Clinical Characteristics and Surgical Outcomes of Carotid Body Tumors: Data from the Carotid Paraganglioma Cooperative International Registry (CAPACITY) Group.

BACKGROUND: This study's objective was to conduct a multinational registry of patients with carotid body tumors (CBTs) and to analyze patients' clinical characteristics, treatments, and outcomes. METHODS: Retrospective study from the Carotid Paraganglioma Cooperative International Registry involving eleven medical centers in Bolivia, Ecuador, Mexico, and Spain, of all patients with a CBT who underwent resection between 2009 and 2019. RESULTS: A total of 1432 patients with a CBT surgically treated were included. Median patient age was 54 years (range: 45-63 years), and 82.9% (1184) of the study cohort were female. While at low altitude, the proportion of female-to-male cases was 2:1, at high altitude, this proportion increased to 8:1, with statistically significant differences (p = .022). Median operative time was 139 min (range: 110-180 min), while median operative blood loss was 250 ml (range: 100-500 ml), with statistically significant difference in increased blood loss (p = .001) and operative time (p = .001) with a higher Shamblin classification. Eight (0.6%) patients suffered stroke. Univariate analysis analyzing for possible factors associated with increased odds of stroke revealed intraoperative vascular lesion to present an OR of 2.37 [CI 95%; 1.19-4.75] (p = 0.001). In 245 (17.1%), a cranial nerve injury was reported. Seven (0.5%) deaths were recorded. CONCLUSION: The most common CBT type on this cohort was hyperplasic, which might be partially explained by the high altitudes where these patients lived. Increased blood loss and operative time were associated with a higher Shamblin classification, and the risk of stroke was associated with patients presenting transoperative vascular lesions.

Effect of Remote Ischemic Preconditioning on the Incidence of Contrast-Induced Nephropathy in Patients Undergoing Endovascular Aneurysm Repair (Remote Ischemic Preconditioning-Endovascular Aneurysm Repair Study).

BACKGROUND: Contrast-induced nephropathy (CIN) is a major inconvenience in the use of iodinated contrast media (ICM) and it is associated with a significant increase in morbidity and mortality and cost of hospitalization. Remote ischemic preconditioning (RIPC) is a noninvasive and cost-effective tissue protection technique that has showed to be beneficial in decreasing renal insult in patients receiving intravascular contrast. AIM: The primary outcome of this study is to evaluate the impact of RIPC on the incidence of CIN in patients undergoing endovascular aneurysm repair. METHODS: Patients suffering from aortic aneurysm were recruited prior to the administration of ICM. Randomization was used to assign patients into the control/RIPC groups. Biochemical parameters determined renal function before and after surgery in immediate (24-72 hr) and at 30 days of follow-up. RESULTS: Of the 120 patients included in the study, 98,3% were male. Mean age was 73 years (range: 56-87 years). Diabetes and chronic renal failure (considering estimated glomerular filtration [eGFR] <60) was present prior to administration of ICM in 29.16% and 38.33%, respectively. RIPC was applied in 50% (n = 60) of the patients. A total of 24.17% developed CIN regardless of fluidotherapy, RIPC, and other protective strategies. RIPC did not influence outcomes in terms of incidence on CIN, serum creatinine, urea, eGFR, or microalbuminuria in immediate postoperative period. However, the group of RIPC patients showed a statistically significant benefit in renal function in terms of serum creatinine (1.46 ± 0.3 vs. 1.03 ± 0.5; P < 0.001), urea (61.06 ± 27.5 mg/dL vs. 43.78 ± 12.9 mg/dL; P = 0.003), and an increase in eGFR (56.37 ± 23.4 mL/min/1.73 m2 vs. 72.85 ± 17.7 mL/min/1.73 m2; P = 0.004) at 30 days of follow-up. CONCLUSIONS: RIPC seems to be a reasonable, effective, and low-cost technique to alleviate effects of ICM on the renal parenchyma in endovascular aneurysm repair procedures during short-term postoperative period.

