In-111-labeled white blood cell uptake in noninfected closed fracture in humans: prospective study

Since indium-111 white blood cell (In-111 WBC) scintigraphy is often used to evaluate for osteomyelitis in bone fractures, it is important to know if noninfected fractures have In-111 WBC uptake. Twenty-seven noninfected closed fracture sites in 19 patients were prospectively evaluated with technetium-99m methylene diphosphonate bone scintigraphy and In-111 WBC scintigraphy. In-111 WBC uptake was present in 41% of the 27 sites. In the 11 positive sites, the In-111 WBC uptake was 1+ (definite but minimal) in 55%, 2+ (moderate) in 36%, and 3+ (marked) in 9%. The visual intensity of the radioactive uptake on In-111 WBC scintigrams relative to that on bone scintigrams was less in 82%, equal in 9%, and greater in 9%. The visual size of the area of uptake on In-111 WBC scintigrams and bone scintigrams was smaller in 36%, equal in 55%, and greater in 9%. Factors that may help distinction of In-111 WBC uptake due to fracture alone from infection associated with fracture are discussed.     

Abdominal aortic replacement with a left-sided inferior vena cava: transperitoneal and left retroperitoneal approaches

An unsuspected left-sided inferior vena cava (IVC) can present a formidable challenge for the surgeon attempting aortic reconstructive surgery. A 73-year-old man with aorto-iliac occlusive disease and a 64-year-old man with a seven centimeter (cm) abdominal aortic aneurysm (AAA) each underwent an aorto-femoral bypass graft in the setting of a left-sided cava. In the former case the conventional transperitoneal approach was utilized and in the latter case the extended left retroperitoneal incision was employed. The technical details required in performing these procedures and the developmental anatomy of this and other major venous anomalies are discussed.     

Endograft infection leading to rupture of aortic aneurysm

Aortic endografting has quickly been accepted as a less morbid method of aneurysm repair. However, preservation of the aortic sac after endografting remains a liability of this procedure. Late rupture has occurred, albeit rarely. Graft infections are another rare complication of endografting. We present the first reported case, to our knowledge, of aortic rupture secondary to infection of an aortic endograft.     

肾移植术后妊娠4例

1病例资料本组4例患者来自我院(1994/2004)468例肾移植术后患者,妊娠时年龄(27.5±2.3)岁,妊娠距肾移植时间(30.2±10.5)mo,原发病3例为慢性肾小球肾炎,1例为1型糖尿病.均为首次移植患者,供肾热缺血时间(6.0±2.1)min,冷缺血时间(8.4±1.2)h,供、受者ABO血型相容,淋巴细胞毒性试验阴性.     

An Outbreak of Porcine Reproductive and Respiratory Syndrome Virus in Switzerland Following Import of Boar Semen

An outbreak of porcine reproductive and respiratory syndrome virus (PRRSV) occurred in November 2012 in Switzerland (CH), traditionally PRRSV‐free. It was detected after a German boar stud informed a semen importer about the detection of PRRSV during routine monitoring. Tracing of semen deliveries revealed 26 Swiss sow herds that had used semen from this stud after its last negative routine monitoring and 62 further contact herds. All herds were put under movement restrictions and examined serologically and virologically. As a first measure, 59 sows from five herds that had previously been inseminated with suspicious semen were slaughtered and tested immediately. Investigations in the stud resulted in 8 positive boars with recent semen deliveries to CH (Seven with antibodies and virus, one with antibodies only). In one boar out of six tested, virus was detected in semen. Of the 59 slaughtered sows, five from three herds were virus‐positive. In one herd, the virus had spread, and all pigs were slaughtered or non‐marketable animals euthanized. In the remaining herds, no further infections were detected. After confirmatory testings in all herds 3 weeks after the first examination gave negative results, restrictions were lifted in January 2013, and Switzerland regained its PRRSV‐free status. The events demonstrate that import of semen from non‐PRRS‐free countries – even from negative studs – poses a risk, because monitoring protocols in boar studs are often insufficient to timely detect an infection, and infections of sows/herds occur even with low numbers of semen doses. The outbreak was eradicated successfully mainly due to the high disease awareness of the importer and because immediate actions were taken before clinical or laboratory diagnosis of a single case in the country was made. To minimize the risk of an introduction of PRRSV in the future, stricter import guidelines for boar semen have been implemented.     

