Repair of injuries to the thoracic aorta and great vessels: Auckland, New Zealand 1995-2004

BACKGROUND: Traumatic injury to the aorta and great vessels is a surgical emergency with survivors who reach hospital typically having suffered multiple injuries. There are several diagnostic and treatment options available, with new modalities emerging to challenge the gold standards. A review of recent trends in management of these injuries in Auckland, New Zealand was carried out and patient outcomes assessed. METHODS: The charts of patients admitted to Auckland and Green Lane Hospital's cardiothoracic intensive care unit, with a diagnosis of injury to the thoracic aorta or great vessels since 1995 were retrospectively reviewed. Imaging techniques, injury types and treatment methods were analysed along with survival and neurological morbidity. RESULTS: In the study period our unit operated on 29 cases of traumatic rupture of the thoracic aorta or great vessels. Digital subtraction angiography and more recently, multidetector computed tomography scanning have been used to diagnose the injury. Twenty-seven injuries were to the aorta and two to the innominate artery. The 30-day survival rate of those reaching the operating theatre was 90%. There was one case of postoperative hemiparesis and five cases of recurrent laryngeal nerve injury, but none of spinal cord ischaemic injury. Endoluminal stent grafting was carried out for one patient, without complication. CONCLUSIONS: Good survival rates exist for those who reach surgery for traumatic rupture of the aorta or great vessels. Multidetector computed tomography scanning is an alternative to digital subtraction angiography, potentially reducing treatment delay. In addition endoluminal grafting as opposed to open repair has been reported as a safe technique. The injury remains a surgical emergency requiring urgent diagnosis and transfer to an equipped cardiothoracic unit for definitive treatment.     

T cell lymphoplasmacellular and eosinophilic infiltration of the pancreas with involvement of the gallbladder and duodenum in non-alcoholic duct-destructive chronic pancreatitis

Background Non-alcoholic duct destructive chronic pancreatitis is a rare entity with specific pathological features. The majority of the patients are from Japan. We report a case with involvement of the distal bile duct, the gallbladder, the duodenum and the ampulla, and present a review of patients from Europe and the USA since 1997.Case presentation A 56-year-old man presented with a 3-month history of mild acute pancreatitis and obstructive jaundice, followed by increasing weight loss, lethargy and epigastric pain. CT showed a mass in the head of the pancreas. ERCP demonstrated a smooth stricture of the intra-pancreatic main bile duct and an irregular, incomplete, stricture in the main pancreatic duct. A pancreatic cancer could not be reliably excluded, and, therefore, he underwent a pylorus-preserving Kausch–Whipples pancreatoduodenectomy.Results Histopathology showed typical peri-ductal T cell-rich lymphoplasmacellular and eosinophilic infiltration of the pancreas, with involvement of the distal bile duct but, also, unusual inflammatory infiltration of the gallbladder, the duodenum and the ampulla.Conclusion The inflammatory process in non-alcoholic duct-destructive chronic pancreatitis can affect the entire pancreato-biliary region and mimics pancreatic cancer. Currently, there are no definitive criteria for pre-operative diagnosis, so it is very difficult for one to avoid resection.     

Risk factors and prevalence of perioperative cognitive dysfunction in abdominal aneurysm patients

