Temporal variability of readmission determinants in postoperative vascular surgery patients.

INTRODUCTION: Clinical information continues to be limited regarding changes in the temporal risk profile for readmissions during the initial postoperative year in vascular surgery patients. We set out to describe the associations between demographics, clinical outcomes, comorbidity indices, and hospital readmissions in a sample of patients undergoing common extremity revascularization or dialysis access (ERDA) procedures. We hypothesized that factors independently associated with readmission will evolve from "short-term" to "long-term" determinants at 30-, 180-, and 360-day postoperative cutoff points. METHODS: Following IRB approval, medical records of patients who underwent ERDA at two institutions were retrospectively reviewed between 2008 and 2014. Abstracted data included patient demographics, procedural characteristics, the American Society of Anesthesiologists score, Goldman Criteria for perioperative cardiac assessment, the Charlson comorbidity index, morbidity, mortality, and readmission (at 30-, 180-, and 360-days). Univariate analyses were performed for readmissions at each specified time point. Variables reaching statistical significance of P< 0.20 were included in multivariate analyses for factors independently associated with readmission. RESULTS: A total of 450 of 744 patients who underwent ERDA with complete medical records were included. Patients underwent either an extremity revascularization (e.g. bypass or endarterectomy, 406/450) or a noncatheter dialysis access procedure (44/450). Sample characteristics included 262 (58.2%) females, mean age 61.4 ± 12.9 years, 63 (14%) emergent procedures, and median operative time 164 min. Median hospital length of stay (index admission) was 4 days. Cumulative readmission rates at 30-, 180-, and 360-day were 12%, 27%, and 35%, respectively. Corresponding mortality rates were 3%, 7%, and 9%. Key factors independently associated with 30-, 180-, and 360-day readmissions evolved over the study period from comorbidity and morbidity-related issues in the short-term to cardiovascular and graft patency issues in the long-term. Any earlier readmission elevated the risk of subsequent readmission. CONCLUSIONS: We noted important patterns in the temporal behavior of hospital readmission risk in patients undergoing ERDA. Although factors independently associated with readmission were not surprising (e.g. comorbidity profile, cardiovascular status, and graft patency), the knowledge of temporal trends described in this study may help determine clinical risk profiles for individual patients and guide readmission reduction strategies. These considerations will be increasingly important in the evolving paradigm of value-based healthcare.

Pre-injury neuro-psychiatric medication use, alone or in combination with cardiac medications, may affect outcomes in trauma patients.

BACKGROUND: Recent review of older (≥45-years-old) patients admitted to our trauma center showed that more than one-third were using neuro-psychiatric medications (NPMs) prior to their injury-related admission. Previously published data suggests that use of NPMs may increase patients' risk and severity of injury. We sought to examine the impact of pre-injury NPM use on older trauma patients' morbidity and mortality. MATERIALS AND METHODS: Retrospective record review included medication regimen characteristics and NPM use (antidepressants-AD, antipsychotics-AP, anxiolytics-AA). Hospital morbidity, mortality, and 90-day survival were examined. Comparisons included regimens involving NPMs, further focusing on their interactions with various cardiac medications (beta blocker - BB; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker - ACE/ARB; calcium channel blocker - CCB). RESULTS: 712 patient records were reviewed (399 males, mean age 63.5 years, median ISS 8). 245 patients were taking at least 1 NPM: AD (158), AP (35), or AA (108) before injury. There was no effect of NPM monotherapy on hospital mortality. Patients taking ≥3 NPMs had significantly lower 90-day survival compared to patients taking ≤2 NPMs (81% for 3 or more NPMs, 95% for no NPMs, and 89% 1-2 NPMs, P < 0.01). Several AD-cardiac medication (CM) combinations were associated with increased mortality compared to monotherapy with either agent (BB-AD 14.7% mortality versus 7.0% for AD monotherapy or 4.8% BB monotherapy, P < 0.05). Combinations of ACE/ARB-AA were associated with increased mortality compared to ACE/ARB monotherapy (11.5% vs 4.9, P = 0.04). Finally, ACE/ARB-AD co-administration had higher mortality than ACE/ARB monotherapy (13.5% vs 4.9%, P = 0.01). CONCLUSIONS: Large proportion of older trauma patients was using pre-injury NPMs. Several regimens involving NPMs and CMs were associated with increased in-hospital mortality. Additionally, use of ≥3 NPMs was associated with lower 90-day survival.

