Organ donation: what else can be done besides legislature?

With the ongoing organ shortage for transplantation, Singapore has adopted an organ opt‐out scheme: Human Organ Transplant Act (HOTA) that presumes consent unless specified otherwise. Likewise, receptivity of doctors and medical students (MS), as future doctors, can positively influence organ donation (OD) rates. We explored the knowledge and attitudes of MS toward OD. MS from all five yr of medical school were recruited using self‐administered questionnaires. There were 294 completed questionnaires with 49.3% males and 45.6% pre‐clinical students. The MS were generally knowledgeable about organ transplantation, but deficient in the knowledge of some aspects of HOTA. The majority of the MS were receptive toward OD. Traditional values rather than religion were possible barriers toward OD. 50.7% of the MS were concerned that donated organs may be inappropriately used, while 32% had concerns that doctors would prematurely terminate treatment if the patient is a potential organ donor. Fewer clinical students shared such concerns, compared with the pre‐clinical students. The MS have a good understanding of basic tenets of OD and are receptive toward OD. Potential barriers for OD advocation are local traditional values and reservations regarding the appropriate use of harvested organs and provision of appropriate care to donor patients. These concerns are areas to address.     

What can be done about acute renal failure?

Acute renal failure (ARF) complicates the clinical course of as many as 5% of all hospitalized patients with the critically ill and injured disproportionably at risk. Considerable effort has been expended to develop techniques to prevent ARF or to facilitate its resolution. However, to date, studies have failed to demonstrate that drugs can prevent onset or deterioration of renal function in the critically ill, and some studies have even suggested harm. Recent data suggest that NAC can reduce the incidence of ARF secondary to radio-contrast agents and improved techniques for RRT and, perhaps, new drugs aimed at improving cellular repair, will improve outcome from ARF in the future.     

Should endovascular repair be used for small abdominal aortic aneurysms?

The outcomes of endovascular repair for small abdominal aortic aneurysm (4.0-4.9 cm) is reported. All patients undergoing endovascular abdominal aortic aneurysm repair between 2000 and 2006 with maximal diameter 4.0 to 4.9 cm form the small aneurysm study cohort. Data were analyzed retrospectively and life-table methods were used. Of 743 endovascular repairs, 132 (17.8%) were performed for small abdominal aortic aneurysm. Perioperative complication rate was 9.1%. Freedom from aneurysm expansion was 96% at 1 year, 86% at 3 years, and 77% at 5 years. Overall survival was 98%, 93%, and 84% at 1, 3, and 5 years, respectively. Perioperative 30-day mortality was 0.8% with an aneurysm-related mortality of 1.5% at 5 years. There were no deaths from delayed aneurysm rupture. Endovascular repair of small abdominal aortic aneurysm is associated with low perioperative morbidity and mortality compared with published results for open repair, and treatment threshold can be reduced to 4 cm in selected patients.     

What should be done in the event of incidental meningioma?

Background and purpose

The growing use of magnetic resonance and computed tomography imaging has facilitated the diagnosis of brain tumours even before the presence of clinical signs. A significant proportion of incidental lesions identified will be meningiomas, i.e. more than 40% of the diagnosed meningiomas are not associated with clinical signs. The natural history of incidental asymptomatic intracranial meningiomas must be known to develop the optimal therapeutic strategy: what is the tumor growth rate? How many asymptomatic tumours eventually become symptomatic?

Method

The literature was reviewed in an attempt to answer these questions.

Results

In cases of incidental meningioma, its location, size and radiological aspect, the patient's age, the eventual unknown symptoms and the multiplicity of the lesions must all be considered. The radiological characteristics associated with low tumoral growth rate are the existence of calcifications and hypointense regions on T2-weighted MR images. On the radiological aspect, more than 60% of asymptomatic meningiomas will not grow in size. However, some meningiomas, even small in size, must be treated because of their location or the risk of producing neurological deficits.

Conclusion

We recommend neurosurgical consultation for all patients with an incidental meningioma.     

Endoluminal thoracic aortic repair: does the parachute need to be randomized?

Development of endoluminal repair has substantially reduced mortality and morbidity associated with repair of the thoracic aorta. It has significant advantages over conventional surgical repair, particularly in the management of acute dissection and thoracic aortic injury. Despite these perceived advantages it is important to realize that no level 1 data are available to prove safety and/or efficacy. Because the advantages are perceived to be so great these data are unable to be accrued and it is important that clinicians involved with this procedure keep rigorous data and undertake ongoing evaluation to ensure that clinical perceptions are eventually underpinned by robust data.     

Endovascular approach to treat aortic pseudoaneurysms: could it be a safe alternative?

Aortic pseudoaneurysm is a rare complication after blunt chest trauma or cardiac surgical procedures and can occur at the site of cannulation or root vent insertion on the ascending aorta. These pseudoaneurysms have the potential to expand, erode, and rupture, and detecting this condition before complications occur is the key to successful management. We had replaced the mitral valve with a 31-mm bioprosthesis in an 82-year-old patient and repaired an ascending aorta aneurysm, but a computed tomography scan on postoperative day 18 revealed a pseudoaneurysm at the site of the previous aortic cannulation. Because of the patient's advanced age and multiple comorbidities, we sealed off the neck of the pseudoaneurysm with a 12-mm Amplatzer Vascular Plug in the interventional cardiology suite instead of subjecting her to a surgical repair involving redo sternotomy and a period of circulatory arrest. Deployment of the Amplatzer plug effectively shut off flow into the pseudoaneurysm, and the patient recovered well. Although the optimal management strategy for aortic pseudoaneurysms is a matter of controversy, endovascular interventions may be a safer alternative to surgery for patients with multiple comorbidities.     

