Analysis of medical risk factors and outcomes in patients undergoing open versus endovascular abdominal aortic aneurysm repair

OBJECTIVE: The emergence of endovascular repair (ER) for infrarenal abdominal aortic aneurysm (AAA) has provided surgeons with a new technique that should ideally improve patient outcomes. To more accurately characterize the advantages of ER versus traditional/open AAA repair (TOR), we compared the preoperative medical risk factors (PMRFs) and perioperative outcomes (PO) of those patients undergoing elective treatment of infrarenal AAA with ER and TOR over a recent 18-month period at our center. METHODS: Through our institutional vascular surgery patient registry, all patients undergoing aortic aneurysm repair of any type between December 1999 and June 2001 were identified. Only those patients undergoing elective infrarenal AAA repair were analyzed. Hospital records were examined for all patients, and PMRF and PO were assessed via Society for Vascular Surgery/International Society for Cardiovascular Surgery reporting guidelines. Student t, chi(2), Fisher exact, or Wilcoxon rank sum tests were applied where appropriate to determine differences among PMRF and PO according to method of aneurysm repair. RESULTS: During the 18-month study period, a total of 199 aortic aneurysms were repaired at our institution. Ninety-nine elective infrarenal AAA repairs made up the study cohort (ER, n = 33; TOR, n = 66). When examined by method of aneurysm repair, no differences existed in demographics or AAA size. Patients undergoing ER had a significantly greater degree of preoperative pulmonary comorbidity than patients undergoing TOR (P <.001). However, no differences existed in terms of American Society of Anesthesiologists classification or cardiac (P =.52), cerebrovascular (P =.44), diabetic (P =.51), hypertensive (P =.90), hyperlipidemia (P =.91) or renal (P =.23) comorbidities between the two groups. Perioperative morbidity and mortality rates were also not significantly different by method of repair. ER was associated with shorter operative time, intensive care unit stay, and overall hospital length of stay (P <.0001). However, subsequent operative procedures related to the AAA repair were performed more frequently after ER (TOR = 1.5% versus ER = 15.2%; P = 0.015). CONCLUSION: These results suggest that ER offers improvements in hospital convalescent and operating room times but no beneficial impact on overall morbidity and mortality rates when similar PMRFs exist, especially when used at medical centers where low morbidity and mortality rates are already established for TOR. Other centers performing ER should undertake such an analysis to assess its impact on their patients.     

Total and Visceral Adiposity Are Associated With Prevalent Vertebral Fracture in Women but Not Men at Age 62 Years: The Newcastle Thousand Families Study

Low body weight is an established risk factor for osteoporosis and fracture, but the skeletal risks of higher adiposity are unclear and appear sex‐specific and site‐dependent. The aim of this study was to investigate associations of total fat mass (TFM), visceral adipose tissue (VAT), and C‐reactive protein (CRP) with bone mineral density (BMD) and prevalent vertebral fracture (VF) in men and women aged 62 years. A total of 352 men and women aged 62.5 ± 0.5 years from the Newcastle Thousand Families Study cohort received dual‐energy X‐ray absorptiometry (DXA) evaluations of femoral neck and lumbar spine BMD, of the lateral spine for vertebral fracture assessment, and of the whole body for TFM and VAT (GE Lunar CoreScan, Madison, WI, USA). Plasma CRP, FRAX scores, falls in the last 12 months, and occupation at age 50 years were also included in the analysis. Vertebral fractures were less prevalent in women than in men (odds ratio [OR] = 0.33, p < 0.001) and BMD or FRAX scores did not differ between participants with and without VF. Women with VF were heavier and had higher TFM, VAT, and CRP than women without (p < 0.001). In women, greater (+1 SD) TFM and VAT increased the odds of any grade VF (TFM: OR = 1.06, p = 0.001; VAT: OR = 2.50, p = 0.002), and greater VAT mass increased the odds of prevalent mild VF (OR = 2.60, p = 0.002). In contrast, there were no associations in men. In both sexes, after controlling for body weight, neither VAT nor CRP were associated with BMD. In conclusion, irrespective of BMD, total and visceral adiposity were associated with prevalent VF in women but not in men. High fat mass, particularly if visceral, should be considered when assessing VF risk in women. Risk factors for VF in men require further investigation, particularly given their high prevalence. © 2017 American Society for Bone and Mineral Research.     