BACKGROUND: Perioperative delirium is common in high-risk surgery and is associated with age, education, preoperative cognitive functioning, pre-existing medical conditions, and postoperative complications. We investigated these factors as well as lifestyle and demographic variables by using cognitive measures that were more sensitive than those used in previous studies. METHODS: Extensive medical and demographic data were collected on 102 patients between 41 and 88 years of age to identify comorbidities and lifestyle considerations preoperatively. Elective abdominal aortic aneurysm surgery was performed under combined general/epidural anesthesia with postoperative epidural analgesia. A battery of sensitive, cognitive measures was administered preoperatively, at the time of discharge from hospital, and 3 months postoperatively. Symptoms of delirium were assessed during the first 6 postoperative days using Diagnostic and Statistical Manual of Mental Disorders-4th Edition criteria. Intraoperative and postoperative data, including medications, vital signs, conduct of the surgery and anesthesia, complications, and details of pain control, were collected. RESULTS: Delirium occurred in 33% of the patients during the first 6 days after surgery. Longer duration of delirium was related to lower education, preoperative depression, and greater preoperative psychoactive medication use. Characteristics of the surgery and hospital stay were unrelated to the development of delirium. Patients who were diagnosed with delirium had lower cognitive scores during each of the three assessment periods, even when controlling for age and education. Logistic regression analysis indicated that the most powerful preoperative predictors of delirium were number of pack years smoked (P = .001), mental status scores (P = .003), and number of psychoactive medications (P = .005). CONCLUSION: A significant proportion of patients undergoing elective abdominal aortic aneurysm repair are susceptible to the development of delirium and are at risk for cognitive dysfunction after surgery. Our findings have implications for promoting long-term lifestyle changes, including smoking cessation and improved management of mental health as risk-reduction strategies.     

Otoplasty

Multiple techniques have been advocated over the years for the appropriate and natural-appearing correction of the prominent ear. There is no single technique that can re-create the complex three-dimensional nature of the otherwise normal human ear. We have to evaluate each individual ear and patient and correct the abnormalities with a technique that each surgeon feels comfortable with and that can repeatedly provide gratifying results. Ultimately, the simplest technique that can obtain the maximum effect should be employed. A concentration on the male patient and specific concerns with these patients are discussed. Multiple techniques are presented to adequately treat a variety of anatomic variations. Surgical complications and their treatment are also discussed.     

Randomised controlled crossover trial of humidified continuous positive airway pressure in mild obstructive sleep apnoea

BACKGROUND: It is unclear whether continuous positive airway pressure (CPAP), the treatment of choice for severe obstructive sleep apnoea (OSA), is effective at improving outcomes in mild OSA. METHODS: To help define the role of humidified CPAP in mild OSA, a randomised crossover study was undertaken of patients with an apnoea hypopnoea index (AHI) of 5-30/hour. Subjective sleepiness, objective wakefulness, mood, reaction time, and quality of life were measured at baseline, after 3 weeks treatment with humidified CPAP and 3 weeks sham CPAP (2 week washout). RESULTS: Twenty nine of 31 enrolled patients (age 25-67 years, seven women, mean (SD) body mass index 31.5 (6) kg/m2) completed the protocol. Humidified CPAP improved polysomnographic indices of OSA and Epworth Sleepiness Scale (2.4 points (95% CI 0.6 to 4.2)). Objective wakefulness (modified maintenance of wakefulness test) showed a trend towards improvement (5.2 minutes (95% CI -0.6 to 11)). Mood (Hospital Anxiety and Depression Scale), quality of life (SF 36, Functional Outcomes of Sleep Questionnaire), and reaction times (Psychomotor Vigilance Task) were not improved more than sham CPAP. Compliance with humidified and sham CPAP both averaged 4.9 hours/night. Placebo effects were evident in many outcomes and there was no clear treatment preference. CONCLUSIONS: Humidified CPAP improves subjective sleepiness and possibly objective wakefulness but not reaction times, quality of life, or mood. These results do not support the routine use of CPAP in all patients with mild OSA, but offers some support for the trialling of CPAP in those with severe sleepiness.     

