Oral bisphosphonates for osteoporosis in adult males with intellectual disabilities.

INTRODUCTION: Oral bisphosphonates are first-line agents for treating osteoporosis in men, but there are no studies regarding efficacy of oral bisphosphonates for treatment of osteoporosis in ambulatory male adults with intellectual disability. METHODS: Nine adult males with intellectual disability and increased fracture risk had been treated with weekly or monthly oral bisphosphonates, vitamin D and calcium for 1-3 years. Post-treatment bone mineral density (BMD), serum 25(OH)D, parathyroid hormone and C-telopeptide of type I collagen were then determined for the first time. RESULTS: Weekly or monthly oral bisphosphonates were well tolerated and led to significant increases in BMD in all 9 individuals. Serum 25(OH)D level enhanced the "pecent increase of BMD" that occurred in response to bisphosphonate treatment (p < .05). CONCLUSIONS: Weekly or monthly oral bisphosphonates are well tolerated by ambulatory adult males with ID and are effective in increasing BMD. Higher serum levels of vitamin D appear to improve the efficacy of bisphosphonates and therefore reduce fracture risk in adult males with intellectual disability.

Decreased mean perfusion pressure as an independent predictor of acute kidney injury after cardiac surgery.

Acute kidney injury after cardiac surgery (AKICS) is common. Previous studies examining the role that mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) may have on AKICS have not taken into account how baseline central venous pressure (CVP) and mean perfusion pressure (MPP) (i.e. MAP - CVP) can influence its evolution. To assess whether the change in MPP to the kidneys (i.e. delta MPP or DMPP) during CPB compared to baseline is an independent predictor of AKICS. After ethical approval, a retrospective observational study was performed on all patients undergoing CPB between October 2013 and June 2015 at a university-affiliated hospital. Known risk factors for the development of AKICS were recorded, as were the MPP values at baseline and during CPB. From this, statistical modelling was performed to identify predictors of postoperative AKICS. 664 patients were identified. Analysis was performed on 513 patients after exclusion. On logistic regression, significant and independent predictors of AKICS included: d20DMPP (cumulative duration of MPP values during CPB that were 20% below baseline and exceeded three consecutive minutes) (P = 0.010); baseline CVP; age; pre-operative creatinine level; and left ventricular (LV) dysfunction (ejection fraction (EF) < 45%). On alternative modelling, the cumulative number of MPP values during CPB that were 10% below baseline was also independently associated with AKICS (P = 0.003). Modelling without taking into account CVP also supported this association. The duration of differences in perfusion pressure to the kidneys during CPB compared to baseline is an independent predictor of AKICS.

Age does not predict need for reintervention in patients with critical limb ischemia.

OBJECTIVE: Conventional wisdom holds that patients with a need for intervention for femoropopliteal occlusive disease at a younger age have more aggressive disease, although there is a paucity of support in the literature. The purpose of this study was to evaluate this assumption. METHODS: A retrospective cohort of patients undergoing endovascular or open revascularization for femoropopliteal occlusive disease for critical limb ischemia during a 4-year period was assembled. Demographic information, comorbidities, disease characteristics, and time to last follow-up, repeat intervention, amputation, or death was recorded. The patients were stratified by age into a young (≤55 years) group, middle (56-77 years) group, and elderly (≥78 years) group. Univariate and multivariate statistical methods were used to evaluate the primary outcome. RESULTS: The study included 124 patients with a mean age of 64.4 ± 0.8 years. Progression to reintervention or amputation occurred in 50% of the patients during the follow-up period, with 18% dying before having an outcome. Kaplan-Meier analysis showed a trend toward significance (P = .06) in time to reintervention, amputation, or death among the three groups, with time to event of 253, 1083, and 504 days for the young, middle, and elderly groups, respectively. However, differences based on age were not significant (P = .57) in Cox regression analysis. CONCLUSIONS: There does not appear to be an association between time to reintervention and patient age.

Right-sided adenoma detection with retroflexion versus forward-view colonoscopy.

