Double traumatic caroticocavernous fistula and its treatment by detachable balloons

Summary A case with two separate fistulous caroticocavernous communications on the same side and their successful endovascular management with preservation of the carotid artery are reported.     

Regional Anesthesia for Children Undergoing Orthopedic Ambulatory Surgeries in the United States, 1996–2006

Background

Our objective was to evaluate national trends in regional anesthetic techniques among children undergoing ambulatory orthopedic procedures.

Purpose and Questions

We aimed to determine whether an increase in regional anesthetics was primarily driven by an increase in the number of peripheral nerve blocks performed rather than an increase in neuraxial techniques. We further aimed to determine whether the proportion of peripheral nerve blocks performed in conjunction with general anesthesia has increased over time.

Patients and Methods

Our study sample included any pediatric patient (i.e., <18 years old) who underwent an orthopedic ambulatory procedure in 1996 and 2006. We obtained data on ambulatory surgical procedures by accessing the Centers for Disease Control and Prevention’s National Survey of Ambulatory Surgery. Patient demographics (age, gender), procedure information, and anesthesia-related variables were analyzed for each year.

Results

The proportion of peripheral nerve blocks performed for ambulatory surgery more than doubled from 1996 (4.4 %) to 2006 (8.1 %). A significantly larger proportion of orthopedic procedures were being performed with a combination of peripheral nerve blocks and general anesthesia (1.2 % in 1996 and 43 % 2006). The use of neuraxial anesthesia for lower extremity surgeries decreased over the 10-year period (1.1 and 0.4 % in 1996 and 2006, respectively).

Conclusions

There was a significant increase in the use of peripheral nerve blocks for children undergoing ambulatory orthopedic procedures in the USA, while neuraxial techniques became less common over the 10-year period. The peripheral nerve blocks were frequently performed in conjunction with general anesthesia.     

Decision curve analysis assessing the clinical benefit of NMP22 in the detection of bladder cancer: secondary analysis of a prospective trial

Study Type – Decision analysis (based on alternative scenarios) Level of Evidence 2b What's known on the subject? and What does the study add? Several studies have shown that abnormal levels of nuclear matrix protein 22 (NMP22) are associated with bladder cancer, and NMP22 has been approved by the FDA as a urinary biomarker for bladder cancer detection and surveillance. However, the benefit of adding NMP22 to the clinical care of patients remains unclear. Decision curve analysis incorporates the consequences of clinical decisions, such as an increased number of unnecessary cystoscopies or missed cancers.

OBJECTIVE

• ? To employ decision curve analysis to determine the impact of nuclear matrix protein 22 (NMP22) on clinical decision making in the detection of bladder cancer using data from a prospective trial.

PATIENTS AND METHODS

• ? The study included 1303 patients at risk for bladder cancer who underwent cystoscopy, urine cytology and measurement of urinary NMP22 levels.
• ? We constructed several prediction models to estimate risk of bladder cancer. The base model was generated using patient characteristics (age, gender, race, smoking and haematuria); cytology and NMP22 were added to the base model to determine effects on predictive accuracy.
• ? Clinical net benefit was calculated by summing the benefits and subtracting the harms and weighting these by the threshold probability at which a patient or clinician would opt for cystoscopy.

RESULTS

• ? In all, 72 patients were found to have bladder cancer (5.5%). In univariate analyses, NMP22 was the strongest predictor of bladder cancer presence (predictive accuracy 71.3%), followed by age (67.5%) and cytology (64.3%).
• ? In multivariable prediction models, NMP22 improved the predictive accuracy of the base model by 8.2% (area under the curve 70.2–78.4%) and of the base model plus cytology by 4.2% (area under the curve 75.9–80.1%).
• ? Decision curve analysis revealed that adding NMP22 to other models increased clinical benefit, particularly at higher threshold probabilities.

CONCLUSIONS

• ? NMP22 is a strong, independent predictor of bladder cancer.
• ? Addition of NMP22 improves the accuracy of standard predictors by a statistically and clinically significant margin.
• ? Decision curve analysis suggests that integration of NMP22 into clinical decision making helps avoid unnecessary cystoscopies, with minimal increased risk of missing a cancer.

     

Rupture of the sinus of valsalva into the pulmonary artery

Congenital aneurysms of the sinus of Valsalva are rare lesions that can rupture into any cardiac chamber, due to the central position of the aortic root. Rupture into the pulmonary artery, however, is very rare. We encountered an 18-year-old girl with rupture of the right coronary sinus into the pulmonary artery. During surgical correction, the girl was also found to have a small outlet ventricular septal defect, which was obscured by multiple hypertrophied septal trabeculae in the right ventricular outflow tract.     