Thirty-three vascular residency programs among 13 countries joining forces to improve surgical education in times of COVID-19: A survey-based assessment.

BACKGROUND: Academic interaction with mentors has almost become minimal due to the current pandemic of COVID-19. The objective of this study is to introduce how a group of vascular surgery residencies joined forces to improve surgical education in times of COVID-19. METHODS: On May 2020, a group of Hispanic American vascular residency programs created webinar sessions of arterial and venous clinical cases among vascular residents across Latin America and Europe. Participants were surveyed via email. Questions were about the perceived quality and utility of the webinars; answers were stratified into negative (disagree), neutral, and positive (agree). RESULTS: There have been 60 sessions and 118 clinical cases presented. The survey was answered by 106 participants, 82 males (78.8%) and 24 women (23.0%). Fifty-four (51.9%) were board-certified vascular surgeons, 49 (47.1%) vascular surgery residents, and 2 (1.9%) general surgery residents. Mean age of the participants was 41.5 years (range: 25-74 years). Mean years of vascular surgery practice or experience were 11.2 years (range: 0-45 years). The residency programs involved in this project were from 13 different countries. Most answers received were positive for both perceived quality and utility of the webinars. CONCLUSION: Globalization and technology provide an opportunity for international education, with the goal of building well-rounded and academic vascular surgeons. This group is just the beginning of a large collaborative group among Hispanic American countries, hoping that more residency programs will join, with the aim of breaking borders in the education of vascular surgery.

Off-Label Use of a Flared Endograft Limb for Treatment of a Complicated Anastomotic Abdominal Aortic Pseudoaneurysm: Reverse Deployment Throught Axillary Artery.

A case of complicated abdominal aortic pseudoaneurysm not suitable for open repair is described. It was treated by means of endovascular methods with a flared endograft limb. The uniqueness of this case is the absence of a suitable femoral access, requiring the deployment of the graft in a reversed configuration through axillary artery. The technique is described and the need of imaginative off label use of endovascular devices in such emergent cases is discussed.

Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease.

BACKGROUND: The aim of this study was to analyze duplex ultrasound (DUS) and intraoperative angiography concordance for diagnosis of lower limb peripheral artery disease and its value for surgical planning. MATERIALS AND METHODS: This was a prospective, observational study, including patients who underwent revascularization of the lower limbs during 2018, diagnosed by DUS only or combined with preoperative computed tomography (CT) angiography. The concordance between preoperative DUS or CT angiography and the intraoperative angiography was studied using the Cohen kappa coefficient (k). The degree of agreement between the DUS-based surgical plan and the final surgical technique was also evaluated. RESULTS: Fifty-one patients were included, with mean age of 71.8 ± 11.96 years (46-94); 23 had chronic kidney disease (45%). In 17 patients (34%), preoperative CT angiography was also performed. DUS showed a sensitivity of 100% (95% confidence interval (CI) [83.3-100%]), 80% (95% CI [50.21-100%,]), and 100% (95% CI [96.43-100%]) at the iliac, femoral, and popliteal sector, respectively, and a specificity of 93.55% (95% CI [83.29-100%]), 95.45% (95% CI [84.48-100%]), and 90.48% (95% CI [75.54-100%]) at the iliac, femoral, and popliteal sector, respectively. The positive predictive value for DUS was 60% (95% CI [7.06-100%]), 88.9% (95% CI [62.8-100%]), and 87.5% (95% CI [68.17-100%]) for the iliac, femoral, and popliteal sectors, respectively, whereas the negative predictive value was 100% (95% CI [98.28-100%]), 91.3% (95% CI [77.61-100%]), and 100% (95% CI, [97.37-100%]). The concordance between DUS and intraoperative angiography showed a k index of 0.587 (P = 0.000) in the iliac sector, 0.799 in the femoral sector (P = 0.000), and 0.699 in the popliteal sector (P = 0.000). The concordance between CT angiography/intraoperative angiography had a k index of 0.71 in the iliac sector (P = 0.0093), 0.566 in the femoral sector (P = 0.006), and 0.5 in the popliteal sector (P = 0.028). DUS-based surgical plan was accurate in 86% of cases (n = 44). CONCLUSIONS: Our experience suggests that DUS arterial mapping of the femoral and popliteal areas is better than CT angiography and can be considered as a unique preoperative imaging test during the surgical planning in patients undergoing a lower limb revascularization procedure.