BACKGROUND: Colonoscopy and polypectomy can prevent up to 80% of colon cancer; however, a significant adenoma miss rate still exists, particularly in the right side of the colon. OBJECTIVE: To assess whether retroflexion in the right side of the colon significantly improves the adenoma detection rate (ADR) over forward-view assessment. DESIGN: Multicenter prospective cohort study. SETTING: Three tertiary care public and 2 private hospitals. PATIENTS: A total of 1351 consecutive adult patients undergoing elective colonoscopy. INTERVENTION: Withdrawal from the cecum was performed in the forward view initially and identified polyps removed. Once the hepatic flexure was reached, the cecum was reintubated and the right side of the colon was assessed in the retroflexed view to the hepatic flexure. MAIN OUTCOME MEASUREMENTS: ADR in the retroflexed view when compared with forward-view examination of the right side of the colon. RESULTS: Retroflexion was successful in 95.9% of patients, with looping the predominant (69.6%) reason for failure. Forward-view assessment of the right side of the colon identified 642 polyps, of which 531 were adenomas yielding a polyp and ADR of 28.57% and 24.64%, respectively. Retroflexion identified a further 84 polyps of which 75 were adenomas, improving the polyp and ADR to 30.57% and 26.4%, respectively. LIMITATIONS: Observational study. CONCLUSION: Right-sided retroflexion was successful in most of our cohort with a statistically significant but small increase in ADR. Right-sided retroflexion is safe when performed by experienced endoscopists with no adverse events observed in this cohort. ( CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12613000424707.).

Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: a national experience (with videos).

BACKGROUND: Recent medical literature on novel lumen-apposing stents for the treatment of pancreatic fluid collections (PFCs) is limited by small numbers, solo operators, and single-center experience. OBJECTIVE: To evaluate a recently developed lumen-apposing, fully covered self-expandable metal stent (FCSEMS) in the management of PFCs. DESIGN: Retrospective case series. SETTING: Thirteen tertiary and private health care centers across Australia. PATIENTS: Forty-seven patients (median age 51 years) who underwent endoscopic management of PFCs. INTERVENTION: Insertion of FCSEMS after PFC puncture under EUS guidance. A subgroup of 9 patients underwent direct endoscopic necrosectomy. MAIN OUTCOME MEASUREMENTS: Technical and clinical success rate, adverse event rate. RESULTS: The technical success rate was 53 of 54 patients (98.1%), and the initial clinical success rate was 36 of 47 (76.6%), which was sustained for more than 6 months in 34 of 36 (94.4%). Early adverse events included 4 cases (7.4%) of stent migration during direct endoscopic necrosectomy, 4 cases (7.4%) of sepsis, 1 case (1.9%) of bleeding, and 1 case (1.9%) of stent migration into the fistula tract. Late adverse events were 6 (11.1%) spontaneous stent migrations, 3 (5.6%) recurrent stent occlusions, 3 (5.6%) tissue ingrowth/overgrowth, and 2 (3.7%) bleeding into PFC. The majority of stents inserted (48 of 54, 88.9%) and removed (31 of 35, 88.6%) in our study were described by the operator as superior to pigtail stents with regard to ease of use. LIMITATIONS: Retrospective study. CONCLUSION: Although FCSEMSs are technically easier to insert and remove compared with traditional pigtail stents, there are significant limitations to the widespread use of FCSEMSs in the management of PFCs. These include cost, adverse events, and lower-than-expected resolution rates.

Impact of psychological factors on objective ambulatory measures in patients with intermittent claudication.