The Metabolic Syndrome in Patients Undergoing Knee and Hip Arthroplasty : Trends and In-Hospital Outcomes in the United States

We evaluated the impact of metabolic syndrome (MetS) on perioperative outcomes in patients undergoing total joint arthroplasty. Using the Nationwide Inpatient Sample, patients with MetS were identified if they had at least 3 of 4 component comorbidities (obesity, dyslipidemia, hypertension, and diabetes). Patient demographics, in-hospital outcomes, and cost were compared between patients with and patients without MetS. Trends were studied for 3-year periods between 2000 and 2008. The prevalence of MetS increased over time, reaching 14% (total knee arthroplasty) and 8.7% (total hip arthroplasty) most recently. Metabolic syndrome was overproportionately prevalent among female total knee arthroplasty recipients, male total hip arthroplasty recipients, and patients in the minority race group. In the regression analysis, MetS was an independent risk factor for the development of major complications, nonroutine discharge, and increased hospital cost. Given the increasing rates of MetS and its association with higher risk for major complications among total joint arthroplasty recipients, further research into the impact of this disease complex is warranted.     

Combined pharmacotherapy and psychotherapy in the acute and continuation treatment of elderly patients with recurrent major depression: a preliminary report.

OBJECTIVE: The authors examined the rate of response to the combination of nortriptyline and interpersonal psychotherapy for acute and continuation treatment of elderly patients with recurrent major depression. METHOD: The subjects were 73 elderly patients, 61 of whom completed treatment. Nortriptyline steady-state blood levels were maintained at 80-120 ng/ml, and interpersonal psychotherapy was administered weekly for 9.1 weeks (medium) of acute therapy and was decreased from biweekly to triweekly during 16 weeks of continuation therapy. During acute treatment nonresponding patients also received brief adjunctive pharmacotherapy with lithium or perphenazine. RESULTS: Of the 61 subjects given adequate trials of nortriptyline and interpersonal psychotherapy, 48 (78.7%) achieved full remission (Hamilton depression rating of 10 or lower over 16 weeks of continuation therapy), 10 patients (16.4%) did not respond (Hamilton rating never below 15), and three achieved only partial remission (Hamilton rating of 11-14). Early versus late onset was not associated with a difference in response rate. During the placebo-controlled, double-blind transition to maintenance therapy, 19 (76.0%) of the 25 patients randomly assigned to placebo maintenance conditions showed continued recovery and six relapsed. None of the 24 patients assigned to nortriptyline conditions relapsed. CONCLUSIONS: Use of nortriptyline plus interpersonal psychotherapy for 9.1 weeks (median) of acute and 16 weeks of continuation therapy appears to be associated with good response and relatively low attrition but about a 25% chance of relapse during double-blind discontinuation of nortriptyline. These data require confirmation in a controlled clinical trial of acute and continuation therapy.     

First heart sound spectra in relation to anterior mitral-leaflet closing velocity

A mathematical model is presented to relate mitral valve leaflet closing velocity to the subsequent vibrational magnitude following valve closure. This relationship is investigated experimentally by means of phonocardiographic and echocardiographic recordings from 17 human subjects. Fast Fourier transform analysis of digitised first heart sounds from each subject reveals that the sound intensities in different frequency bands are not uniformly related to the valve-leaflet closing velocity, obtained from the anterior mitral leaflet echocardiogram. It is found that, in the frequency range up to 150 Hz, closing velocity correlates best with sound intensity in the 30–45 hz bandwidth.     

Pulmonary reactions to inhaled cotton dust: An animal model for byssinosis

Groups of guinea pigs were exposed to respirable particles of cotton dust obtained from opening and carding rooms of a textile mill. The bulk cotton dust was resuspended with a modified sonic sifter. Exposures were conducted 6 hr/day at concentrations varying between 16 and 25 mg/m³. The particle size for these exposures varied around a 3 μm aerodynamic equivalent diameter. In animals exposed for 5 days, a pulmonary effect began to develop 3 hr after the start of exposure on the first day and was maximal 18 hr postexposure. The pulmonary effect faded during the ensuing weekdays as daily exposures continued. In one group exposed for 6 weeks, 5 days/week, the pulmonary effect was apparent on each Monday and faded during the week. The pulmonary response can best be characterized as a reflex restriction of breathing from stimulation of vagal nerve endings, resulting in rapid shallow breathing. This effect was exaggerated upon challenge of the animals with air containing 10% CO₂. In humans this pattern of rapid shallow breathing is associated with symptoms of shortness of breath, dyspnea, breathlessness, and fatigue upon exertion. Such symptoms are characteristic of those reported by workers exposed to cotton dust. This animal model is proposed for further evaluation of the possible relationship between the acute responses to cotton dust and the development of a chronic response.