未破裂颅内动脉瘤直径与其血流动力学、形态学及瘤壁强化的关系

目的 观察未破裂颅内动脉瘤（UIA）直径与其血流动力学、形态学及瘤壁强化（AWE）的关系。方法 对前瞻性纳入的85例UIA患者行数字减影血管造影（DSA）、高分辨率MR管壁成像（HRMR-VWI）及四维血流MRI （4D flow MRI），观察其100枚UIA的血流动力学、形态学及AWE，计算UIA纵横比（AR）、大小比（SR）、顶颈比（DNR）、高宽比（HWR）、强化率（ER）及壁面切应力（WSS）；比较直径<7 mm （n=78）及≥ 7 mm （n=22） UIA各参数的差异。结果 直径<7 mm与≥ 7 mm UIA患者既往蛛网膜下腔出血（SAH）史、动脉瘤相关症状、SR、DNR、形态、AWE、ER及WSS差异均有统计学意义（P均<0.05）。多因素logistic回归分析显示，既往SAH史、UIA的SR、形态及ER为其直径≥ 7 mm的独立危险因素。WSS与UIA直径、SR及ER均呈负相关（r=-0.70、-0.67、-0.63，P均<0.001）。观察者间判断AWE的一致性极高（Kappa=0.87），测量ER及WSS的一致性均好（ICC=0.946、0.871，P均<0.001）。结论 既往SAH史，UIA的SR、形态及ER均为其直径≥ 7 mm的独立危险因素。     

针刀松解寰枕筋膜治疗颈源性眩晕的疗效研究

目的:研究针刀松解寰枕筋膜治疗颈源性眩晕的疗效。方法:选取2017年1月至2018年1月佛山市健翔医院收治的颈源性眩晕患者96例作为研究对象,按照随机数字表法随机分为对照组和观察组,每组48例。对照组患者给予3次/周针灸、局部按摩治疗,观察组患者给予1次/周的针刀松解寰枕筋膜治疗,均治疗3周。依照《颈性眩晕评估量表(ESCV)》分析2组患者治疗前后颈性眩晕评分变化、椎动脉血流动力学变化,比较2组患者血清中内皮源性超极化因子(EDHF)的含量和一氧化氮(NO)水平,统计2组患者的治疗有效率、眩晕症状缓解时间及生命质量变化。结果:观察组患者治疗后总有效率为97.92%高于对照组的81.25%(P<0.05),眩晕有效缓解时间明显缩短,眩晕评分显著高于对照组(P<0.05);观察组患者治疗后椎动脉的平均血流、收缩期血流、舒张期血流速度、血清中NO及EDHF水平明显上升,血管搏动指数显著下降(P<0.05);生命质量评分显著升高(P<0.05)。结论:针刀松解寰枕筋膜能够通过改善颈源性眩晕患者的椎动脉血流动力学,有效治疗患者的颈源性眩晕。     

Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty

IntroductionThe free radial forearm (FRFA) flap is universally still considered as the gold standard technique in penile reconstruction. Typically, a considerably large flap is required, often involving almost the entire circumference of the forearm. Partial necrosis may occur at the distal-most (dorsoradial) part of the flap as a result of insufficient perfusion.AimTo describe a new technique using the posterior interosseous artery (PIOA) to supercharge FRFA phalloplasty.MethodsIn a 12-month period, all patients having FRFA flap phalloplasty were enrolled. Perioperative, after complete flap dissection, an indocyanine green perfusion scan was performed. In case of insufficient perfusion at the distalmost part of the flap, a supramicrosurgical anastomosis was performed between the FRFA pedicle and the PIOA (artery only).Main Outcome MeasuresStudied outcomes included the rate of marginal necrosis, surgical time, postoperative posterior interosseous nerve damage and urethral complications (fistula, stenosis or necrosis).ResultsA total of 27 FRFA flap phalloplasties was performed. Anastomosis of the PIOA was needed in 15 cases. No marginal necrosis was observed in these cases. There were no cases of postoperative posterior interosseous nerve damage. There were no significant differences in urethral complications (fistula, stenosis or necrosis) between the 2 groups.Clinical ImplicationsIn selected cases where insufficient perfusion of the dorsoradial part of the flap is present, patients may benefit from arterial supercharging to prevent postoperative marginal necrosis.Strength & LimitationsStrengths include a single surgeon, thus lending continuity of skill and technique, a consecutive series, and 100% short-term follow-up. Limitations include single institution series and a limited number of patients.ConclusionArterial supercharging is effective in improving perfusion of large FRFA flaps used in phalloplasty when dorsoradial hypoperfusion is detected on an indocyanine green perfusion scan. It is a technically challenging addition to the standard technique because of the small size of the vessels, the close relationship between the PIOA and the posterior interosseous nerve, and the vulnerability of the newly constructed intra-flap anastomosis.De Wolf E, Claes K, Sommeling CE, et al. Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty. J Sex Med 2019;16:1111–1117.     