OBJECTIVE: The purpose of this study was to evaluate the difference in objective measures of ambulation and psychosocial factors in patients with intermittent claudication (IC) stratified by type D personality, which incorporates elements of social inhibition and negative affectivity. METHODS: During a 1-year period, routine history and physical examination, ankle-brachial index, and pulse volume recording were performed on IC patients. Questionnaires assessing type D personality and psychosocial factors were also collected. The 6-minute walk test (6MWT) was performed, assessing symptoms and distance walked. Univariate and multivariate methods were used to assess the association between ambulation and type D personality. RESULTS: Seventy-one patients were enrolled (mean age, 62.5 ± 1.1 years; mean ankle-brachial index, 0.55 ± 0.03). Mean distance to symptoms and total distance walked were 83.7 ± 80.1 m and 206.5 ± 126.3 m, respectively. Type D personality was present in 29.6% of the population (n = 21). On 6MWT, 83.1% of all patients developed symptoms, and 57.4% quit because of symptoms. Univariate analysis of objective measures of ambulation demonstrated lower distance to symptoms in the type D group and trends toward lower total distance walked and quitting the 6MWT. Multivariate models showed increased odds of quitting the 6MWT (odds ratio, 7.71; P = .01) and less total distance walked by an average of 33.2 ± 13.3 m (P = .02) for the type D group. CONCLUSIONS: Despite equivalent demographic, medical, and psychosocial factors, the type D group was limited in ambulation, suggesting that type D personality is a strong predictor of disease impact in patients with IC.

The current practice standard for colonoscopy in Australia.

BACKGROUND: Despite having one of the highest rates per capita for colonoscopy worldwide, colorectal cancer remains the second most commonly diagnosed malignancy in Australia. OBJECTIVE: Our aim was to document colonoscopy/polypectomy practice nationwide and assess whether significant differences exist. DESIGN: Observational study. SETTING: Online survey conducted nationally in 2012. PARTICIPANTS: Medical practitioners registered with the Gastroenterological Society of Australia practicing colonoscopy. MAIN OUTCOME MEASUREMENTS: Rates of polypectomy techniques for varying polyp sizes, postpolypectomy bleeding prophylaxis techniques, and adenoma detection practices. To assess whether variations exist according to practice location, specialty, and experience and comparison of practice with a previous American cohort. RESULTS: Of the 846 members contacted, 244 (28.8%) responded. The cohort consisted primarily of consultant gastroenterologists (182/244, 74.6%). The cold-snare technique was preferred (165/244, 67.6%) for polyps 3 mm in size; however, this decreased rapidly with increasing polyp size (5 mm [120/244, 49.2%] and 7-9 mm [18/244, 7.4%]). EMR was the preferred method of resection for polyps 7 to 9 mm in size (148/244, 60.7%). The withdrawal technique predominantly consisted of double-passing high-risk areas and rectal retroflexion (134/244, 54.9%). Significant differences across specialty, location, and experience included polypectomy method for diminutive polyps, the use of EMR, and retroflexion. LIMITATIONS: Survey-based study and response rate. CONCLUSION: Although variations in colonoscopy and polypectomy practice exist, the majority of our cohort performs cold-snare polypectomy for diminutive polyps and pass high-risk, poorly visualized areas twice on withdrawal. This is a significant shift in practice from that of the U.S. cohort studied 10 years earlier.

Detecting insect pollinator declines on regional and global scales.

Recently there has been considerable concern about declines in bee communities in agricultural and natural habitats. The value of pollination to agriculture, provided primarily by bees, is >$200 billion/year worldwide, and in natural ecosystems it is thought to be even greater. However, no monitoring program exists to accurately detect declines in abundance of insect pollinators; thus, it is difficult to quantify the status of bee communities or estimate the extent of declines. We used data from 11 multiyear studies of bee communities to devise a program to monitor pollinators at regional, national, or international scales. In these studies, 7 different methods for sampling bees were used and bees were sampled on 3 different continents. We estimated that a monitoring program with 200-250 sampling locations each sampled twice over 5 years would provide sufficient power to detect small (2-5%) annual declines in the number of species and in total abundance and would cost U.S.$2,000,000. To detect declines as small as 1% annually over the same period would require >300 sampling locations. Given the role of pollinators in food security and ecosystem function, we recommend establishment of integrated regional and international monitoring programs to detect changes in pollinator communities.

New species of the cleptoparasitic bee genus Stelis (Hymenoptera: Megachilidae, Anthidiini) from the Nearctic Region.