Can renal dysfunction after infra-renal aortic aneurysm repair be modified by multi-antioxidant supplementation?

BACKGROUND: Renal failure after lower torso ischemia is a serious problem, partly caused by hypotension and indirect reperfusion injury. This injury is partly due to the formation of oxygen free radicals by activated neutrophils. This injury results in albuminuria and renal function impairment. There are indications that free radical damage in indirect reperfusion injury can be diminished by administering extra antioxidants before and during reperfusion. METHODS: In this prospective randomised study we have looked at the influence of a multi-antioxidant supplementation on renal function in patients undergoing an elective open infrarenal abdominal aneurysm repair. The patients received either standard treatment (n=22) or standard treatment with additional antioxidants perioperatively (Allopurinol, vitamin E and C, N-acetylcysteine and mannitol). For renal function we have looked at the albumin/creatinine ratio in urine and 24 hr creatinine clearance. RESULTS: Despite significantly increased serum total antioxidant capacity, the group receiving extra antioxidants showed no decrease in the albumin/creatinine ratio in urine. There was however a significantly higher creatinine clearance in this group at day 2. CONCLUSIONS: The results indicate that the diminished renal function after infrarenal aneurysm repair may be influenced by antioxidant therapy.     

Are bicuspid aortic valves a limitation for aortic valve repair?

Objective: To compare the mid-term results after aortic valve (AV) repair in bicuspid AVs with those in tricuspid AVs. Methods: Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n = 43) and tricuspid AV (n = 57). Aortic regurgitation (AR) more than moderate was present in 31/43 and 21/57 patients in the bicuspid AV and the tricuspid AV group, respectively. Concomitant root replacement by either the reimplantation or the remodeling technique was performed in 42 patients (bicuspid AV 17/43, tricuspid AV 25/57). All patients were prospectively studied with postoperative and further annual clinical assessment and echocardiography. Follow-up was 99% complete with a mean follow-up time of 22 months. Results: Three patients died during the initial hospitalization, all due to postoperative cardiac failure. Overall actuarial 3 years’ survival was 93 ± 4.2% without significant differences between the two groups. Overall actuarial 3 years’ freedom from AV-related reoperation was 86 ± 5.1% without significant differences between the groups (85 ± 9.7% for bicuspid AV, 86 ± 6.0% for tricuspid AV; log-rank test: p = 0.98). Overall actuarial 3 years’ freedom from recurrent AR ≥ moderate was 100% and AR > trace was 71.3 ± 8.2% without significant differences between the groups (76.5 ± 11.7% for bicuspid AV, 71.4 ± 9.4 for tricuspid AV; log-rank test: p = 0.97). Conclusions: The mid-term outcome in terms of survival, freedom from reoperation or recurrent AR is similar for both groups of patients after AV repair procedures. Therefore, we advocate valve repair also in patients presenting with an insufficient bicuspid AV.     

Knotted intravascular catheters--what should be done?

INTRODUCTION: Fixed intravasal catheters are mainly caused by knots. Removal can be achieved by intervention or surgical exploration, but this is associated with additional morbidity and mortality. METHODS: 2 patients were operated for knotted catheters in our institution during the last 2 years, and their records are demonstrated. Treatment options, possible complications, catheter types and locations of knotting are analyzed by a medline search. RESULTS: the search revealed the data from 115 patients. 53 (46.1%) of all "lost" catheters were Swan-Ganz catheters. In 60.9% the catheters could be removed by radiological interventions. Open revision was necessary in 33% of all cases. The catheters were left in place when the clinical condition of the patient did not allow removal (n = 7). However, these patients suffered from a high mortality (5 of 7 patients). Over all mortality reached 8.7%. In the own two cases one removal by sternotomy and one by exploration of the right internal jugular vein were necessary, both operations succeeded without complications. CONCLUSION: Most of all "lost" intravasal catheters are removed by radiological intervention; only one third needs open surgical therapy. These procedures are harmful for the patient and bear considerable risks for complications.     

Can minilaparotomy abdominal aortic aneurysm repair be performed safely and effectively without special skills?

BACKGROUND: The purpose of this study was to determine whether a surgeon without special skills can perform minimal incision abdominal aortic aneurysm repair as safely and effectively as traditional retroperitoneal aneurysmectomy. METHODS: After informed consent, eligible patients were randomized into minilaparotomy and retroperitoneal groups. The minilaparotomy repair consisted of a short transabdominal midline incision, intraabdominal retraction of the bowel, control of back bleeding with balloon catheters, and hand-sewn anastomoses. The retroperitoneal approach was performed through a left vertical-lateral abdominal incision. RESULTS: Twenty-six patients were randomly treated by minilaparotomy approach (n = 14) or retroperitoneal approach (n = 12) from December, 1999, to May 2001. Parameters for speed of recovery were indistinguishable and of no clinical significance. In the long-term follow-up (mean period, 27 months), no patients in the minilaparatomy group complained of discomfort from the incision, whereas 4 patients in the retroperitoneal group complained of discomfort (P < 0.05). CONCLUSIONS: Minilaparotomy approach can be performed safely and effectively without specialized skill. With regard to wound discomfort, the minilaparotomy technique is excellent. The minilaparotomy approach is therefore a useful alternative to traditional repair.