Moderately increased alcohol consumption is associated with higher pressure wave reflections and blood pressure in men

Background and aimsIncreased alcohol consumption has been associated with CVD risk. Subclinical arterial damage (SAD) precedes the onset of cardiovascular disease (CVD), and allows early identification and study of the pathophysiology of CVD. Reliable, noninvasive vascular biomarkers are available for the early detection of SAD and reclassification of CVD risk. To investigate the association of alcohol consumption with multiple SAD biomarkers and central hemodynamics in a large sample of Greek adults with CVD risk factors.Methods and resultsThis cross-sectional study was conducted with 938 participants (43.5% men) and collected data on SAD biomarkers, central hemodynamics, and dietary intake. Multiple linear regression analysis was performed according to sex after adjusting for several confounders. In men, alcohol consumption of 20–30 g/d was positively associated with mean, diastolic, and peripheral systolic blood pressure (BP). The consumption of >30 g/d was positively associated with the augmentation index. In women, no statistically significant associations were found between alcohol consumption and BP or SAD indices. No statistically significant associations were found between alcohol consumption and arterial compliance or distensibility in both sexes.ConclusionIn men even a small deviation from the current recommendation for alcohol consumption is associated with both higher BP indices and pressure wave reflections. The absence of association in women might be due to very low alcohol intake, even in the high consumption group. More studies are needed to verify our findings and establish the above associations in each sex.     

Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery

BackgroundPenile prosthesis surgery has witnessed a migration from the inpatient to ambulatory surgical care setting. However, little is known about the cost savings afforded by this change in care setting and whether or not these savings come at the expense of worse perioperative outcomes.AimThe aim of this study was to identify predictors of index penile prosthesis (PP) surgery care setting, and whether ambulatory vs inpatient surgery is associated with comparable perioperative outcomes and costs.MethodsThis was a retrospective cohort study using all-payer claims data from the 2014 Healthcare Cost and Utilization Project State Databases from Florida and New York. Patient demographics, regional data, total charges (converted to costs), and 30-day revisit rates were abstracted for all patients undergoing index placement of an inflatable or malleable PP. Multivariable logistic and linear regression adjusted for facility clustering was utilized.OutcomesThe outcomes were index surgical and 30-day postoperative costs, as well as 30-day revisit rates.ResultsOf the 1,790 patients undergoing an index surgery, 394 (22.0%) received care in the inpatient setting compared to 1,396 (78.0%) in the ambulatory setting. Adjusted index procedural ($9,319.66 vs $ 10,191.35; P < .001) and 30-day acute care costs ($9,461.74 vs $10,159.42; P < .001) were lower in the ambulatory setting. The underinsured experienced lower odds of receiving surgery in the ambulatory setting (Medicaid vs private: odds ratio [OR] 0.19; 95% CI 0.06?0.55; P < .001). There was no difference in risk-adjusted odds of experiencing a 30-day revisit between patients undergoing surgery in the ambulatory vs inpatient settings (OR 1.31; 95% CI 0.78?2.21; P = .3).Clinical TranslationAmbulatory PP surgery confers significant cost savings and is associated with comparable perioperative outcomes relative to inpatient-based surgery.ConclusionsBoth clinical and nonclinical factors predict the care setting of index PP surgery. Notably, underinsured patients experienced lower odds of undergoing ambulatory surgery. Ambulatory surgery was less costly with similar 30-day revisit rates relative to inpatient-based care.Berger A, Friedlander DF, Herzog P, et al. Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery. J Sex Med 2019;16:1451–1458.