Celiac trunk segmental arterial mediolysis: a rare cause of arteriopathy.

A 50-year-old male patient, without a previous medical history, presented sudden severe abdominal pain with no alterations in the blood analysis. A CT-Angiography (CTA) was performed that showed a wall thickening of the celiac trunk extended to the hepatic artery with a filiform lumen and no involvement of the splenic artery. There were no signs of intestinal or liver ischemia, therefore no further radiological tests were performed. The proteinogram and serology were normal, with no immunological and acute phase reactant markers, excluding vasculitis. It appeared as an isolated lesion with no signs of arterial dissection or pseudoaneurysms of the remaining abdominal vessels or the aorta. Therefore, it was considered as a Segmental Arterial Mediolisis (SAM).

Prospective Study of the Iliac Branch Device E-liac in Patients with Common Iliac Artery Aneurysms: 12 Month Results.

OBJECTIVES: At 12 months follow up of the PLIANT study, clinical success and efficacy of the E-liac Stent Graft System (JOTEC GmbH, Hechingen, Germany) were evaluated. Clinical success was defined as aneurysm exclusion (no type I, III, IV endoleak) with primary patency of the internal iliac artery (IIA) and external iliac artery (EIA) on the E-liac implantation side. METHODS: In this prospective multicentre European observational study, clinical and morphological data of 45 patients (93% male, mean age 72 y) were prospectively collected in 11 European centres between July 2014 and June 2016. Forty patients underwent an aorto-iliac (three patients bilaterally) treatment and five an isolated iliac treatment. RESULTS: At 12 months follow up, data were available for 42 patients. Overall clinical success at 12 months was 90%, with a survival rate of 100%. Four patients (10%) did not achieve clinical success, one with an internal iliac artery (IIA) occlusion on the E-liac implantation side, one with an infrarenal type Ia endoleak, and two with type Ib endoleaks in IIA. At 12 months the primary patency rate in the internal iliac artery on the iliac side branch implantation side was 98%. Two patients (5%) received E-liac related re-interventions: one caused by an edge stenosis at the distal end of the graft limb in the external iliac artery (EIA) and one caused by thrombo-embolism in the external iliac artery. Thus, for the EIA, primary and secondary patency rates were 98% and 100%, respectively. CONCLUSIONS: The low device related re-intervention rate of 5%, the high survival rate of 100%, and the high primary patency rates of 98% for the IIA and EIA at 12 month follow up demonstrate the safety and efficacy of the E-liac Stent Graft System. Long term 36 month results are awaited to confirm the efficacy and durability.

EVAR Approach for Abdominal Aortic Aneurysm with Horseshoe Kidney: A Multicenter Experience.

BACKGROUND: Horseshoe kidney is a congenital abnormality, with an incidence of 0.25% of the total population. Only 0.12% of patients who undergo an abdominal aortic aneurysm repair might also have a coexisting horseshoe kidney. We present a series of 10 cases auspiciously treated with an endovascular approach along with their respective patient evolutions. A review of the literature is also presented. MATERIALS AND METHODS: A retrospective review of the medical records (January 2004-December 2013) of 10 patients with abdominal aortic aneurysms and horseshoe kidney treated with endovascular repair was done. Patients were treated at 6 different centers in 3 different countries. Demographics, clinical status, medical history, anatomical morphology of the aneurysms and kidneys, as well as surgical outcomes were all analyzed. RESULTS: The median age was 67.5 years (range 47-81), and the median aortic aneurysmal diameter was 57 mm (49-81 mm). A total of 35 arteries provided renal perfusion. There were 13 right renal arteries and 13 left renal arteries, all successfully preserved, with 9 isthmus arteries covered. Median hospital stay consisted of 3.5 days (1-14 days). All aortic aneurysms were successfully excluded with no endoleaks, hematomas, wound infections, or renal failure. During a median follow-up of 7 years, 3 patients died of myocardial infarction 7 years after endovascular aortic repair (EVAR), and the other 7 patients are doing well, with a median aneurysm reduction size sac of 16.5 mm. CONCLUSIONS: Endovascular repair is a safe and efficient endovascular option for the treatment of patients presenting concomitant aortic aneurysm and horseshoe kidney, with excellent short- and medium-term outcomes. To our knowledge, our study represents the largest series of cases with horseshoe kidney successfully treated via EVAR without significant complications.