Descriptions and diagnoses of ten new Nearctic species of Stelis subgenus Stelis are presented: S. alta, S. anasazi, S. anthocopae, S. broemelingi, S. imperialis, S. joanae, S. lamelliterga, S. occidentalis, S. paiute, and S. shoshone. Six of these species have been reared from trapnests. Host associations, all within the tribe Osmiini (Megachilidae), are provided.

Role of statin therapy and angiotensin blockade in patients with asymptomatic moderate carotid artery stenosis.

BACKGROUND: The purpose of this study was to evaluate the 10-year outcome of patients presenting with asymptomatic moderate carotid artery stenosis, and to determine which factors correlate with progression of disease to stroke or revascularization. METHODS: A retrospective review of all new patients presenting with asymptomatic moderate carotid artery stenosis from July 1998 to December 2001 was undertaken. Patients were consecutively identified and included by using duplex ultrasonography to identify moderate carotid disease. Variables were recorded for all patient encounters through June 2010. The primary end point was occurrence of ipsilateral cerebrovascular stroke or revascularization event (SORE). Statin therapy and angiotensin blockade (STAB) were categorized as follows: STAB(0)-medical treatment with neither statin therapy nor angiotensin blockade, STAB(1)-treatment with only one of the two, STAB(2)-treatment with both. An amortized cost model analyzed the cost of SORE-free survival. RESULTS: Over a 42-month period, 468 carotids in 366 patients with an average age of 69.0 ± 8.7 years were evaluated. Over a mean follow-up of 6.6 ± 2.7 years, SORE occurred in 150 (32.1%) carotid arteries. Hyperlipidemia was predictive of SORE (hazard ratio [HR]: 1.543, 95% confidence interval [CI]: 1.053-2.262, P = 0.03). Medical therapies protective against SORE were beta-blockade (HR: 0.612, 95% CI: 0.435-0.861, P < 0.05), STAB(1) (HR: 0.487, 95% CI: 0.336-0.706, P < 0.01), and STAB(2) (HR: 0.149, 95% CI: 0.089-0.248, P < 0.01). At 10 years, SORE-free survival in STAB(2) was 82.7% ± 4.6%, STAB(1) was 56.3% ± 5.0%, and STAB(0) was 29.3% ± 5.4% (P < 0.01). The cost per SORE-free year in STAB(2) was $1,695.40 ± $275.60, STAB(1) was $3,916.80 ± $605.44, and STAB(0) was $4,126.40 ± $427.23 (P < 0.01). CONCLUSION: These data demonstrate the clinical and financial advantage of using both statin therapy and angiotensin pathway blockage in patients with asymptomatic moderate carotid artery stenosis.

Malnutrition and low muscle strength are independent predictors of clinical outcomes and healthcare costs after liver transplant.

BACKGROUND & AIMS: Malnutrition and sarcopenia are associated with increased morbidity and mortality in cirrhosis but conflicting data are reported after liver transplantation (LT), with little known about the economic burden of malnutrition at LT. This study aims to investigate the impact of pre-transplant malnutrition and muscle strength on post-transplant clinical outcomes and healthcare costs. METHODS: Pre-transplant nutritional status (via subjective global assessment, SGA) and handgrip strength (HGS) were assessed in patients transplanted from 2009-2017. Descriptive statistics and regression analysis were used to analyse the association between nutrition and muscle function with post-LT clinical outcomes and hospital costs. RESULTS: 373 patients (70% male, median age 55 [IQR: 47, 60]) were transplanted, with 79% malnourished and mean HGS 31.4 ± 9.35 kg for males and 17.6 ± 5.78 kg for females. Malnutrition and reduced HGS independently predicted adverse post-transplant outcomes. ICU length of stay (LOS) was associated with severe malnutrition (HR (time to discharge (TTD)) 0.706, p = 0.014) and low HGS (HR (TTD) 0.692, p = 0.003); hospital LOS with severe malnutrition (HR (TTD) 0.759, p = 0.049) and low HGS (HR (TTD) 0.730, p = 0.011), and post-transplant infection with severe malnutrition (OR 1.76, p = 0.042) and low HGS (OR 1.83, p = 0.015). Accordingly, hospital costs were 30% higher in severely malnourished compared to well-nourished recipients (p = 0.012). Neither malnutrition or impaired HGS were associated with post-transplant mortality. CONCLUSIONS: This large cohort study demonstrates malnutrition and muscle weakness are independently associated with early post-transplant morbidity, namely infection and ICU and hospital LOS; with significantly increased hospital costs. Strategies to combat malnutrition and deconditioning pre-transplant may improve patient and health system outcomes after LT.