Phimosis as a presenting feature of diabetes

OBJECTIVE

To determine the prevalence of diabetes in men presenting with phimosis, and to establish the incidence of undiagnosed diabetes in men presenting with acquired or life‐long phimosis.

PATIENTS AND METHODS

We prospectively collected data on 100 men (mean age 38.5 years, range 17–82) who presented to our department with phimosis during 2006. Urinary glucose levels and random serum glucose levels were analysed, and if abnormal, the patient had further diagnostic tests for diabetes.

RESULTS

In all, 31 men presented with a life‐long history of phimosis and 69 with a history of acquired phimosis. There was no history of diabetes and no abnormal serum glucose levels in those with life‐long phimosis. Eighteen of 69 (26%) of those with acquired phimosis had a history of type 2 diabetes. Type 2 diabetes was newly diagnosed in four of 50 (8%) men presenting with acquired phimosis and no history of a glycaemic disorder. A further two (4%) were diagnosed with impaired fasting glycaemia and impaired glucose tolerance. Urine analysis was positive for glucose in all new diagnoses of glycaemic disorders, except in one man.

CONCLUSION

Diabetes can be associated with acquired phimosis in almost a third of cases, and 12% of men presenting with acquired phimosis and no history of diabetes were diagnosed with a disorder of glycaemic control. Therefore it is important that serum glucose levels are analysed when assessing men with acquired phimosis.     

Evaluation of the airway and preparation for difficulty

Preoperative airway evaluation is essential to consider which is the best method of maintaining and protecting the airway during surgery and whether problems with airway management are likely. In general surgical patients, the prevalence of difficult intubation is low and tests have poor predictive power. This means that the patient may be evaluated as normal but prove to be difficult. The absence of reliable prediction in general surgical patients means that airway strategy holds the key to successful management. Where there are obvious abnormalities in the history, examination or imaging the preoperative evaluation will allow choice of the most appropriate airway strategy which may include preparation of the patient, assembling of alternative airway equipment, advice and help from a more senior or skilled anaesthetist or aid from a surgical colleague or assistant.     

Diagnostic Splenectomy for Visceral Leishmaniasis

A 57-year-old-man with a history of malaise, fever,night sweats and shortness of breath presented a diagnostic challenge to his medical team. He was pancytopaenic and had splenomegaly on admission but other investigations, including bone marrow aspiration, proved inconclusive. After the patient deteriorated clinically, the general surgical team was requested to perform a diagnostic splenectomy. The histology of this showed infection with visceral leishmaniasis. He recovered completely with Amphotericin treatment. Although this is a rare condition, particularly for the general surgeon, this case highlights the difficult position surgeons are often put in when performing major surgery diagnostically.     

Characterization of circulating monocytes expressing HLA-DR or CD71 and related soluble factors for 2 weeks after severe, non-thermal injury