Radioprotection Measures during the Learning Curve with Hybrid Operating Rooms.

BACKGROUND: Endovascular procedures come with a potential risk of radiation hazards both to patients and to the vascular staff. Classically, most endovascular interventions took place in regular operating rooms (ORs) using a fluoroscopy C-arm unit controlled by a third party. Hybrid operating rooms (HORs) provide an optimal surgical suit with all the qualities of a fixed C-arm device, while allowing the device to be controlled by the surgical team. The latest studies suggest that an operator-controlled system may reduce the radiation dose. The purpose of the present study is to determine the amount of absorbed radiation using an HOR in comparison with a portable C-arm unit and to assess whether the radioprotection awareness of the surgical team influences the radiation exposure. The primary end point was the effective dose in milliSievert (mSv) for the surgical team and the average dose-area product (ADAP) in Gray-meters squared (Gym2) for patients. METHODS: The values of absorbed radiation of the surgical team's dosimeters were collected from January 2015 to May 2016. The HOR was installed in June 2015, and a radioprotection seminar was given in October 2015. The HOR-issued radiation, measured by the maximum dose-area product, ADAP, average dose (AD) per procedure, maximum dose per procedure per month, maximum fluoroscopy time, average fluoroscopic time, peak skin dose, and average skin dose (ASD), was collected monthly from September 2015 to July 2016. The timeline was divided into 3 periods: 5 months pre-HOR (Pre-HOR), 5 months after the HOR installation (PreS-HOR), and 5 months after a radioprotection seminar (PostS-HOR). RESULTS: The average number of procedures per month was 22.55 (±4.9), including endovascular aneurysm repair/thoracic endovascular aneurysm repair, carotid, visceral, and upper and lower limb endovascular revascularization. The average amount of absorbed radiation by the surgeons during PreS-HOR was 1.07 ± 0.4 mSv, which was higher than the other periods (Pre-HOR 0.06 ± 0.03 mSv, P = 0.002; PostS-HOR 0.14 ± 0.09 mSv, P = 0.000, respectively). The ADAP during PreS-HOR was 0.016 ± 0.01 Gym2, which was lower than the PostS-HOR (0.001 ± 0.002 Gym2) (P = 0.034). The AD during PreS-HOR was 0.78 ± 0.3 Gy and 0.39 ± 0.3 Gy during PostS-HOR (P = 0.098). The ASD during PreS-HOR was 0.40 ± 0.2 Gy and 0.20 ± 0.1 Gy during PostS-HOR (P = 0.099). CONCLUSIONS: In our experience, the HOR increases the amount of absorbed radiation for both patients and surgeons. The radioprotection seminars are of utmost importance to provide a continued training and optimize the use of ionizing radiation while using an HOR. Despite the awareness of the surgical team in the radioprotection field, the amount of absorbed radiation using an HOR is higher than the one using a C-Arm unit.

Prospective study of the E-liac Stent Graft System in patients with common iliac artery aneurysms: 30-Day results.