Impact of operative indication and surgical complexity on outcomes after thoracic endovascular aortic repair at National Surgical Quality Improvement Program Centers.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) devices are increasingly being utilized to treat aortic pathologies outside of the original Food & Drug Administration (FDA) approval for nonruptured descending thoracic aorta aneurysms (DTAs). The objective of this study was to evaluate the outcomes of patients undergoing TEVAR, elucidating the role of surgical and pathologic variables on morbidity and mortality. METHODS: National Surgical Quality Improvement Program (NSQIP) data were reviewed for all patients undergoing endovascular thoracic aorta repair from 2005 to 2007. The patients' operative indication and surgical complexity were used to divide them into study and control populations. Comorbid profiles were assessed utilizing a modified Charlson Comorbidity Index (CCI). Thirty-day occurrences of mortality and serious adverse events (SAEs) were used as study endpoints. Univariate and multivariate models were created using demographic and clinical variables to assess for significant differences in endpoints (P ≤ .05). RESULTS: A total of 440 patients undergoing TEVAR were identified. When evaluating patients based on operative indication, the ruptured population had increased mortality and SAE rates compared to the nonruptured DTA population (22.6% vs 6.2%;P < .01 and 35.5% vs 9.1%;P < .01, respectively). Further analysis by surgical complexity revealed increased mortality and SAE rates when comparing the brachiocephalic aortic debranching population to the noncovered left subclavian artery population (23.1% vs 6.5%; P = .02 and 30.8% vs 9.1%; P < .01, respectively). Multivariate analysis demonstrated that operative indication was not a correlate of mortality or SAEs (odds ratio [OR], 0.95; P = .92 and OR, 1.42; P = .39, respectively); however, brachiocephalic aortic debranching exhibited a deleterious effect on mortality (OR, 8.75; P < .01) and SAE rate (OR, 6.67; P = .01). CONCLUSION: The operative indication for a TEVAR procedure was not found to be a predictor of poor patient outcome. Surgical complexity, specifically the need for brachiocephalic aortic debranching and aortoiliac conduit, was shown to influence the occurrence of SAEs in a multivariate model. Comparative data, such as these, illustrate real-world outcomes of patients undergoing TEVAR outside of the original FDA-approved indications. This information is of paramount importance to various stakeholders, including third-party payers, the device industry, regulatory agencies, surgeons, and their patients.

Preoperative statin therapy is associated with improved outcomes and resource utilization in patients undergoing aortic aneurysm repair.

INTRODUCTION: This study hypothesized that preoperative statin therapy would have a protective effect on patients undergoing elective abdominal aortic aneurysm (AAA) repair and that the risk-reduction effect of these agents would result in a reduction in subsequent total hospital costs. METHODS: All patients who underwent an elective endovascular AAA repair (EVAR) or open AAA repair (OAR) between 2004 and 2007 were retrospectively reviewed. Clinical end points included postoperative days, length of hospital stay, postoperative complications (myocardial infarction, stroke, renal failure, hemorrhage, pneumonia, urinary tract infection, wound infection), and 30-day mortality. The financial end point was total hospital cost associated with the procedure. RESULTS: We identified 401 patients, consisting of 173 EVAR patients (43%) and 228 OAR (57%). Despite a higher Society for Vascular Surgery risk score, the EVAR statin cohort had significantly reduced postoperative days (1.9 +/- 0.2 vs 2.3 +/- 0.3, P < .05) and hospital length of stay (2.3 +/- 0.3 vs 2.8 +/- 0.4, P < .05) compared with the nonstatin EVAR cohort. Postoperative complications (4.4% vs 14.7%, P < .05) and the mortality rate (0.0% vs 5.9%, P < .05) were significantly decreased in the OAR statin cohort compared with the nonstatin OAR cohort and trended to be decreased in the EVAR statin group. Statin therapy translated into a lower total cost per patient of $3,205 for EVAR and $3,792 for OAR (P < .05). CONCLUSION: With respect to both clinical outcome measures and subsequent resource utilization, statin therapy is associated with a beneficial effect in patients undergoing elective AAA repair. These data suggest that preoperative statin therapy should be an integral part of the risk optimization for patients undergoing AAA repair.