Elevated white cell count at commencement of peritoneal dialysis predicts overall and cardiac mortality

BACKGROUND: Higher total white blood cell counts (WCC) have been shown in the general population to be strongly and independently predictive of coronary heart disease and all-cause mortality. The aim of the present study was to evaluate the prognostic value of WCC in patients commencing peritoneal dialysis (PD). METHODS: A cohort of 323 patients (mean age 55.1 +/- 17.7 years, 54% male, 81% Caucasian) commencing PD at the Princess Alexandra Hospital between January 1, 1998 and March 31, 2003 were prospectively followed until death, completion of PD therapy, or otherwise to the end of the study (January 2, 2004), at which point data were censored. Individuals with failed renal transplants (N= 17) and those with acute infections at the time of PD onset (N= 12) were not included. A multivariate Cox's proportional hazards model was applied to calculate hazard ratios and adjusted survival curves for time to death or cardiac death, adjusting for baseline demographic, clinical, and laboratory characteristics. RESULTS: Median actuarial patient survival was 3.9 years [95% confidence interval (CI) 3.2-4.7 years]. The highest quartile of WCC (>9.4 x 10(9)/L) was significantly and independently associated with increased risks of both death from all causes [adjusted hazard ratio (HR) 2.27, 95% CI 1.09-4.74, P < 0.05] and cardiac death (HR 3.75, 95% CI 1.2-11.8, P < 0.05). Other adverse risk factors included older age, lower serum albumin, and the presence of coronary artery disease. Similar associations were found between mortality and PMN count, but not lymphocyte count. CONCLUSION: Elevated baseline WCC or PMN count at the commencement of PD (in the absence of acute infection) strongly predicts all-cause and cardiovascular mortality. These data suggest that new PD patients with higher WCC may warrant closer monitoring and extra attention to modifiable cardiovascular risk factors.     

Musculoskeletal disorders among full-time homemakers in poor communities

OBJECTIVE: To examine factors associated with self-reported musculoskeletal disorders (MSD) among full-time female homemakers. METHODS: Data on socio-demographic characteristics, lifestyle and health were collected on 1266 married women aged 15-59 years living in poor suburbs in the outskirts of Beirut, Lebanon. Independent associations with MSD of factors and characteristics were examined using odds ratios (ORs) derived from multiple logistic regression. RESULTS: Women's age, weight, and number of children were significantly, positively, independently associated with self-reported MSD, while women's conduct of specific household tasks were not. Women with MSD were more likely to be stressed than women without MSD (OR = 1.5). CONCLUSION: A major finding of this study was the positive association between distress and musculoskeletal disorders. The measures used to assess women's involvement in housework did not account for the duration of time spent performing each household task. Better measures of domestic labor, including housework and childcare, are required to understand better their impact on the health of full-time homemakers and on MSD in particular. Intervention programs to alleviate MSD in full-time homemakers should address psychosocial factors.     

Depressive symptoms have an independent, gradient risk for coronary heart disease incidence in a random, population-based sample

PURPOSE: Depression is a risk factor for incident coronary heart disease (CHD), and predicts poor prognosis for patients post-myocardial infarction (MI). Few population-based, prospective studies have tested a gradient risk for depressive symptoms on CHD incidence. METHODS: The sample (n=1302) was derived from the Nova Scotia Health Survey-1995 (NSHS95), an age- and sex-stratified, random, population-based health survey. All subjects were 45 years or older, free of overt CHD at baseline, and completed the Center for Epidemiological Studies-Depression (CES-D) scale. Covariates included age, sex, body mass index, physical activity level, family history of premature CHD, diastolic blood pressure, lipids, smoking, alcohol use, diabetes, and education level. For the 4 years following NSHS95, MI-related hospitalizations (ICD-9-CM code 410) and CHD-related deaths (ICD-9-CM codes 410-414) were extracted from the provincial, universal healthcare registry. RESULTS: Fifty-two participants experienced a CHD event. A one standard-deviation increase in CES-D score was associated with a 1.32 hazard risk (confidence interval, 1.01-1.71) of CHD events, controlling for established CHD risk factors. CONCLUSIONS: An independent, gradient association between depression and incident CHD was detected in a population-based sample with complete 4-year CHD data. This evidence supports the value of investigating mechanisms linking depression and CHD.