Non-robotic thoracoscopic internal mammary artery preparation in the pig. A training model

Notwithstanding non-robotic, thoracoscopic preparation of the internal mammary artery (IMA) is a difficult surgical task, an appropriate experimental training model is lacking. We evaluated the young domestic pig for this purpose. Four domestic female pigs (30-40 kg body weight) were used for this study. Bilateral thoracoscopic preparation of the IMA was carried out under continuous, pressure controlled CO(2) insufflation. A 30 degrees rigid thoracoscope was inserted through a 10-mm port in the 5th/6th intercostal space (ICS) dorsally to the posterior axillary line. The dissection instrument (Ultracision Harmonic Scalpel) was inserted (5-mm port) in the 7th ICS at the posterior axillary line and the endo-forceps (5-mm port) in the 5th ICS at the posterior axillary line. Thoracoscopic IMA preparation in pig resulted more difficult than in man. A total of seven IMAs were prepared in their full intrathoracic length. A change in the preparation technique (lateral detachment of the endothoracic muscle) improved the safety of the procedure, allowing all four respective IMAs to be prepared safely, while the initial technique ensued an injury for 2 out of 3 vessels. The described young domestic pig model is suitable for experimental training of bilateral thoracoscopic IMA preparation.     

Comparison with computed tomography of two ultrasound devices for diagnosis of abdominal aortic aneurysm

Screening for abdominal aortic aneurysms (AAAs) in patients at risk will become more cost effective if a simple, inexpensive, and reliable ultrasound device is available. The aim of this study was to compare a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner (based on bladder scan technology) with computed tomography (CT) for diagnosing AAA. A total of 146 patients (mean age 69 +/- 10 years; 127 men) were screened for the presence of AAAs (diameter >3 cm) using CT. All patients were examined with the handheld ultrasound device and the volume scanner. Maximal diameters and volumes were used for the analyses. AAAs were diagnosed by CT in 116 patients (80%). The absolute difference of aortic diameter between ultrasound and CT was <5 mm in 88% of patients. Limits of agreement between ultrasound and CT (-6.6 to 9.4 mm) exceeded the limits of clinical acceptability (+/-5 mm). An excellent correlation between ultrasound and CT was observed (r = 0.98). The correlation coefficient between the volume scanner and CT was 0.86, with agreement of 90% and kappa value of 0.73. Using an optimal cut-off value of >56 ml, defined by receiver-operating characteristic curve analysis, sensitivity, specificity, and the positive and negative predictive values of the volume scanner for detecting AAA were 90%, 90%, 97%, and 71%, respectively. In conclusion, this study shows that a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner can effectively identify patients with AAAs confirmed by CT.     

The effect of intensified lipid-lowering therapy on long-term prognosis in patients with peripheral arterial disease

BACKGROUND: The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are associated with improved outcome in patients with peripheral arterial disease. Statins may also have beneficial properties beyond their lipid-lowering effect. METHODS: A prospective, observational cohort study was conducted at a university hospital from 1990 to 2005 to examine whether higher doses of statins and lower low-density lipoprotein (LDL) cholesterol levels are both independently associated with improved outcome in peripheral arterial disease. Enrolled were 1374 consecutive patients (age, 61 +/- 10 years, 73% male) with peripheral arterial disease (ankle-brachial index 相似文献   

Evaluation of complications in endoscopic extraperitoneal radical prostatectomy in a modular training programme: a multicentre experience

Objectives  Structured mentor-based “modular surgical training (MST)” has proved to be an effective way to teach endoscopic extraperitoneal radical prostatectomy (EERPE) safely to residents, even those without previous experience in laparoscopic surgery. We report on complications in early patient series from two centres where EERPE was established by MST held at the same teaching centre. Methods  Three trainees from two departments underwent MST at the same teaching centre. Thereafter, they were supervised by their mentor at their hospital. Peri-operative and post-operative complications of the first 245 (centre 1) and 288 (centre 2) cases were analysed retrospectively by the revised Clavien classification and compared to a large series (n = 1300) from the teaching centre. P < 0.05 were considered significant. Results  In total, 427 (80.1%) patients were without complications at the training centres. Intra-operative complications occurred in 8 (1.6%) patients. Among 98 (18.3%) patients with post-operative complications, 41 (7.7%) and 7 (1.3%) patients with Clavien grade I and II complications required no or pharmacological treatment, respectively. Totally, 40 (7.5%) patients required surgical intervention (Clavien grade III). Grade IV and V complications were observed in 9 (1.7%) and 1 (0.2%) cases, respectively. A comparison of complications from the training centres and the teaching centre revealed no statistically significant difference. Conclusions  Novice laparoscopic surgeons can safely learn EERPE by a structured, mentor based, modular surgical training programme without putting patients at risk. The complication rates in early patient series are low and comparable to those of the teaching centre. R. Ganzer and R. Rabenalt contributed equally to this work.     