OBJECTIVES: To study the safety and feasibility of the E-liac Stent Graft System® in patients with aorto/iliac aneurysms. METHODS: A prospective multicentric European registry of patients receiving the E-liac Stent Graft System® was conducted. Endpoints of the study included the technical success as well as periprocedural events and 30-day endoleaks, reinterventions, internal and external iliac artery patency and mortality. RESULTS: Between July 2014 and June 2016, a total of 45 patients (93% men, mean age 72 years, range 53-90 years) were enrolled at 11 sites in four European countries. Five patients received an isolated iliac treatment. Thirty-seven patients were treated with a combination of an abdominal stent graft and a unilateral E-liac and three in combination with bilateral E-liac. All E-liac Stent Grafts (48) were implanted in the intended position and the internal iliac arteries were successfully bridged. Two patients did not receive clinical success, due to endoleak type Ia of the aortic stent graft. At 30-day follow-up, clinical success rate was 96%. Three successful endovascular reinterventions were performed within the 30-day follow-up: one due to a type Ia endoleak in the common iliac artery, one due to type Ia endoleak of the aortic stent graft, and one due to bilateral lower limb claudication provoked by stent graft limb stenosis. At 30-day, a 100% survival rate and complete absence of pelvic or buttock ischemia/claudication were reported. Primary patency at 30 days was 100% for the internal iliac artery and 98% for the external iliac artery with an assisted patency of 100% in the latter. CONCLUSIONS: The high clinical success rate, low rates of device-related reinterventions (2%), and excellent patency rate demonstrate the safety and feasibility of the E-liac Stent Graft System. Long-term results are awaited to state efficacy and durability. Clinical Trials.gov. Identifier no. NCT02209194.

A Unique Case of Horner's Syndrome Following Subintimal Haematoma Within an Atherosclerotic Plaque.

Background and Importance We describe a patient with Horner's syndrome caused by an extensive intraparietal hematoma in the wall of the internal carotid artery confused with an arterial dissection. Detection of such pathology instead of dissection or arteritis is important as the management is different. As far as the authors know, it is the first case in which a haematoma within an atherosclerotic plaque is clinically related Horner's syndrome. Clinical Presentation A 81-year-old man presented with acute right hemiplegia and loss of vision of the left eye due to a central retinal artery occlusion. The patient underwent a computerised angiotomography which demonstrated left internal carotid artery occlusion with recanalisation after carotid bifurcation. Clinically, the patient developed a syndrome of Claude-Bernard Horner which replaced the diagnosis on the suspicion that it was a carotid artery dissection. The patient had miosis and ptosis of left eye. In the magnetic resonance angiography, an intramural of a possible hematoma was observed. It was decided to perform surgical treatment of the carotid lesion. Conclusion As this clinical case shows, there are symptomatic courtships that must be studied in detail so as not to confuse the carotid dissection with critical stenosis of the internal carotid artery.

Histological Benefits of Sealants in Tracheal Lesions in Wistar Rats.

INTRODUCTION: The purpose of our study was to compare the effect, on the inflammatory response and fibrosis formation, of four commercially available sealant products applied on an injured trachea in a Wistar rat population. MATERIALS AND METHODS: We compared four different sealants: cyanoacrylate, fibrin/thrombin, albumin/glutaraldehyde, and polyethylene glycol-based hydrogel (PEG). Rats were organized into six groups of similar size. Four of them were experimental, one was a baseline control group (BCG), and the sixth one was a reference control group (RCG). The RCG and experimental groups underwent the same surgical intervention with tracheal puncture, but no sealant was applied in the RCG. The BCG underwent the same cervical and peritracheal dissection without tracheal puncture. Rats were euthanized after eight weeks. RESULTS: The operation was performed on 54 rats, of which 12 died, leaving a final sample of 42 rats. Macroscopic analysis revealed no superficial tracheal or vascular fistulas, nor signs of local abscess. Although the groups treated with cyanoacrylate, fibrin/thrombin, and albumin/glutaraldehyde showed some degree of fibrosis, the treated area of the PEG group showed neither inflammatory nor scar signs. Microscopic assessment of the BCG and RCG showed no remarkable findings. With the exception of the PEG group, which had a light fibrosis and poor inflammatory response as did the BCG and RCG groups, the other groups showed varying degrees of fibrosis and cicatrization. CONCLUSION: Our study showed that the group treated with PEG had a mild inflammatory and fibrotic response, which is useful in tracheal or tracheobronchial surgical procedures. However, groups treated with cyanoacrylate, fibrin/thrombin, and albumin/glutaraldehyde showed fibrosis and cicatrization.