Airglow and star photographs in the daytime from a rocket.

Photographs of the constellation Cygnus taken in the daytime from altitudes above 100 kilometers indicate that the day sky brightness in the wave-length region from 3600 to 7000 angstroms is only slightly brighter than the night sky viewed from the ground. No diffuse cloud of particles was apparent in the vicinity of the rocket payload, but discrete particles must be considered in the design of instruments for rockets and satellites. The resultant data and reports of star sightings from manned spacecraft indicate similar optical environments for both types of vehicles, that is, discrete particles and relatively low levels of background brightness, only slightly brighter than the night sky as an upper limit.

Complications associated with pulmonary artery catheters: a comprehensive clinical review.

Care for the critically ill patient requires maintenance of adequate tissue perfusion/oxygenation. Continuous hemodynamic monitoring is frequently utilized to achieve these objectives. Pulmonary artery catheters (PAC) allow measurement of hemodynamic variables that cannot be measured reliably or continuously by less invasive means. Inherent to every medical intervention are risks associated with that intervention. This review categorizes complications associated with the PAC into four broad groups--complications of central venous access; complications related to PAC insertion and manipulation; complications associated with short- or long-term presence of the PAC in the cardiovascular system; and errors resulting from incorrect interpretation/use of PAC-derived data. We will discuss each of these four broad categories, followed by in-depth descriptions of the most common and most serious individual complications.

Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies.

Given the increasing complexity of both the modern health care environment and the overall patient population, reduction of medical errors is a high priority task for health policy makers and medical/surgical community alike. The problem of retained surgical foreign bodies (RSFB) has existed ever since the humans first performed surgical procedures. Retained surgical foreign bodies continue to be a significant problem with an incidence between 0.3 and 1.0 per 1,000 abdominal operations. Retained surgical foreign bodies have the potential to cause harm to the patient and carry profound professional and medico-legal consequences to surgical trainees, surgical practitioners, hospitals, and health systems. Currently, there are no known methods of entirely eliminating the occurrence of RSFB. In this manuscript, the authors discuss the available evidence with regards to risk factors associated with RSFB as well as methods of minimizing the incidence of RSFB. Modern technological advances designed to decrease the incidence of RSFB (radio-frequency tagging of surgical sponges) and improved perioperative patient processing (multiple 'checks and balances' and better provider-to-provider communication) are reviewed. The authors also explore the relationship between RSFB and surgical training with emphasis on education in early recognition, prevention, and focus on team-oriented training strategies.

Stable isotopic characterization of a coastal floodplain forest community: a case study for isotopic reconstruction of Mesozoic vertebrate assemblages.

Stable isotopes are powerful tools for elucidating ecological trends in extant vertebrate communities, though their application to Mesozoic ecosystems is complicated by a lack of extant isotope data from comparable environments/ecosystems (e.g. coastal floodplain forest environments, lacking significant C4 plant components). We sampled 20 taxa across a broad phylogenetic, body size, and physiological scope from the Atchafalaya River Basin of Louisiana as an environmental analogue to the Late Cretaceous coastal floodplains of North America. Samples were analysed for stable carbon, oxygen and nitrogen isotope compositions from bioapatite and keratin tissues to test the degree of ecological resolution that can be determined in a system with similar environmental conditions, and using similar constraints, as those in many Mesozoic assemblages. Isotopic results suggest a broad overlap in resource use among taxa and considerable terrestrial-aquatic interchange, highlighting the challenges of ecological interpretation in C3 systems, particularly when lacking observational data for comparison. We also propose a modified oxygen isotope-temperature equation that uses mean endotherm and mean ectotherm isotope data to more precisely predict temperature when compared with measured Atchafalaya River water data. These results provide a critical isotopic baseline for coastal floodplain forests, and act as a framework for future studies of Mesozoic palaeoecology.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSION: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSION: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

Temporal changes in hematologic markers after splenectomy, splenic embolization, and observation for trauma.

