There is a consensus in the literature that regional anesthesia (RA) improves local hemodynamic parameters in comparison to local anesthesia (LA) during arteriovenous fistula (AVF) surgical construction. However, the effects of both techniques on fistula patency and failure rates are still controversial. The aim of this meta-analysis is to synthesize evidence from published randomized trials and observational studies regarding the safety and efficacy of RA versus LA in AVF surgical construction. A computer literature search of PubMed, Scopus, Web of Science, and Cochrane Central retrieved six randomized trials (462 patients) and one retrospective study (408 patients). Pooling data using RevMan software (version 5.3) showed that RA was superior to LA in terms of primary fistula patency rate (RR = 1.22, 95% CI [1.08, 1.37], p = 0.0010); however, both types were comparable in terms of primary fistula failure rate (RR = 0.81, 95% CI [0.47, 1.40], p = 0.46). In comparison to LA, RA was associated with improved hemodynamic parameters including fistula blood flow (MD = 25.08, 95% CI [19.40, 30.76], p<0.00001), brachial artery diameter (SMD = 2.63, 95% CI [2.17, 3.08], p<0.00001), and outflow venous diameter (SMD = 0.93, 95% CI [0.30, 1.75], p = 0.004). Postoperative complications were comparable between both groups (OR = 0.23, 95% CI [0.05, 0.97], p = 0.05). In conclusion, RA was associated with higher primary patency rates of AVF and improved local blood flow in comparison to LA; however, both procedures were comparable in terms of primary failure rates and postoperative complications. Larger well-designed trials with longer follow-up periods should compare both techniques in terms of long-term patency rates and safety outcomes.

Avulsion fractures of the tibial eminence, although generally a rare injury pattern, are more common in children and adolescents than in adults. Many open and arthroscopic techniques are available with variable degrees of satisfying results and incidence of complications and adverse effects. Arthroscopic fixation appeared to improve the functional outcomes with fewer complications than the open fixation. New techniques were reported using commercially available suspension sling devices for the acromioclavicular joint that offers an easy and rapid method of fixation. However, this technique has the disadvantages of the presence of hardware (button) over the tibial anterior cruciate ligament attachment inside the joint and the need to drill a relatively large tunnel through the center of the avulsed fragment that may increase the chance of fracture. So small-diameter tunnels need to be drilled that will decrease bone loss and growth plate injury in children and adolescents. We describe here a technique that offers a better 4-point fixation through the anterior cruciate ligament with fewer complications by avoiding drilling through the avulsed fragment, absence of hardware inside the joint, and decreasing bone loss in adolescents by drilling only smaller transosseous tunnels and allowing for correction of the fixation using a special configuration of knots and cortical button.

Background Allogeneic hematopoietic stem cell transplantation (HSCT) from HLA-matched sibling donor for patients with sickle cell disease (SCD) provides excellent curative potential with acceptable rates of graft rejection and other common post transplant complications. However, in the United States, only 18% of patients with SCD have an HLA-matched sibling donor. Hence, multiple studies adopted various strategies to figure out alternative donors with favorable outcomes. Poor engraftment, graft versus host disease (GVHD) and regimen related toxicities are the main obstacles following alternative-donor transplant. To overcome these complications, different modalities had been experimented targeting the source of the stem cell, CD34 and TNC cell counts, pre-transplant conditioning regimens and adding immunosuppressive drugs pre/post transplant. However, so far there is no worldwide consensus about robust strategy for alternative donor HSCT. Aim The aim of this review is to systematically evaluate the outcomes of alternative-donor HSCT in patients with SCD in pediatric population, and correlate the outcomes with experimented interventional regimens. Methods We searched PubMed, SCOPUS, Embase, Cochrane and Clinical trials.gov from 2000 till February 2018. We utilized the Systematic Reviews and Meta-Analyses guidelines for Preferred Reporting Results (PRISMA). Two reviewers independently screened titles/abstracts, assessed full-text articles, extracted data from included articles, and assessed their quality. Risk of bias in the included studies was assessed using ROBINS-I tool. Data of platelet/neutrophil recovery, acute/chronic GvHD incidence and overall survival were pooled in a single-arm meta-analysis approach. Results Of the 2886 records examined, 19 met predefined criteria. 16 studies were included in the meta-analysis. 12 clinical trials, 5 cohort observational studies and 2 case reports. All studies had a sample size <50. The pooled times of platelet and neutrophil recovery were 31.55 and 20.15 days, respectively. The pooled incidences of acute and chronic GvHD were 36.1% and 21.7, respectively (Figure 1). The pooled one-year overall survival was 90.3% and two-years was 88.3%. Neutrophil engraftment was earlier and more sustained after using Reduced Intensity Conditioning, 16 days (7-32) compared to 23 days (12-42) after Myelo-ablative Conditioning, (P=0.013). Platelet engraftment was earlier and more sustained after using Reduced Intensity Conditioning, 29 days (15-204) in comparison to 62 days (18-123) after Myelo-ablative Conditioning, (P=0.026). The median duration of neutrophil engraftment after mismatched related donors was 14 days (14-17), after unrelated donors was 14 days (9-25) , after haplo-identical transplantation was 14 days (12-16), after umbilical cord blood transplantation (UCBT) was 23 days (7-42), (P=0.001). The median duration of platelet engraftment after haplo-identical and mismatched related transplantation was 19 days, after matched unrelated donors was 19 days (18-24), after mismatched unrelated donors was 22 day (19-37) and after UCBT was 47 days (15-204), (P=.001). There was no significant difference in acute/chronic GvHD between different types of alternative donors but acute GvHD was significantly less in Myelo-ablative Conditioning compared to Reduced Intensity Conditioning (P=.036) Conclusion Our systematic review showed better outcomes with using Myelo-ablative Conditioning and post transplant cyclophosphamide in haplo-identical transplantation compared to using Reduced Intensity Conditioning. Adding pre-transplant immunosuppressive drugs in haplo-identical transplantation didn't significantly improve the outcomes. In unrelated donor no significant difference between Myelo-ablative Conditioning and Reduced Intensity Conditioning but adding Mesenchymal Stem Cell to the reduced intensity regimen improved the outcomes. In UCBT and mismatched related donors, Reduced Intensity Conditioning had better outcomes especially with high doses of TNC and CD34 cell counts and with applying Mesenchymal Stem Cell or adequate dose of Alemtuzumab. Randomized controlled trials are mandated to generate standardized regimen in the setting of alternative-donor HSCT. Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.