BACKGROUND: Severe injury is associated with changes in monocytes that may contribute to poor outcomes. Longitudinal characterization of monocyte response patterns after trauma may provide added insight into these immunological alterations. METHODS: Venous blood obtained seven times during post-injury days 1 through 13 from 61 patients with an injury severity score >20 was assessed by flow cytometry for monocytes (CD14+) expressing HLA-DR or CD71 (transferrin receptor) and for circulating levels of interleukin (IL) 1alpha, IL-1beta, IL-6, soluble CD14 (sCD14), tumor necrosis factor-alpha (TNF-alpha), prostaglandin E(2) (PGE(2)), thromboxane B(2) (TXB(2)), and endotoxin. Urine neopterin was measured by high-pressure liquid chromatography, expressed as a neopterin-creatinine ratio. RESULTS: Trauma patients had leucocytosis days 1 through 13, monocytosis days 5 through 13, reduced proportions of CD14+HLA-DR+ cells days 2 through 5, and elevated proportions of CD14+CD71+ cells days 1 through 13. Neopterin was elevated all days, peaking on day 10. sCD14 was elevated days 2 through 13, and there were sporadic elevations of IL-1alpha, IL-1beta, IL-6, TNF-alpha, PGE(2), TXB(2), and endotoxin. Sepsis syndrome patients (n = 6) had larger and more prolonged reductions in CD14+HLA-DR+ cells and higher neopterin values, in comparison with uneventful patient outcomes. CONCLUSIONS: Altered proportions of monocytes expressing HLA-DR and CD71 and elevated sCD14 and urine neopterin levels, for up to 2 weeks after severe injury, underscores an extended period of profound immunological effects. Additional studies to more fully assess temporal monocyte response patterns after severe injury, including activation, may be warranted.     

Modulation of vascular remodeling induced by a brief intraluminal exposure to the recombinant R7020 strain of Herpes simplex-1

OBJECTIVE: Vascular remodeling in response to injury or low shear stress (or both) is characterized by neointimal hyperplasia and luminal contraction. When profound, the response leads to restenosis after percutaneous endovascular intervention as well as to de novo stenosis in vein grafts. It has recently been reported that exposure of vein patches to neurovirulence-attenuated Herpes simplex virus-1 (HSV-1) decreases neointimal hyperplasia and increases luminal area. This experiment tested the hypothesis that R7020, a more highly attenuated mutant of HSV-1, would modulate the vascular remodeling response of experimental vein grafts chronically exposed to low shear stress. METHODS: The external jugular veins of 31 New Zealand white rabbits were clamped and intraluminally exposed to vehicle (phospate-buffered saline solution, n = 11), R7020 2.5 x 10(8) plaque forming units [PFU]/mL (n = 8), or R7020 2.5 x 10(9) PFU/mL (n = 12) for 10 or 30 minutes at an average pressure of 80 mm Hg. After exposure, an end-to-side distal external jugular-to-common carotid artery anastomosis was created, resulting in a widely patent arteriovenous fistula. The external jugular was suture-ligated just proximal to the thoracic inlet, distal to a small 10- to 50-microm venous tributary, creating a reversed vein "graft" segment immediately and abruptly exposed to arterial pressure (48 +/- 3 mm Hg) and low shear stress (0.12 +/- .02 dyne/cm(2)). In the 29 animals (N = 31) that survived to harvest, 26 grafts were found to be patent and were analyzed further. Nine grafts were harvested within the first week after operation, snap frozen in liquid nitrogen, and assayed for the presence of the Herpes viral immediate-response protein ICP0 by Western blot analysis. The 17 remaining grafts were perfusion-fixed, excised, stained, and analyzed morphometrically by digital planimetry. RESULTS: In patent grafts, the hemodynamic environment of low shear stress was maintained (shear stress at harvest, 0.26 +/- .06 dyne/cm(2)). Western blot analysis revealed the presence of ICP0 in R7020-exposed vein grafts after 2, 3, 7, and 14 days; ICP0 was not detected in unexposed vein grafts or adjacent carotid arteries. After 4 weeks, vein grafts exposed to R7020 exhibited a statistically significantly increased ratio of luminal radius to wall thickness, indicating altered remodeling (vehicle, 6.7 +/- 1.3; R7020 2.5 x 10(8), 9.1 +/- 1.3; R7020 2.5 x 10(9) ratio, 11.3 +/- 1.4; P < .05 for high dose compared with vehicle). CONCLUSION: A brief exposure of the neurovirulence-attenuated HSV-1 strain R7020 results in an increased ratio of luminal radius to wall thickness in experimental vein grafts chronically exposed to low shear stress.     