INTRODUCTION: The spleen is one of the most commonly injured abdominal solid organs during blunt trauma. Modern management of splenic trauma has evolved to include non-operative therapies, including observation and angioembolization to preclude splenectomy in most cases of blunt splenic injury. Despite the shift in management strategies, relatively little is known about the hematologic changes associated with these various modalities. The aim of this study was to determine if there are significant differences in hematologic characteristics over time based on the treatment modality employed following splenic trauma. We hypothesized that alterations seen in hematologic parameters would vary between observation (OBS), embolization (EMB), and splenectomy (SPL) in the setting of splenic injury. METHODS: An institutional review board-approved, retrospective study of routine hematologic indices examined data between March 2000 and December 2014 at three academic trauma centers. A convenience sample of patients with splenic trauma and admission lengths of stay >96 h was selected for inclusion, resulting in a representative sample of each sub-group (OBS, EMB, and SPL). Basic demographics and injury severity data (ISS) were abstracted. Platelet count, red blood cell (RBC) count and RBC indices, and white blood cell (WBC) count with differential were analyzed between the time of admission and a maximum of 1080 h (45 days) post-injury. Comparisons between OBS, EMB, and SPL groups were then performed using non-parametric statistical testing, with statistical significance set at p < 0.05. RESULTS: Data from 130 patients (40 SPL, 40 EMB, and 50 OBS) were analyzed. The median age was 40 years, with 67 % males. Median ISS was 21.5 (21 for SPL, 19 for EMB, and 22 for OBS, p = n/s) and median Glasgow Coma Scale (GCS) was 15. Median splenic injury grade varied by interventional modality (grade 4 for SPL, 3 for EMB, and 2 for OBS, p < 0.05). Inter-group comparisons demonstrated no significant differences in RBC counts. However, mean corpuscular volume (MCV) and RBC distribution width (RDW) were elevated in the SPL and EMB groups (p < 0.01). Similarly, EMB and SPL groups had higher platelet counts than the OBS group (p < 0.01). In aggregate, WBC counts were highest following SPL, followed by EMB and OBS (p < 0.01). Similar trends were noted in neutrophil and monocyte counts (p < 0.01), but not in lymphocyte counts (p = n/s). CONCLUSION: This study describes important trends and patterns among fundamental hematologic parameters following traumatic splenic injuries managed with SPL, EMB, or OBS. As expected, observed WBC counts were highest following SPL, then EMB, and finally OBS. No differences were noted in RBC count between the three groups, but RDW was significantly greater following SPL compared to EMB and OBS. We also found that MCV was highest following OBS, when compared to EMB or SPL. Finally, our data indicate that platelet counts are similarly elevated for both SPL and EMB, when compared to the OBS group. These results provide an important foundation for further research in this still relatively unexplored area.

From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment.

Ultrasound is a ubiquitous and versatile diagnostic tool. In the setting of acute injury, ultrasound enhances the basic trauma evaluation, influences bedside decision-making, and helps determine whether or not an unstable patient requires emergent procedural intervention. Consequently, continued education of surgeons and other acute care practitioners in performing focused emergency ultrasound is of great importance. This article provides a synopsis of focused assessment with sonography for trauma (FAST) and the extended FAST (E-FAST) that incorporates basic thoracic injury assessment. The authors also review key pitfalls, limitations, controversies, and advances related to FAST, E-FAST, and ultrasound education.

Axillary to common iliac arteriovenous graft for hemodialysis access: Case report and review of 'exotic' axillary-based grafts.

A 58-year-old Caucasian male with end-stage renal disease and peripheral arterial disease was referred to us for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. Magnetic resonance venography (MRV) of his chest revealed extensive bilateral venous occlusions due to numerous past hemodialysis access catheters. The patient was scheduled for right lower extremity arteriovenous graft placement, but intraoperatively was found to have severe peripheral arterial disease and a thromboendarterectomy was performed instead. Lower body venous imaging demonstrated patent iliac veins. Based on these anatomic considerations a right axillary artery to right common iliac vein polytetrafluoroethylene (PTFE) graft was placed. The graft required revision twice--once for graft ultrafiltration at the arterial end of the graft and once for needle stick infection--but continues to serve as sufficient access after 15 months. Grafts based off the axillary artery have become increasingly popular in recent years and several venous outflow options have been considered, each with distinct advantages. The common iliac vein offers a central location with high flow rate and low probability of infection. Axillary artery to iliac vein arteriovenous grafting may have a place in the vascular surgeon's armamentarium for complex vascular access cases.

Developmental and evolutionary novelty in the serrated teeth of theropod dinosaurs.

