Recognition and management of impending vein-graft failure. Importance for long-term patency

A previous report from this group indicated a very poor long-term patency rate (19%) for occluded femoro-distal vein grafts that require initial thrombectomy prior to patch angioplasty for documented stenosis. Patients with vein grafts were therefore followed up by Doppler pressure determinations of the ankle/brachial index (ABI) postoperatively at three weeks, six weeks, and every four months thereafter for two years in an effort to identify vein-graft failure prior to actual thrombosis. During the past six years we performed 322 vein grafts of which 29 grafts were identified by diminished Doppler ABI and were found to have stenotic segments on subsequent arteriography. Twenty-two of these patients (group 1) underwent reconstruction with patch angioplasty resulting in a five-year cumulative patency rate of 82%. The remaining seven patients (group 2) underwent percutaneous transluminal angioplasty of their stenotic segments yielding a significantly lower five-year patency rate of 43%. These two groups were compared with a third group fo 25 patients with thrombosed grafts mandating initial thrombectomy prior to patch angioplasty. The thrombectomized group 3 patients demonstrated a significantly lower five-year cumulative patency rate of 28%. These data suggest that patients with femoro-distal bypass vein grafts be followed up at frequent intervals early in their postoperative course with determinations of Doppler ABI measurements. Any significant reduction in Doppler ABI compared with the highest postoperative Doppler determination should be aggressively evaluated with digital-subtraction or routine angiography in an effort to locate a stenotic lesion prior to graft thrombosis. Patients found to have such a graft stenosis are then ultimately treated with patch angioplasty in anticipation of satisfactory long-term patency rates.     

Factors in the development of the spinal stenosis syndrome.

The spinal stenosis syndrome is a potential hazard when congenital or developmental narrowing of the bony canal, particularly in its lateral recesses where it can be demonstrated by axial tomography, places the emergent nerve root and its blood supply at risk to further small compressive elements. When lumbar disc degeneration allows rotatory and lateral instability, posterolateral bulging of the annulus fibrosus into the root canal occurs when weight is taken on the ipsilateral lower limb. Symptoms of the spinal stenosis syndrome do not arise until the development of this instability. To relieve the symptoms, the nerve root must be freely mobilised and decompressed by full lateral decompression, with partial or total facetectomy if necessary, by enucleation of the intervertebral disc and by removal of the posterolateral portions of the annuli fibrosi.     

Factors influencing the outcome of degenerative lumbar spinal stenosis

The objective of this study was to evaluate the influence of decreased dural sac cross-sectional area and baseline clinical parameters on the outcome of patients treated surgically or conservatively for lumbar spinal stenosis. Computed tomography or magnetic resonance imaging scans of 37 patients were digitized and the dural sac cross-sectional area was calculated. This parameter and baseline clinical, socioeconomic, and anthropometric data of the patients were correlated with 1-year and 2-year follow-up data. The decrease in dural sac cross-sectional area negatively affected walking capacity on follow-up controls in patients treated conservatively, whereas such a relation was not observed among surgically treated patients. Female sex was the main parameter that worsened the global outcome of degenerative lumbar spinal stenosis, particularly after surgical treatment.     

Factors influencing the development of Moyamoya Phenomenon

Summary Both the Moyamoya Phenomenon and occlusion of the internal carotid fork are essential radiological findings in true Moyamoya Disease of unknown aetiology. However, the Moyamoya Phenomenon is often observed in occlusive diseases of the internal carotid bifurcation of known aetiology. The authors recently observed acute development of the unilateral Moyamoya Phenomenon following severe vasospasm of the anterior and middle cerebral arteries due to rupture of an anterior communicating aneurysm.The following four factors have been suspected of contributing to development of the Moyamoya Phenomenon: 1. The chronology of arterial occlusion. 2. Extent and location of occlusion. 3. The cause of occlusion. 4. Anatomical and functional disposition of the basal circulation.As regards the chronology, chronic or slowly progressive arterial stenosis has been thought to be a mandatory factor in development of a Moyamoya network, which plays an important role in the form of collateral channels. However, based on the findings outlined in this paper, the congenital factor may be the most important of the four factors.     

Factors influencing the development of wound infection following free-flap reconstruction for intra-oral cancer.

Wound infection following tissue transfer in head and neck oncology is common. Factors known to be associated with infective complications include blood transfusion, pre-operative radiotherapy, duration of surgery, duration of pre-operative stay and a history of smoking. The present study specifically examined 100 consecutive patients on a standard antibiotic protocol undergoing free flap reconstruction following resection of cancers of the oral cavity or oropharynx. Despite prophylactic antibiotics, 21 patients developed a head and neck wound infection. No statistically significant association was found between infective wound complications and a history of smoking, pre-operative radiotherapy or chemotherapy, length of pre-operative hospital stay, duration of surgery, or number of units of blood transfused. We conclude that, in this group of patients, wound infection is a common and difficult problem, but with no statistically significant association with any of the variables studied.     