The impact of socioeconomic factors on outcome and hospital costs associated with femoropopliteal revascularization.

INTRODUCTION: Within the context of healthcare system reform, the cost efficacy of lower extremity revascularization remains a timely topic. The impact of an individual patient's socioeconomic status represents an under-studied aspect of vascular care, especially with respect to longitudinal costs and outcomes. The purpose of this study is to examine the relationship between socioeconomic status and clinical outcomes as well as inpatient hospital costs. METHODS: A retrospective femoropopliteal revascularization database, which included socioeconomic factors (household income, education level, and payor status), in addition to standard demographic, clinical, anatomical, and procedural variables were analyzed over a 3-year period. Patients were stratified by income level (low income [LI] <200% federal poverty level [$42,400 for a household of 4], and higher income [HI] >200% federal poverty level) and revascularization technique (open vs endovascular) and analyzed for the endpoints of primary assisted patency, amortized cost-per-day of patency, and limb salvage. Data were analyzed with univariate and multivariate techniques. RESULTS: A total of 187 cases were identified with complete data for analysis, 146 in the LI and 41 in the HI cohorts. LI patients differed from HI patients by mean age (66.2 +/- 1.0 vs 61.8 +/- 1.5 years, P = .04), high school graduate rate (51.4% vs 85.4%, P < .001), presence of tissue loss (30.1% vs 14.6%, P = .05), female gender (43.7% vs 22.0%, P = .01) and preoperative statin use (45.8% vs 75.6%, P < .001). There were no differences with respect to other comorbidities including smoking status, presence of diabetes, renal insufficiency, anatomic factors or treatment modality (open vs endovascular). Ninety-seven patients underwent endovascular revascularization. The following outcomes were noted in the endovascular subset of LI and HI patients respectively: primary assisted patency (66% vs 71%, P = NS) and 12-month cost-per-day of patency ($166.30 +/- 77.40 vs $22.45 +/- 12.45, P = .05). Ninety-eight patients underwent open revascularization, with the following outcomes in LI and HI patients respectively: primary assisted patency (78% vs 86%, P = NS) and 12-month cost-per-day of patency ($319.43 +/- 225.44 vs $40.47 +/- 4.63, P = .07). Of the 77 patients with critical limb ischemia, 19 underwent eventual amputation. Multivariate analysis demonstrated that income above 100% of the federal poverty line was protective against limb loss (odds ratio 0.06, 95% confidence interval 0.01-0.51, P < .001). CONCLUSION: Income level correlates with advanced presentation, advanced age, and lack of statin use. Although primary assisted patency rate is not affected by income status, an increased cost-per-day of patency and inferior limb salvage is found in lower income patients.

A contemporary rural trauma center experience in blunt traumatic aortic injury.