Durability of thoracoabdominal aortic aneurysm repair in patients with connective tissue disorders

OBJECTIVE: Thoracoabdominal aortic aneurysm (TAAA) repair is a durable procedure performed with reasonable perioperative mortality and morbidity in patients with atherosclerotic aortic disease. However, the long-term outcome and durability of TAAA repair performed in patients with a connective tissue disorder (CTD) is not well known. METHODS: The records of 257 patients who underwent TAAA repair at the Johns Hopkins Hospital between January 1992 and December 2001 were reviewed. Survival analysis was performed with Kaplan-Meier analysis, and subgroups were compared with the log-rank test. Multivariable analysis was performed with the Cox proportional hazards model and logistic regression. RESULTS: Patients with CTD (n = 31) were seen earlier (mean age, 48.6 +/- 2.9 years) than patients without CTD (mean age, 69.1 +/- 0.6 years; P <.0001, Mann-Whitney U test) and had a greater incidence rate of aortic dissection (52% versus 19%; P <.0001, chi(2) test) and extent I or II aneurysm (77% versus 64%; P =.04). The perioperative (30-day) mortality rate was 6.5% in patients with CTD, which was similar to the rest of the cohort (P =.39, Fisher exact test). The incidence rate of paraparesis/paraplegia was 12.9%/6.5% in patients with CTD, and CTD was the only factor predictive of paraparesis (P =.03; odds ratio, 9.3; logistic regression). The cumulative survival rate among the entire cohort was 53.4% +/- 4.4% at 5 years (Kaplan-Meier), and no difference was seen among patients with or without CTD (P =.16, log-rank test) or among different Crawford extents (P =.29). Of the two late (>6 months) deaths in patients with CTD, none were from aortic rupture or dissection, compared with two of 31 late deaths in patients without CTD. Multivariable analysis confirmed that postoperative renal failure (P =.03) predicted mortality but neither CTD (P =.93), nor Crawford extent (P =.21, Cox regression) predicted mortality. Among survivors, no mean difference was found in largest aortic diameter on follow-up imaging in patients with or without CTD (4.7 +/- 0.3 cm versus 4.4 +/- 0.3 cm; P =.47, Mann-Whitney U test). The cumulative graft patency rate, representing long-term graft stability and with death, rupture, dissection, or recurrent aneurysm as endpoints, was 47.5% +/- 4.6% at 5 years (Kaplan-Meier) and was similar in patients with or without CTD (P =.10, log-rank test). CONCLUSION: TAAA repair appears to be a durable operation, with a reasonable 5-year patient survival rate and a low risk of postoperative paraplegia or additional aortic events. Patients with CTD can expect their outcome, including long-term survival and aortic stability, to be similar to patients without CTD.     

Immediate postoperative thrombolytic therapy: an aggressive strategy for neurologic salvage when cerebral thromboembolism complicates carotid endarterectomy

A 42-year-old man with a high-grade left internal carotid artery (ICA) stenosis demonstrated on a duplex scan was referred to us. A cerebral arteriogram confirmed a greater than 90% left internal carotid stenosis, but with the unexpected finding of a moderate amount of thrombus in the proximal ICA. He underwent emergent left carotid endarterectomy, but during the operation, only a small amount of thrombus was identified as adherent to the atherosclerotic plaque. he awakened in the operating room with a dense right hemiplegia and aphasia. Immediate reexploration demonstrated a patent endarterectomy site, a distal thromboembolectomy was performed without extraction of thrombus, and urokinase (250,000 Units) was infused into the distal ICA. He reawakened with an unchanged right hemiplegia and aphasia. The patient then underwent an urgent postoperative carotid and cerebral arteriogram that demonstrated an embolus to the middle cerebral artery. he was treated with the superselective infusion of urokinase (500,000 Units), with almost complete resolution of the clot. Over the course of the next 48 hours, the patient made a nearly complete neurologic recovery, and he was discharged from the hospital with only a slight facial droop. At 2 months' follow-up he was completely neurologically healthy. To our knowledge this is the first reported case of urokinase administered in the immediate postoperative period in the angiography suite to treat a thromboembolus complicating a carotid endarterectomy.     

Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery.

BACKGROUND: Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta. METHODS: One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones. RESULTS: Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups. CONCLUSIONS: In patients undergoing surgery of the abdominal aorta, thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia, offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia.