical complication of acute myocardial infarction (MI). The outcome of conventional surgery in post-MI VSD patients complicated by cardiogenic shock is extremely poor. We report two cases of a post-MI VSD stabilized with extracorporeal membrane oxygenation support followed by successful patch repair.

Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience

Objective The aim of the study is to describe the real-world use of the P2Y12 inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT). Materials and Methods We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used. Results Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was <2 g/dL; nine patients received blood transfusions consistent with the type of surgery, but no life-threatening or fatal bleeding occurred. Conclusion Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.