Tooth morphology and development can provide valuable insights into the feeding behaviour and evolution of extinct organisms. The teeth of Theropoda, the only clade of predominantly predatory dinosaurs, are characterized by ziphodonty, the presence of serrations (denticles) on their cutting edges. Known today only in varanid lizards, ziphodonty is much more pervasive in the fossil record. Here we present the first model for the development of ziphodont teeth in theropods through histological, SEM, and SR-FTIR analyses, revealing that structures previously hypothesized to prevent tooth breakage instead first evolved to shape and maintain the characteristic denticles through the life of the tooth. We show that this novel complex of dental morphology and tissues characterizes Theropoda, with the exception of species with modified feeding behaviours, suggesting that these characters are important for facilitating the hypercarnivorous diet of most theropods. This adaptation may have played an important role in the initial radiation and subsequent success of theropods as terrestrial apex predators.

Influence of acute intracerebroventricular (i.c.v.) administration of adrenocorticotrophin (ACTH) on LH secretion in male rats: effect of pretreatment (i.c.v.) with ACTH antiserum on the serum LH response to an acute ether stress.

Adult male rats with chronic indwelling intracerebroventricular (i.c.v.) and jugular catheters were given an i.c.v. injection (over 1 min) of 1, 10, 100 ng or 1 microgram ACTH(1-24), or 300 ng ACTH(4-10) or saline, and blood samples were taken 0, 5, 15, 30 and 60 min later. Increasing dosages of ACTH(1-24) caused a dose-related rise in serum LH levels. Peak levels of serum LH (ranging from 157 to 473% of pretreatment levels) were reached 5-15 min after treatment, and then serum LH values returned to pretreatment levels by 60 min. The serum LH response to 1 microgram ACTH(1-24) did not differ from the response to 100 ng ACTH(1-24). Administration (i.c.v.) of 300 ng ACTH(4-10) was also effective in increasing serum LH values. Repeated withdrawal of blood during the experiment increased serum corticosterone values in all groups (including saline-treated), but i.c.v. administration of ACTH(1-24) or ACTH(4-10) did not further increase serum corticosterone levels. Two additional groups of rats were injected i.p. with either saline or pentobarbital (30 mg/kg body weight) 1 h before i.c.v. administration of 10 ng ACTH(1-24) and blood samples were taken as in the other groups. The animals in these groups did not show a rise in serum LH concentrations in response to ACTH(1-24). In a third experiment, rats were pretreated (i.c.v.) with either ACTH antiserum (ACTH-Ab) or normal rabbit serum 15 min before a 2-min ether stress. The ether stress evoked a significant rise in serum LH concentrations within 15 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Exophthalmos and elevated thyroxine levels in association with lithium therapy.

Although goiter formation and hypothyroidism are not infrequent following lithium therapy, the association of exophthalmos and/or elevated thyroxine levels with lithium is uncommon. We describe a 62 year old man who rapidly developed exophthalmos, elevated circulating thyroxine, elevated TSH levels and elevated radioiodine uptake within six weeks of reexposure to lithium carbonate. When the medication was stopped, all indices of thyroid function returned to normal and the proptosis receded from 22 to 17mm. Lithium decreases secretion of preformed thyroid hormone and the secondary elevation of TSH levels usually restores euthyroid status. We propose that in our patient, because triiodothyronine levels remained normal, the pituitary was refractory to the normal inhibitory feedback effect of thyroxine and that continued hypersecretion of TSH resulted in hyperthyroidism

Empty sella secondary to suprasellar colloid cyst of foregut (respiratory) origin. Case report.

An enlarged sella turcica was discovered in a 40-year-old man who had bitemporal headaches. A pneumoencephalograph revealed a third ventricular cyst, dilated lateral ventricles, and an empty sella. The colloid cyst was lined by foregut epithelium, probably originating in the respiratory tract, and dense connective tissue. This case is the first instance of an empty sella associated with a colloid cyst of the third ventricle. It is proposed that enlargement of the mass in the third ventricle caused increased pulsation pressure of the cerebrospinal fluid, and that in the presence of an incompetent diaphragma sellae the subarachnoid space expanded into the sella. The origin of third ventricle cysts is reconsidered. It is concluded that suprasellar colloid cysts may arise from endoderm, ectoderm, neuroepithelium, or a combination of these epithelia.

Comparison of the effects of some CYP3A and other enzyme inducers on replicative DNA synthesis and cytochrome P450 isoforms in rat liver.