The posterior shearing tibial plateau fracture: treatment and results via a posterior approach

OBJECTIVES: This study was designed to describe the fracture patterns and early results of treatment of posterior shearing tibial plateau fractures. DESIGN: Retrospective case series. SETTING: Tertiary care hospital. PATIENTS: Thirteen patients identified from prospective trauma database with posterior shearing tibial plateau fractures. INTERVENTION: Open reduction and internal fixation through a posterior approach to the knee. MAIN OUTCOME MEASUREMENTS: Functional outcome assessed by Musculoskeletal Functional Assessment score and Visual Analogue Scale pain scores. Clinical and radiographic outcome. RESULTS: A consistent fracture pattern was identified with a primary, inferiorly displaced posteromedial shear fracture with variable amounts of lateral condylar impaction. The average duration of clinical patient follow-up was 20 (range, 13-27) months. All fractures healed after index surgery. Two complications (1 wound dehiscence and 1 flexion contracture) were all managed nonoperatively. Three independent surgeons graded patients' articular reduction, with good interobserver reliability (intraclass correlation coefficient = 0.82). The average Musculoskeletal Function Assessment dysfunction score for the 9 patients who responded was 19.5/100, and average resting Visual Analogue Scale pain score was 1.8 cm/10 cm, indicating good function. The functional outcome score was significantly related to the quality of articular reduction (P < 0.017, R = 0.456). CONCLUSIONS: Posterior shearing tibial plateau fractures form a consistent pattern. They can be successfully managed using a posterior approach with direct reduction and buttress fixation of articular fragments. Quality of articular reduction is one factor that influences short-term functional outcome.     

The rights and interests of doctors and patients: does the new Victorian Health Professions Registration Act 2005 strike a fair balance?

From July 2007, the Health Professions Registration Act 2005 (Vic) will significantly alter the medical disciplinary process in Victoria. For practitioners: Formal hearings for allegations of serious unprofessional conduct will be heard by the Victorian Civil and Administrative Tribunal (VCAT); There will be no right of appeal from a VCAT decision other than on a point of law; The maximum fine for serious unprofessional conduct will increase from $2000 to $50 000; Performance standards panels (PSPs) will be established to conduct informal hearings, with a power to impose conditions on registration; and Costs of the new system will cause an increase in annual registration fees. For complainants: There are new avenues for conciliation; There is a right to seek a review of certain Medical Practitioners Board of Victoria decisions; and Reasons for a PSP decision will be provided. Despite government argument that these changes will make the health complaints handling system fairer, the new Act has the potential to diminish the rights and interests of doctors.     

Effect of age on the abundance and fragmentation of link protein of the human intervertebral disc

The link proteins of the human intervertebral disc were studied in tissue extracts by sodium dodecyl sulfate/polyacrylamide gel electrophoresis (SDS/PAGE), followed by immunoblotting, using a specific monoclonal antibody. Three link proteins were detected, corresponding in electrophoretic mobility to those present in articular cartilage. As with articular cartilage, the largest link protein predominates in the young, whereas in the adult the smallest link protein is equally abundant and internal fragmentation of the link proteins occurs. Only in the newborn is the quantity of extractable link protein comparable to that from articular cartilage. In the adult, the disc contains much less link protein than is present in autologous articular cartilage. Neither the amount nor heterogeneity of the link protein differs among different levels within the lumbar spine, although the proportions of the three proteins can differ between the anulus fibrosus and nucleus pulposus. The anulus always contained more extractable link protein relative to tissue wet weight than the nucleus, and the nuclear link protein, at least in adolescents, contained a greater proportion of the smallest link protein. Such changes in the quantity and structure of the disc link proteins may affect the properties of the proteoglycan aggregates and, thus, could influence disc function.