[Incidence of contrast induced nephropathy in patients who underwent an aortic endovascular repair]. / Incidência De Nefropatia Induzida Por Contraste Em Pacientes Operados De Reparação Aórtica endovascular.

INTRODUCTION: Intravascular iodinated contrasts are essencial in endovascular therapy. One of their major inconveniences is contrast-induced nephropathy (CIN), which has been associated with an increase in complications and prolonged hospital stay. AIM: To analyze the incidence of CIN in patients undergoing endovascular aneurysm repair (EVAR) in our hospital. MATERIAL AND METHODS: A retrospective study including patients (n=129) treated with EVAR between January 2014 - September 2015. Information was gathered concerning age, history of diabetes, hypertension, pre-existing chronic kidney disease and previous treatment with diuretics or metformin. We analyzed serum levels of urea, creatinine, sodium, potassium and glomerular filtrate (GF), at baseline, at 24hours, peak levels during post-operative period and before discharge. The amount of intravascular contrast and periprocedureral hydration were correlated to creatinine and GF to determine their effect on CIN. RESULTS: Of 129 patients, 11 (8.53%) developed CIN. A significant difference was found between preoperative and postoperative levels of urea and sodium, both p<0.001.Volume of contrast was the only variable that presented a statistically significant association with increase of creatinine levels in postoperative period (p=0.032). Worsening of glomerular filtrate showed a statistically significant association with preoperative levels of urea (p=0.036) and GF (p= 0.019). Fluid-therapy before or after exposure to contrast did not show any influence on the outcome. CONCLUSIONS: The incidence of CIN depends mainly on baseline GF and amount of contrast, and it is barely associated with hydration during the perioperative period. Since there is no specific treatment for CIN, the best practice is its prevention.

Aneurysmal degeneration of brachial artery in kidney transplant receptors after arteriovenous fistula ligation.

OBJECTIVES: True brachial artery aneurysms are. Recent case reports have suggested aneurysmal degeneration of brachial artery in kidney transplant receptors after arteriovenous fistula (AVF) ligation. We present a study on the evolution of the brachial artery in this context in our center. MATERIAL AND METHODS: This is a descriptive study in kidney transplant receptors in whom AVF was ligated between 2008 and 2015. Patients with AVF in both upper limbs were excluded. Diameters of axillary artery, brachial artery in middle portion and its bifurcation, as well as brachial artery flow were measured using Dupplex ultrasound in AVF and contralateral limb. Both groups were compared using the Student t-test for paired samples. RESULTS: 20 patients were included in the study and had a mean age of 59.35 ± 2.49 years. The median time of use of AVF for hemodialysis was 729 days (range 120-6117) and the median time in which AVF was patent was 2261 days (range 791-7091). Mean diameters (in mm) of axillary artery, brachial in middle portion and bifurcation were respectively 9.33 ± 1.07, 7.5 ± 0.61 and 5.81 ± 0.43 in AVF arm and 5.6 ± 2.8, 4.4 ± 0.1, 4.9 ± 0.15 in control limb, finding statistically significant differences (p <0.01) in brachial and axillary arteries. 5 patients (25%) developed aneurysm, 2 of which (10%) underwent surgery and 3 are on follow up. CONCLUSION: True incidence of brachial artery aneurysm in kidney receptors following AVF ligation is high. Careful follow up with physical examination and dupplex scanning are needed to find this complication.

Prognostic significance of an elevated neutrophil-lymphocyte ratio in the amputation-free survival of patients with chronic critical limb ischemia.