INTRODUCTION: Traumatic aortic injury (TAI) is a rare yet highly lethal injury associated with blunt force deceleration injury. The adoption of thoracic endovascular aortic repair (TEVAR) has become a safer option than traditional open repair. The purpose of this study is to review a rural trauma center experience with TAI. METHODS: A retrospective analysis was performed, reviewing all patients who presented with TAI between 2000 and 2009. Clinical, anatomical, and procedural variables of all cases were systematically reviewed. Clinical endpoints included mortality, and aortic-related mortality, and hospital length of stay. The study population was stratified by those that underwent surgical repair (SR) and those managed medically (MM). RESULTS: Fifty-six patients presented with blunt TAI; 35 patients (62.5%) were surgically repaired (22 open, 13 TEVAR), while 21 (37.5%) were MM. The only difference in comorbidities was a higher rate of coronary artery disease in MM. Mean hospital arrival time (SR, 188.6 ± 30.3 minutes, MM, 253 ± 65.3 minutes), aortic injury grade (SR, 2.7 ± 0.1; MM, 2.3 ± 0.2), and injury severity score were not significantly different between the groups. Head Abbreviated Injury Score (AIS) was worse in the MM group, while chest AIS was worse in the SR group (P < .05). There were nine (42.9%) deaths in the MM group, while there were only two (5.7%) in the SR group (P < .001). There was no significant difference in aortic-related mortality. Mean follow-up time was not statistically different. CONCLUSION: These data provide a group of stable patients to examine the management of TAI in the endovascular era. The low aortic-related mortality in the MM group demonstrates that there is time for a thorough evaluation in patients sustaining TAI who arrive without hemodynamic instability.

Improving informed consent for patients undergoing radical prostatectomy using multimedia techniques: a prospective randomized crossover study.

OBJECTIVE: to compare the comprehension gained by standard consent (SC) vs a unique interactive multimedia presentation (IMP), for radical prostatectomy (RP), as informed consent for RP requires that the patient understands the procedure and potential complications. PATIENTS AND METHODS: forty patients undergoing RP were prospectively randomized to SC or IMP, followed by a 26-question test on critical aspects of the surgery and its implications. The groups were crossed over and re-tested, with a subsequent statistical analysis. SC involved typical verbal interaction and consultation with physicians and nurses, whilst the IMP provided consistent and animated information on these topics, and included multiple-choice questions probing understanding of key points. Progression through the IMP only occurred with correct responses; incorrect responses prompted a review of the information before repeating the question. Telephone interviews assessed usability, overall understanding, educational level and primary language. RESULTS: the patient groups had similar demographics. The IMP group (78%) had significantly higher knowledge test scores (P < 0.001) than the SC group (57%), suggesting a better understanding of the implications of surgery. This was maintained on crossover, with the SC group scores improving by 11% compared to testing before IMP (P < 0.001). The initial IMP group scores were unchanged on crossover and repeat testing (P < 0.05). CONCLUSION: IMP provides better patient understanding than SC for RP, by ensuring that the procedure and risks have been explained consistently, and by actively testing the patient. Such tools assist in obtaining ethical and legally informed consent, thus increasing patient knowledge whilst reducing patient anxiety and potential dissatisfaction or medico-legal consequences when less than ideal outcomes occur.

The association of periprocedural hypertension and adverse outcomes in patients undergoing catheter-directed thrombolysis.