Factors influencing the origination and development of intracranial meningioma

Basing on analysis of the clinico-laboratory investigations results the risk factors, provoking origination of intracranial meningioma (IM), were revealed in periods of maximal activity of an organism, pubertal and climacteric changes: hormonal disorders, roentgen irradiation, hereditary-genetic factors, cranio-cerebral trauma. In 8 patients receptors of estrogens and progesterone were revealed. Influence on these factors would permit to increase the possibilities of treatment with nonoperable and recurrent IM.     

Factors influencing the development of end-stage renal disease

Epidemiological evidence is needed to design effective strategies for preventing chronic kidney disease (CKD) and end-stage renal disease (ESRD). Several types of health check are routinely performed in Japan, including the screening of asymptomatic individuals, but the potential benefits of these procedures remain unknown. We evaluated the predictors of ESRD, using community-based mass screening and a dialysis registry. This approach revealed the significance of proteinuria, hypertension, obesity, anemia, and high fasting plasma glucose levels (which indicate diabetes mellitus; DM), for the risk of developing ESRD. Lifestyle-related factors, such as smoking, alcohol consumption, and low levels of exercise, are also associated with these conditions and, in particular, with a high risk of ESRD. Over-nutrition and low levels of exercise can ultimately lead to DM, hypertension, hyperlipidemia, and obesity, and are important risk factors worldwide for cardiovascular diseases, CKD, and ESRD. The early detection and treatment of predictors of ESRD, along with appropriate treatment for CKD, may decrease the incidence of ESRD. In addition, the economic burden caused by the costs of dialysis presents a compelling argument for implementing a cost-effective preventive strategy against ESRD.     

Factors influencing wound complications: a clinical and experimental study.

Burst abdomen, incisional herniation, sinus formation and post-operative wound infection continue to bedevil the surgeon. A prospective study of 1129 laparotomy wounds defined the extent of the problem; 1.7% incidence of dehiscence, 7.4% herniation and 6.7% sinus formation, all significantly associated with wound infection. Mass closure reduced the dehiscence rate from 3.8% to 0.76%. Infection reduced wound strength in a rat laparotomy model due to a decrease in fibroblast concentration and activity. A monofilament non-absorbable suture was shown experimentally to be the most suitable suture for closing infected abdominal wounds. Electron microscopy demonstrated bacteria in the interstices of infected multifilament sutures. A randomised clinical trial comparing polyglycolic acid and monofilament nylon in the closure of abdominal wounds confirmed the experimental findings; polyglycolic acid resulted in a significantly higher wound failure rate with no decrease in sinus formation. A mass closure technique using monofilament nylon is recommended for laparatomy closure and efforts should continue to reduce wound sepsis.     

腰椎间孔狭窄症的MRI图像分析与临床意义

目的:通过对腰椎旁矢状位MRI图像的分析,探讨影响腰椎间孔形态、孔内神经根周围环境的主要因素,寻找在腰椎旁矢状位MRI图像上评价腰椎间孔狭窄症(LPS)的主要量化指标。方法:2007年1月至2009年8月接受MRI检查,并经手术证实为LPS的35例MRI图像进行系统回顾性分析,其中男27例,女8例;年龄35～82岁,平均54.5岁;病史4个月～8年,平均32个月。同时与37例正常腰椎间孔的MRI图像作对比性研究,观察两组资料矢状位MRI图像上L4,5、L5S1椎间孔有效空间的垂直径、上位矢状径、根孔比例,分析引起LPS的主要因素。结果:LPS组L4,5、L5S1椎间孔有效空间的垂直径、上位矢状径小于正常组,椎间孔有效空间的根孔比例大于正常组。腰椎间盘、纤维环后外侧突出,黄韧带肥厚是LPS的主要软组织性因素;关节突关节、椎体后外缘终板平面增生肥大,骨赘突入椎间孔是LPS的主要骨性因素;神经根的水肿、粘连是LPS的主要根性因素,且多种因素往往复合存在。结论:软组织性、骨性、根性因素的复合引起LPS,MRI检查可以充分显示LPS的解剖形态及引起LPS的病理改变,腰椎间孔有效空间的上位矢状径、垂直径、根孔比例可以作为腰椎旁矢状位MRI图像上评价LPS的量化指标。     

Morphology of the ventriculoaortic junction in critical aortic stenosis. Implications for hemodynamic function and clinical management.