BACKGROUND: The aim of this study was to investigate the utility of admission neutrophil-lymphocyte ratio (NLR) in predicting the amputation-free survival (AFS) of patients with critical limb ischemia (CLI) who underwent an elective infrainguinal therapeutic intervention. METHODS: All patients with CLI undergoing elective infrainguinal vascular surgery (open or endovascular) at a single university teaching hospital between January 2005 and December 2009 were retrospectively identified from a prospectively maintained database. The primary end point was AFS. The cut-off of NLR >5 was used to categorize patients into low- and high-NLR groups. Kaplan-Meier analysis and long-rank test were used to compare survival between both groups. Cox regression analysis was conducted to determine independent factors affecting the AFS. RESULTS: During a median follow-up of 31 months, 561 patients with chronic CLI underwent infrainguinal revascularization. Five-year mortality was lower in the NLR <5 group (33%) than in the NLR >5 group (49%) (P ≤ 0.001), and the AFS was significantly higher in the NLR <5 group (50%) than in the NLR >5 group (26%) (P ≤ 0.001). In a multivariate analysis, preoperative NLR >5 was independently associated with 5-year AFS (hazard ratio 2.325, 95% CI 1.732-3.121). CONCLUSIONS: Elevated NLR predicts a worse AFS in patients undergoing infrainguinal vascular revascularization with chronic CLI, suggesting that the NLR conveys powerful prognostic information that is independent of other conventional clinical risk factors.

Cost-effectiveness analysis of the diagnosis of temporal arteritis.

Temporal arteritis (TA) is the most common form of systemic vasculitis. Its diagnosis is based on criteria proposed by the American College of Rheumatology (1990), and its treatment is high-dose corticosteroids. Our objective is to assess the cost of diagnosing TA, and secondarily, cost-effective analysis of different diagnostic strategies (clinical, biopsy, doppler ultrasound) and therapeutic strategies (corticosteroid suspension). MATERIAL AND METHOD: Observational, retrospective study has been carried out on patients with AT (2012-2021). Demographic data, comorbidities, signs and symptoms suggestive of AT were collected. AT was diagnosed with a score ≥ 3 according to American College of Rheumatoloy criteria (ACR-SCORE). The costs of diagnosis and treatment modification were analysed. RESULTS: Seventy-five patients have been included, median age 77 (46-87) years. Headache, temporal pain and jaw claudication were significant for the diagnosis of TA. Patients with a halo on Doppler ultrasound and a positive biopsy have significantly elevated ESR and CRP compared to patients who do not. The cost of the AT diagnosis was 414.7 euros/patient. If we use ACR-SCORE ≥ 3-echodoppler it is 167.2 є/patient (savings 59.6%) and ACR-SCORE ≥ 3-biopsy 339.75 є/patient (savings 18%). If the corticosteroid was removed and a biopsy was performed, 21.6 є/patient (94.7% savings), if the corticosteroid was removed and Doppler ultrasound was performed, 10.6 є/patient (97.4% savings). CONCLUSIONS: Headache, temporary pain and jaw claudication are predictors of AT. Elevated ESR and CRP are predictors of positive biopsy and presence of halo on ultrasound. The uses of ACR-SCORE ≥ 3 with Doppler ultrasound or biopsy, and with corticosteroid suspension, are cost-effective.

Shotgun wound and pellet embolism to the intracranial carotid artery.

Missile embolism into the cerebral circulation is a very unusual complication of shotgun wounds to the chest or neck. We report a case of an 11-year-old boy who sustained an air gunshot wound and pellet embolism to the intracranial carotid artery. The cerebral artery pellet embolus resulted in contralateral hemiplegia. The patient was successfully treated by emergency flow reversal and embolectomy. Because this injury is extremely rare, the literature is reviewed, and several principles are suggested to improve the management.

Influence of aspirin therapy in the ulcer associated with chronic venous insufficiency.