The aim of this study was to investigate the mitogenic effects of some inducers of cytochrome P450 (CYP) isoforms in rat liver. Female Sprague-Dawley CD rats were treated with 100 mg/kg per day of either sodium phenobarbitone (NaPB), barbituric acid (BA), isoniazid (ISN), beta-naphthoflavone (BNF), pregnenolone-16alpha-carbonitrile (PCN), miconazole (MIC) or clotrimazole (CLOT), 75 mg/kg per day methylclofenapate (MCP), 50 mg/kg per day dexamethasone (DEX) and 500 mg/kg per day troleandomycin (TAO) by daily oral gavage for four days. Treatment with all compounds except BA, ISN and MIC, significantly increased relative liver weight. Administration of NaPB, PCN, DEX, MIC, CLOT and TAO all induced total CYP content, and by Western immunoblotting, levels of CYP3A isoforms in hepatic microsomal fractions. Apart from CLOT, all these compounds induced microsomal testosterone 6beta-hydroxylase activity. By measurement of marker enzyme activities and Western immunoblotting with antibodies to CYP1A2, CYP2B1/2 and CYP2E1, BNF, NaPB, ISN and MCP were shown to induce CYP1A2, CYP2B1/2, CYP2E and CYP4A isoforms, respectively. Replicative DNA synthesis was studied by implanting osmotic pumps containing 5-bromo-2'-deoxyuridine 1 day before the commencement of treatment with the enzyme inducers. Hepatocyte labelling index values were significantly increased by treatment with NaPB, PCN, MCP, CLOT and TAO, but not by BA, ISN, BNF, DEX and MIC. These studies demonstrate that while CYP2B and CYP4A enzyme inducers may stimulate replicative DNA synthesis, only some CYP3A enzyme inducers are mitogenic agents in rat liver.

Long-term results of staple capsulorrhaphy for anterior instability of the shoulder.

The results of 204 open staple capsulorrhaphies, performed consecutively as treatment for recurrent anterior instability of the shoulder in 192 patients, were reviewed after an average of ten years (range, two to twenty years). The operation had been performed for recurrent dislocations in 88 per cent of the shoulders and for recurrent subluxations in the remaining 12 per cent. Postoperative instability--dislocation or subluxation--occurred in 22 per cent of the shoulders and increased in frequency logarithmically with the duration of follow-up. In more than half of these shoulders, the episodes of postoperative instability were recurrent. In one-third of the shoulders, the stapling had been combined with a Putti-Platt procedure; in the others, a muscle-splitting approach had been used. The rate of recurrent instability was 8 per cent in the shoulders in which a Putti-Platt procedure had been added and 29 per cent in the shoulders that had been treated by stapling alone. The difference was significant (p = 0.002). Loosening or migration of a staple, or penetration of the articular cartilage by a staple, occurred in twenty-four shoulders (12 per cent); the staple was removed from eighteen of them. There was no significant difference in the rate of loosening or migration between non-barbed and barbed staples (p = 0.92). Pain, physical restrictions, and osteoarthrosis were more frequent in patients who had complications associated with a staple. Although most of the patients (84 per cent of the shoulders) thought that they had benefited from the operation, approximately half (51 per cent of the shoulders) had pain and approximately half (50 per cent of the shoulders) said that the shoulder was sufficiently different from normal to affect the quality of life. Problems with the shoulder that had not been present before the operation caused several patients (5 per cent of the shoulders) to change occupations. The average ranges of internal and external rotation were slightly reduced. The subjective and objective results after the stapling procedure were not as good as previous reports have suggested, and we no longer recommend staple capsulorrhaphy for anterior instability of the shoulder, even when it is augmented by a Putti-Platt procedure.

Lumbar disc herniation in the elderly.

Thirty-two patients older than 60 years underwent surgical treatment for lumbar disc herniation over a 10-year period. Other causes of low-back pain and sciatica were investigated, and bony nerve root entrapment syndromes were not included. Sciatica was a predominant symptom and was present in all patients, with 81% showing positive nerve root tension signs. Motor deficit was found in more than half of the cases. A sequestrated disc was present in 50%. The follow-up ranged from 1 to 10 years with an average of 50 months. Eighty-seven percent of the patients had excellent or good results. There were no poor results and no one required reoperation. Lumbar disc herniation in the elderly is not a common problem, but surgery yields a high rate of satisfactory results if a proper investigation and correct diagnosis is obtained.