The clinical presentation of infants with critical aortic stenosis, as well as the results of surgical treatment, differs from obstruction of the left ventricular outflow tract in older children. To investigate a possible anatomic basis for this situation, we performed a detailed morphometric study of 21 hearts from infants who had critical aortic stenosis and 11 normal hearts from infants less than 3 months of age. In each of the hearts with critical aortic stenosis, only one commissure extended to the sinutubular ridge. The other two commissures were represented by folds in the aortic wall that suspended the leaflet below the level of the sinutubular junction. The leaflet thus had a free edge shorter than the circumference of the sinus, in contrast with the normal valve, in which leaflets always were longer than the circumference of their supporting sinus. Analysis of the fibrous triangles on the ventricular aspect of abnormal valves showed a symmetric three-sinus arrangement. In all but one specimen, however, only the triangle related to the mitral valve was fully developed. Although incision of both rudimentary commissures to the aortic wall should achieve some relief of obstruction, these morphologic features strongly mitigate against surgical restoration of normal function or growth in aortic valves having the morphology observed in this series of hearts.     

Factors influencing hospital implementation of acute pain management practice guidelines.

STUDY OBJECTIVE: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings. DESIGN: Two questionnaire surveys. SETTING: Healthcare Association of New York State, Albany, NY. MEASUREMENT: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital's chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs' survey data with the clinical directors' report of guideline usage. MAIN RESULTS: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements. CONCLUSIONS: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.     

Anatomic characteristics of the pancreatic arteries. Radiologic observations and their clinical significance

Major complications of operations that remove or transplant a portion of the pancreas appear related to the arterial blood supply. Hemorrhage is a result of inadequate control of the appropriate principal arteries, and ischemia and its consequences occur when the arterial blood supply to portions of preserved pancreas has been inadvertently interrupted. This radiographic study of the principal arteries of the pancreas demonstrates that these vessels may be visualized and their origin determined in the vast majority of cases. The application of data gained from preoperative arteriography can potentially decrease the incidence of major complications associated with removal or transplantation of portions of the pancreas.     

宫腔内人工授精临床妊娠率的影响因素分析

目的:分析影响宫腔内人工授精(IUI)临床妊娠率的相关因素。方法:回顾性分析611个周期IUI者的临床资料,探讨女方年龄、不孕年限、不孕类型、所行周期数、周期方案、子宫内膜厚度及形态、处理前精液参数等因素与IUI妊娠率的关系。结果:促排卵周期妊娠率显著高于自然周期(23.03%vs 11.03%,P0.01),第4周期以上的妊娠率较第1、2、3周期明显下降(2.04%vs 21.03%、18.13%、12.67%,P0.01),当女方年龄≥40岁、处理前前向运动精子总数(TPMSC)10×106、前向运动精子百分率20%、正常形态精子百分率2%时,IUI临床妊娠率明显下降(P均0.05)。Logistic回归分析提示周期方案、所行周期数、前向运动精子百分率显著影响IUI临床妊娠率(P0.05)。结论:周期方案、所行周期数、前向运动精子百分率、女方年龄、TPMSC以及精子形态是影响IUI临床妊娠率的重要因素,而不孕年限、不孕类型、子宫内膜厚度及形态对IUI成功率没有明显影响。     

Factors influencing the diagnostic accuracy and management in acute surgical patients

AIM:To evaluate the diagnostic accuracy(DA) in acute surgical patients admitted to a District General Hospital.METHODS: The case notes of all acute surgical patients admitted under the surgical team for a period of two weeks were reviewed for the data pertaining to the admission diagnoses, relevant investigations and final diagnoses confirmed by either surgery or various other diagnostic modalities. The diagnostic pathway was recorded from the source of referral [general practitioner(GP), A and E, in-patient] to the correct final diagnosis by the surgical team. RESULTS: Forty-one patients(23 males) with acute surgical admissions during two weeks of study period were evaluated. The mean age of study group was 61.05 ± 23.24 years. There were 111 patient-doctor encounters. Final correct diagnosis was achieved in 85.4% patients. The DA was 46%, 44%, 50%, 33%,61%, 61%, and 75% by GP, A and E, in-patient referral, surgical foundation year-1, surgical senior house officer(SHO), surgical registrar, and surgical consultant respectively. The percentage of clinical consensus diagnosis was 12%. Surgery was performed in 48.8% of patients. Sixty-seven percent of GP-referred patients, 31% of A and E-referred, and 25% of the in-patient referrals underwent surgery. Surgical SHO made the most contributions to the primary diagnostic pathway.CONCLUSION: Approximately 85% of acute surgical patients can be diagnosed accurately along the diagnostic pathway. Patients referred by a GP are more likely to require surgery as compared to other referral sources. Surgical consultant was more likely to make correct surgical diagnosis, however it is the surgical SHO that contributes the most correct diagnoses along the diagnostic pathway.     

影响消化科静脉留置针使用质量的因素及管理对策

目的探讨提高消化科静脉留置针使用质量的方法。方法分析影响静脉留置针使用质量的因素,采取设置病房静脉输液小组、开展不同层次的技能培训和相关理论知识的学习、加强患者及家属的健康教育以及实施质量监控等对策。结果与实施质量管理前比较,静脉留置针的使用率和一次穿刺成功率显著提高、留置时间显著延长、患者满意度显著提高(P0.05,P0.01)。结论针对性的护理质量管理可有效提高消化科静脉留置针的使用质量。