BACKGROUND: To determine the effect of aspirin on ulcer healing rate in patients with chronic venous insufficiency, and to establish prognostic factors that influence ulcer evolution. METHODS: Between 2001 and 2005, 78 patients with ulcerated lesions of diameter >2 cm and associated with chronic venous insufficiency were evaluated in our hospital. Of these, 51 patients (22 men, 29 women) with mean age of 60 years (range: 36-86) were included in a prospective randomized trial with a parallel control group. The treatment group received 300 mg of aspirin and the control group received no drug treatment; in both groups, healing was associated with standard compression therapy. During follow-up, held weekly in a blinded fashion, there was ulcer healing as well as cases of recurrence. Results were analyzed by intention-to-treat approach. Cure rate was estimated using Kaplan-Meier survival analysis, and the influence of prognostic factors was analyzed by applying the Cox proportional hazards model. RESULTS: In the presence of gradual compression therapy, healing occurred more rapidly in patients receiving aspirin versus the control subjects (12 weeks in the treated group vs. 22 weeks in the control group), with a 46% reduction in healing time. The main prognostic factor was estimated initial area of injury (P = 0.032). Age, sex, systemic therapy, and infection showed little relevance to evolution. CONCLUSIONS: The administration of aspirin daily dose of 300 mg shortens the healing time of ulcerated lesions in the chronic venous insufficiency (CVI). The main prognostic factor for healing of venous ulcerated lesions is the initial surface area of the ulcer.

Clinical prediction rules in acute appendicitis: which combination of variables is more effective at predicting?

BACKGROUND: Clinical prediction rules have been designed to reduce variability and improve the diagnostic process. However, there are no unanimous criteria regarding which of them is the most efficient for the diagnosis of acute appendicitis. AIM: The primary aim of this study was to assess the diagnostic efficacy of the most commonly used clinical prediction rules. The second aim was to identify the combination of the smallest number of clinical and analytical variables that would allow a cost-effective diagnostic approach. METHODS: A retrospective observational study was conducted of 458 patients who were evaluated for right iliac fossa pain between January 2010 and December 2016. The scores tested were Alvarado, AIR, RIPASA, and AAS. Univariate and multiple regressions were used for validation. RESULTS: Alvarado one was the most efficient to establish a positive diagnosis of acute appendicitis. However, the most simplified and predictive combination variables included anorexia, white blood cell count > 8275 leukocytes/mL, neutrophilia (> 75%), abdominal pain < 48 h, migrating pain, and temperature out the range of 37-39ºC. CONCLUSIONS: A new and effective CPR (HMC score) for predicting appendicitis in patients presenting with the right iliac fossa pain has been established.

INTRODUCCIÓN: Las escalas de predicción diagnóstica (EPD) se han diseñado con el objetivo de reducir la variabilidad y mejorar el proceso de diagnóstico. Sin embargo, no existen criterios unánimes sobre cuál de ellas es la más el más eficiente para el diagnóstico de apendicitis aguda. OBJETIVO: El objetivo principal de este estudio fue evaluar la eficacia diagnóstica de las escalas de predicción diagnóstica más utilizadas. El segundo objetivo fue identificar la combinación del menor número de variables clínicas y analíticas que permitieran un enfoque diagnóstico más eficiente. MÉTODOS: Se realizó un estudio observacional retrospectivo de 458 pacientes que fueron evaluados por dolor en la fosa ilíaca derecha entre enero de 2010 y diciembre de 2016. Las escalas evaluadas fueron las de Alvarado, AIR, RIPASA y AAS. Se utilizaron la regresion univariada y la múltiple para la validación de los resultados. RESULTADOS: la escala de Alvarado fue la más eficiente para establecer un diagnóstico de apendicitis aguda. No obstante, la combinación de las siguientes variables: anorexia, recuento de leucocitos > 8275 leucocitos/mL, neutrofilia (> 75%), dolor abdominal < 48 horas, dolor migratorio y temperatura fuera del rango de 37-39ºC, demostró ser la más eficiente para establecer un diagnóstico positivo de apendicitis aguda. CONCLUSIONES: Se ha desarrollada una nueva EPD (escala HMDC) para determinar la presencia de apendicitis en pacientes evaluados por dolor en la fosa ilíaca derecha.