Does female gender or hormone replacement therapy affect early or late outcome after carotid endarterectomy?

OBJECTIVE: Subgroup analyses of the Asymptomatic Carotid Atherosclerosis Study and the North American Symptomatic Carotid Endarterectomy Trial trials have questioned the ability of carotid endarterectomy (CEA) to reduce the risk of stroke in women. The purpose of this study was to test the effect of female gender and estrogen-based hormone replacement therapy on perioperative (30-day) and long-term (5-year) outcomes after CEA. METHODS: From 1988 to 1998, 361 CEAs were performed in 326 patients (246 male, 115 female) by a single surgeon. Retrospective data were collected with chart review, and follow-up data were obtained with clinical examination or telephone interview. Follow-up was possible in 95% of patients. Reoperative CEAs and combined aortic or cardiac procedures were excluded. Statistical analysis used life-table methods, Student t test, and Pearson chi(2) tests when appropriate. RESULTS: Age and preoperative risk factors were similar between women and men. CEA was performed for symptomatic (50% female, 42% male) and asymptomatic carotid stenosis (50% female, 58% male; P =.19). Perioperative (30-day) stroke rate was similar for women and men (3.6% female, 1.2% male; P =.13). No perioperative strokes occurred in asymptomatic patients. With previous stroke or transient ischemic attack, a trend was seen towards an increased perioperative stroke rate in women (7.0% female, 2.8% male; P =.25). Long-term follow-up showed a similar trend in the 5-year stroke rate in symptomatic patients (7.0% female, 2.8 male; P =.23). The stroke-free survival rate was not significantly different between genders (87% female, 75% male; P =.58). Reoperation was performed for asymptomatic recurrent carotid stenosis in five men (2.3%) and two women (1.9%; P =.84). Interestingly, the use of estrogen-based hormone replacement therapy in women showed a trend toward increasing stroke rate at 30 days (1.2% versus 8.7%; P =.08) and at 5 years (2.3% versus 8.7%; P =.16). CONCLUSION: This retrospective study confirms that CEA provides long-term reduction in stroke risk and improved stroke-free survival rates in both men and women. However, women with previous neurologic symptoms and those using hormone replacement therapy appear to be at higher stroke risk at the time of surgery.     

Do voids in a femoral cement mantle affect the outcome?

A total of 156 ceramic versus ultra-high-molecular-weight polyethylene hip prostheses were followed for a minimum of 10 years to compare the outcome of the femoral component in 2 groups: those with and those without radiologically detectable voids in the cement mantle. No significant difference was observed. In this series, voids with a 5-mm diameter had no effect on loosening of the femoral component over a 10-year period.     

Inguinal hernia in female infants: a cue to check the sex chromosomes?

OBJECTIVES: To review the clinical presentation of complete androgen insensitivity syndrome (CAIS) and assess the current practice of considering the diagnosis of CAIS in female infants presenting with inguinal hernia. PATIENTS AND METHODS: AIS arises from target tissue resistance to the actions of androgens due to molecular abnormalities in the androgen receptor. Patients with CAIS are born with normal external female genitalia, and although inguinal hernias are uncommon in female infants, they are a well-known presentation of CAIS. Such patients were identified from the Cambridge Intersex Database and details of presentation, presence and laterality of inguinal hernia and contents, and family history of CAIS, were recorded. A questionnaire detailing different indications for considering CAIS in female infants with a hernia was distributed to members of the British Association of Paediatric Surgeons and the British Society for Paediatric Endocrinology and Diabetes. RESULTS: More than half of patients with CAIS presented with inguinal hernia, of which half were bilateral and a third contained gonads. Completed questionnaires were returned by 87 surgeons and 64 endocrinologists, and most of the surgeons and endocrinologists would consider CAIS in all female infants with a hernia. Bilateral hernias, hernias containing gonads and a family history of CAIS would prompt clinicians to consider the diagnosis. CONCLUSION: Most clinicians agreed that CAIS should be considered in all female infants with inguinal hernia, as this is the commonest mode of presentation in childhood. Macroscopic inspection of the internal genital structures coupled, perhaps, with gonadal biopsy is recommended. Fluorescence in situ hybridization offers a rapid and reliable method to check the sex chromosomes. Liaison between the paediatric surgeon and endocrinologist is essential in management of infants with CAIS.     

Do the manipulations in pediatric inguinal hernia operations affect the vascularization of testes?

Purpose

The aim of this study is to evaluate the effect of manipulations performed in inguinal hernia operations on testicular perfusion, in pediatric age group using Doppler ultrasonography (DUS).

Methods

In this prospective clinical trial, 51 boys who underwent elective inguinal hernia repair were examined before the operation and in early-late postoperative periods. Blood flow indices of centripetal and capsular arteries including peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistivity index (RI) were examined by DUS.

Results

There was a statistically significant increase in early postoperative PSV and RI values compared with preoperative findings. These values turned to normal in late postoperative period. The increase in early and decrease in late postoperative EDV values were not statistically significant compared to preoperative findings.

Conclusions

The surgical manipulations performed in inguinal hernia operations in children cause transient changes in testes vascularization in early postoperative period but turns to normal late postoperatively.     

Do risk perceptions explain sex differences in community integration and participation after spinal cord injury?

Objective

To describe how men and women with spinal cord injury (SCI) rate the risks posed by a set of everyday activities measured using the Risk Inventory for persons with Spinal Cord Injury (RISCI), and to examine whether sex differences are related to community integration and participation.

Design

Cohort study.

Setting

Metropolitan Detroit.