An Empiric Estimate of the Value of Life: Updating the Renal Dialysis Cost-Effectiveness Standard

ObjectivesProposals to make decisions about coverage of new technology by comparing the technology's incremental cost-effectiveness with the traditional benchmark of dialysis imply that the incremental cost-effectiveness ratio of dialysis is seen a proxy for the value of a statistical year of life. The frequently used ratio for dialysis has, however, not been updated to reflect more recently available data on dialysis.MethodsWe developed a computer simulation model for the end-stage renal disease population and compared cost, life expectancy, and quality-adjusted life expectancy of current dialysis practice relative to three less costly alternatives and to no dialysis. We estimated incremental cost-effectiveness ratios for these alternatives relative to the next least costly alternative and no dialysis and analyzed the population distribution of the ratios. Model parameters and costs were estimated using data from the Medicare population and a large integrated health-care delivery system between 1996 and 2003. The sensitivity of results to model assumptions was tested using 38 scenarios of one-way sensitivity analysis, where parameters informing the cost, utility, mortality and morbidity, etc. components of the model were by perturbed +/?50%.ResultsThe incremental cost-effectiveness ratio of dialysis of current practice relative to the next least costly alternative is on average $129,090 per quality-adjusted life-year (QALY) ($61,294 per year), but its distribution within the population is wide; the interquartile range is $71,890 per QALY, while the 1st and 99th percentiles are $65,496 and $488,360 per QALY, respectively. Higher incremental cost-effectiveness ratios were associated with older age and more comorbid conditions. Sensitivity to model parameters was comparatively small, with most of the scenarios leading to a change of less than 10% in the ratio.ConclusionsThe value of a statistical year of life implied by dialysis practice currently averages $129,090 per QALY ($61,294 per year), but is distributed widely within the dialysis population. The spread suggests that coverage decisions using dialysis as the benchmark may need to incorporate percentile values (which are higher than the average) to be consistent with the Rawlsian principles of justice of preserving the rights and interests of society's most vulnerable patient groups.     

Long-term air-exposed functioning hydrocephalus valve with no infection

One of the reasons for shunt infection is valve erosion through the skin. In such cases, it is common practice to instantly relocate the shunt to avoid infection. We present a 77-year-old female patient with a 15-month history of hydrocephalus valve extrusion. Despite her poor mental status, clinical condition and hygiene, and the prolonged extrusion period, she developed neither a local nor a cerebrospinal fluid (CSF) infection. The patient was ultimately treated with shunt removal and repositioning. An extensive literature review revealed no previous report of such a case. This case indicates that under rare conditions, central nervous system (CNS) implantable devices might not become contaminated and may remain functional, even if they remain exposed for prolonged periods.     

Eight- to ten-year clinical and radiographic outcome of a porous tantalum monoblock acetabular component

In a prospective study, the authors used a porous tantalum monoblock acetabular component for primary total hip arthroplasty between November 1997 and June 1999. A total of 156 consecutive primary total hip arthroplasty were done in 143 patients younger than 75 years. A total of 151 hips had a follow-up time from 8 to 10 years. The average preoperative total Harris hip score of 44.0 ± 13.8 increased to 97.0 ± 6.2 at the latest follow-up. The average preoperative Oxford hip score of 43.3 ± 6.5 improved to 13.9 ± 2.3 at the latest follow-up. Radiographic evaluation including the Ein-Bild-Röntgen-Analyse (EBRA) digital system showed no radiographic evidence of gross polyethylene wear, progressive radiolucencies, osteolytic lesions, acetabular fracture, or component subsidence. There were 7 (4.5%) postoperative complications all unrelated to the acetabular component.     

Planning, decision-making and the COMT rs4818 polymorphism in healthy males

Recent evidence suggests that a synonymous polymorphism within the COMT gene (rs4818 C/G) accounts for a greater variation of COMT activity compared to the functional Val158Met polymorphism. This is the first study on the effects of the rs4818 C/G polymorphism on cognition. One hundred and seven healthy males were tested with the Stockings of Cambridge (SoC) and the Iowa Gambling Task (IGT) and then grouped according to their COMT rs4818 C/G status into three groups (G/G, C/G, C/C). ANOVAs showed that C/C individuals had the best performance in the SoC, G/G the worse, while C/G were intermediate. G/G individuals had strikingly better performance in the IGT compared to the other two groups and their performances in the two tasks were inversely related. These results show that the rs4818 C/G polymorphism imparts strong and differential effects on PFC functions. Low prefrontal dopamine levels are disadvantageous for planning in non-emotional problem solving but lead to optimal effects in emotionally informed decision-making. While high prefrontal dopamine levels may be advantageous for non-emotional problem solving, they lead to disadvantageous choices when decision-making depends on processing of emotional feedback.