BACKGROUND: Peripheral thrombolysis is an indispensible tool in the treatment of occlusive peripheral vascular disease (PVD). However, the use of intravascular thrombolytic agents carries a significant risk of morbidity and mortality. The aim of this study is to review a contemporary series of patients treated with catheter-directed thrombolytics in the treatment of occlusive PVD. METHODS: A retrospective analysis was performed reviewing all patients who underwent catheter-directed thrombolytic therapy for PVD with recombinant tissue plasminogen activator (rt-PA) between 2005 and 2008. Data included clinical and demographic variables potentially associated with endpoints of technical success, hemorrhagic complications, and death. Data were analyzed with univariate and multivariate measures. Significance was assigned with p <0.05. RESULTS: Over the 36-month study, 125 thrombolytic procedures were performed. Indication for treatment was occlusive thrombus in native artery (49 cases, 37.6%), vein (13 cases, 10.4%), or arterial bypass graft (63 cases, 49.6%). Twenty three cases (14.3%) used ultrasound-assisted catheter technology. Mean patient age was 57.9 +/- 1.1 years. Technical success was achieved in 82% of cases. Mean rt-PA dose was 47.3 +/- 1.4 mg (13.5 +/- 4.5 mg with ultrasound assisted catheter technology). Hemorrhagic complications occurred in 22.4% of patients with a 5.6% stroke rate. Intracranial hemorrhage (ICH) correlated with poor hypertensive control (systolic blood pressure >160 mmHg; OR, 13.67; CI, 1.59-117.68; p = 0.006) and advanced age (>80 years; OR, 9.04; CI, 1.40-58.57, p = 0.049). Hemorrhagic complications (including minor access site hematomas) correlated with poor hypertensive control (systolic blood pressure >180 mmHg; OR, 3.48; CI, 1.22-9.94; p = 0.021) and in patients with congestive heart failure (OR, 3.26; CI, 1.09-9.76; p = 0.036). Overall mortality occurred in 7 patients (5.6%), 4 as a result of hemorrhagic complications. Correlates of mortality were patients with diabetes mellitus (OR, 8.85; CI, 1.62-48.26; p = 0.003), end stage renal disease (OR, 15.33; CI, 2.07-113.39; p < .001) and congestive heart failure (OR, 6.06; CI, 1.22-30.13; p = .014). Serum fibrinogen levels, pre-procedural hypertension, and rt-PA dosage did not correlate with hemorrhagic complication or death. CONCLUSION: Peripheral thrombolysis with catheter-based technologies has a high incidence of technical success. However, the procedure continues to carry a significant complication rate. This study emphasizes the importance of periprocedural hypertensive control and identifies subgroups of patients at risk of untoward complications. On the basis of these data, the authors advocate stricter blood pressure parameters in patients undergoing peripheral thrombolysis.

Renal-splanchnic steal syndrome: the treatment of chronic mesenteric ischemia with renal angioplasty and stenting.

The clinical syndrome of chronic mesenteric ischemia classically presents with a combination of involuntary weight loss, post prandial abdominal pain, and food fear. With occlusion or stenosis of the celiac and superior mesenteric arteries (SMA) collateral blood flow between mesenteric vessels is common and frequently act as the sole blood supply to the intestine. We present a rare case of chronic mesenteric ischemia in which the main blood supply to the celiac and SMA were collaterals coming off the right renal artery resulting in renal-splachnic steal. After an unsuccessful attempt to cannulate the SMA and celiac vessels it was possible to relieve this patient's symptoms with renal artery stenting.

Cost per day of patency: understanding the impact of patency and reintervention in a sustainable model of healthcare.

BACKGROUND: Healthcare resource utilization is an understudied aspect of vascular surgery. Initial cost of a given procedure is not an accurate reflection of resource utilization because it does not account for procedural durability and efficacy. Herein we describe an amortized cost model that accounts for procedural costs, durability, and re-intervention costs. METHODS: A cost model was developed using patency data endpoints and total hospital costs (direct and indirect) associated with an inital revascularization and subsequent re-interventions. This model was applied to a retrospective database of femoropopliteal reconstructions. One hundred and eighty-three open cases were compared with 198 endovascular cases; and the endpoints of initial cost, amortized cost at 12 months, and assisted patency were examined. RESULTS: The open and endovascular cases were not statistically different with respect to indication, patient co-morbid profiles, or post-procedural pharmacotherapy. Primary assisted patency was better in the open revascularization group at 12 months (78% versus 66%, P < .01). There was a statistically significant higher initial cost for open reconstruction when compared with endovascular ($12,389 +/- $408 versus $6,739 +/- $206, P < .001). However, at 12 months post-procedure, the initial cost benefit was lost for endovascular patients ($229 +/- $106 versus $185 +/- $124, P = .71). There was, however, a trend for endovascular cost savings in claudicants, though this did not reach significance ($259 +/- $189 versus $86 +/- $52, P = .31). For patients with critical limb ischemia, renal dysfunction, and end stage renal disease, the trend favored open surgery. CONCLUSIONS: An amortized cost model provides insight into the healthcare resource utilization associated with a particular revascularization and assistive procedures. The initial cost savings of endovascular therapies are not sustained over time. Cost-savings trends were noted, however, longer follow-up is required to see if these will reach statistical significance.