Participants

One hundred and forty community-dwelling white and African-American men and women with SCI.

Outcome measures

RISCI scores, community integration, and level of and satisfaction with community participation.

Results

Study participants were just over age 40 years, and had been living with SCI for 10.8 years. One-third were women and 40% were African-American. Results showed women with SCI had higher RISCI scores (perceived more dangers) on every item on the RISCI Scale (P < 0.001). The items perceived to hold greatest risk were revealing personal information to others, going on a blind date, and going for a roll (“walk”) alone after dark. Women with higher RISCI scores reported lower community integration (P < 0.05) and lower levels of and lower satisfaction with community participation (P < 0.01). For men, however, RISCI scores were mainly unrelated (except for community integration) to participation measures.

Conclusion

More research is needed to determine whether the levels of risk perceived by women are warranted and whether a sense of vulnerability for women with SCI is unnecessarily limiting their chances at “a good life” after injury.     

Do medications affect outcomes in pelvic pouch construction?

Ileal pouch anal anastomosis is the preferred operation for restoration of intestinal continuity in patients with ulcerative colitis due to favorable functional outcomes and quality of life. However, up to 30% can develop postoperative complications, of which pelvic sepsis is the most dreaded due to impaired pouch function and increased rates of pouch failure. Several modifiable risk factors are associated with postoperative pelvic sepsis including obesity, poor nutritional status, anemia, and immunosuppressive therapy. While the evidence regarding the effect of immunosuppressive therapy on adverse postoperative outcomes is controversial, there is mounting data to suggest the operation performed at the time of immunosuppression exposure is critical for subsequent pouch outcomes. This has resulted in an increased number of pouches being performed as a modified 2-stage or 3-stage approach, a conservative yet safe approach to avoid potential deleterious effects of immunosuppression at the critical step of pouch formation.     

Valve-preserving aortic replacement: does the additional repair of leaflet prolapse adversely affect the results?

OBJECTIVE: Valve-preserving aortic replacement has evolved into an accepted therapeutic option for aortic ectasia with morphologically intact leaflets. Some patients, however, exhibit additional leaflet prolapse. We compared the results of established valve-preserving techniques with those of the combination of valve-preserving aortic surgery and additional repair of leaflet prolapse. METHODS: Between October 1995 and March 2000, 99 patients underwent valve-preserving root replacement by means of root remodeling or valve reimplantation for acute dissection (n = 25), chronic dissection (n = 4), or aneurysm (n = 70). In group A (63 patients) either root remodeling (n = 49) or valve reimplantation (n = 14) was performed with a standard technique. In group B (36 patients) valvepreserving aortic replacement (remodeling, n = 31; reimplantation, n = 5) was combined with repair of leaflet prolapse in the presence of bicuspid (n = 24) or tricuspid (n = 12) valve anatomy. Additional replacement of the aortic arch was required more frequently in group A (group A, n = 43; group B, n = 14; P =.006); otherwise, the groups were comparable. RESULTS: Cardiopulmonary bypass (group A, 133 +/- 31 minutes; group B, 117 +/- 30 minutes; P =.006) and myocardial ischemia times (group A, 96 +/- 25 minutes; group B, 88 +/- 20 minutes; P =.05) were significantly longer in group A. Mortality was not significantly different between groups (group A, 4.8%; group B, 0%). One patient in each group underwent secondary valve replacement, and all other patients had stable valve function. Freedom from aortic regurgitation of grade 2 or greater after 48 months was 93.0% in both groups. CONCLUSION: Repair of leaflet prolapse in conjunction with valve-preserving root replacement leads to midterm results that are equal to those of valve-preserving root replacement for morphologically intact leaflets.     

Does neoadjuvant chemotherapy diminish the sex disparity in bladder cancer survival after radical cystectomy?

IntroductionSex-specific survival disparities for bladder cancer outcomes after radical cystectomy (RC) have been demonstrated in several studies. However, these studies predate the widespread adoption of neoadjuvant chemotherapy (NAC). We evaluated the differences in sex-specific survival between patients who received NAC with those who did not, using a contemporary national outcomes database.MethodsThe National Cancer Data Base was queried from 2004 to 2015 to identify subjects who underwent RC. Kaplan-Meier method with log-rank test was performed to compare all-cause mortality between men and women at each pathologic (p) TNM stage group: T1-4N0, N+ and M+ disease. Associations for all-cause mortality were identified using an adjusted Cox regression analysis, and our findings were confirmed with a subgroup analysis.ResultsA total of 9,835 subjects (7,483 men and 2,532 women) were included in the analysis. Kaplan-Meier survival curves and Cox regression analysis demonstrated female sex was not associated with worse overall survival compared to males (HR 0.947, 95%CI 0.852–1.053, P = 0.947) in the overall cohort. Stratified by pT stage and node positivity, worse overall survival was seen in women with pT4 disease who did not receive NAC compared to men (5-year OS 9.6% women vs. 15.2% men, P < 0.001), but no sex-specific difference was seen across all groups in patients who received NAC. Subgroup multivariable analysis showed that female sex conferred a survival disadvantage for pT4 (HR 1.369, P = 0.026) disease only in patients who did not receive NAC.ConclusionsIn a contemporary cohort of subjects who underwent RC, administration of NAC narrows the sex survival-gap in advanced stage bladder cancer. Strategies to improve NAC usage in women should be adopted to overcome potential sex-specific differences such as delayed diagnosis, anatomic differences in higher stage disease, or altered tumor biology which may contribute to differences in oncologic outcomes.     

Groin hernia repair in young males: mesh or sutured repair?

Background  

Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available. We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair.