The Use of Stroke Volume Variation to Guide Donor Management Is Associated With Increased Organs Transplanted per Donor.

BACKGROUND: There is a national shortage of organs available for transplantation, and utilization rates for thoracic organs are less than 40%. In addition, the optimal method of assessing cardiovascular status during donor management is uncertain. FloTrac is a noninvasive hemodynamic technique that measures cardiac output and fluid responsiveness. Our objective was to measure the impact of using this technique to guide management on fluid balance, vasopressor usage, thyroid hormone usage, and pulmonary function. We hypothesized that FloTrac guidance will increase thoracic organs transplanted per donor (OTPD). METHODS: Data were prospectively collected on a convenience sample of 38 donors after neurologic determination of death. Organs transplanted, net fluid balance, dosage of vasopressors, dosage of thyroid hormone, and Pao2:Fio2 were compared between treatment and control groups. RESULTS: The treatment group had greater thoracic OTPD (1.3 [1.0] vs 0.4 [0.6], P = .004) and overall OTPD (4.3 [1.5] vs 2.7 [1.5], P = .002). Donors in the treatment group maintained a neutral fluid balance, had more thyroid hormone used, and had an improvement in oxygenation. CONCLUSION: The implementation of this technology to aid providers may help ameliorate the shortage of thoracic and overall organs available for transplantation.

Effect of Plasma Sterilization on the Hemostatic Efficacy of a Chitosan Hemostatic Agent in a Rat Model.

INTRODUCTION: The United States military has had success with chitosan (CS)-based hemostatic agents to control trauma-induced hemorrhages. Despite the positive reviews, additional physical forms of CS may enhance its hemostatic efficacy. Additionally, standard sterilization techniques may negatively affect the hemostatic efficacy of CS. We studied the effects of a CS-based hemostatic pad, the Clo-Sur P.A.D.™ (Scion Cardio-Vascular, Inc.), on severe femoral vessel bleeding in a rat model. The effects of different sterilization techniques on the bioadhesivity, surface atomic concentrations, and hemostatic efficacy of the P.A.D. were also evaluated. METHODS: Hemostatic efficacy, bioadhesivity, and surface atomic concentrations of the P.A.D. were evaluated in its unsterilized form, after sterilization with standard e-beam treatment, and after sterilization with one of three types of non-thermal nitrogen plasma: nitrogen gas, air, or nitrous oxide plasma. After standardized puncture of the femoral artery or transection of the femoral vessels, rats were treated with either a CS P.A.D. or gauze pad. RESULTS: The Clo-Sur P.A.D., regardless of sterilization technique, stopped arterial and mixed arterial/venous bleeding in all cases in <90 s with the time to hemostasis (TTH) significantly less for all P.A.D. treatment groups (P < 0.001; n = 4-5/group) compared to gauze-treated controls (n = 3). E-beam sterilized P.A.D.s consistently showed non-significant trends toward increased TTH and worse hemostasis scores compared to unsterilized and plasma sterilized P.A.D.s. Treating e-beam sterilized P.A.D.s with N2 plasma reverted the hemostatic efficacy to levels equivalent to native, unsterilized PADs. CONCLUSION: A CS-based hemostatic pad successfully controlled severe bleeding in a rat model with combined e-beam and plasma sterilized P.A.D.s showing the most promising results. Further studies are warranted.

Assessing candidate serum biomarkers for Alzheimer's disease: a longitudinal study.

Because of the growing impact of late onset cognitive loss, considerable effort has been directed toward the development of improved diagnostic techniques for Alzheimer's disease (AD) that may pave the way for earlier (and more effective) therapeutic efforts. Serum-based biomarkers are the least expensive and invasive modality for screening and routine monitoring. We systematically reviewed the literature to assemble a list of serum biomarkers relevant to AD. In parallel, we conducted a proteomic LC-MS/MS analysis of serum collected from neurologically normal subjects and subjects with mild cognitive impairment (MCI) and early AD (n = 6 in all). Complement C3 and alpha-2-macroglobulin were identified from both the literature review and our proteomic screen for further validation. For these two candidates, ELISA was performed on serum collected from a small independent cohort of subjects for longitudinal analysis. Serum was serially collected from neurologically normal subjects (n = 5) and subjects with MCI who were subsequently followed for a period of two years (n = 5) and regrouped into stable MCI and progressive MCI or AD (n = 6). The ability of each marker to predict which subjects with MCI would progress to dementia and which would remain cognitively stable was assessed. Patients with probable cerebral amyloid angiopathy were also identified (n = 3). This preliminary analysis tested the most-promising serum protein biomarkers for AD and we concluded that none are yet ready for use in the clinical diagnosis and management of dementia. However, a more thorough assessment in longitudinal studies with higher statistical power is warranted.

Mild cognitive impairment: prodromal Alzheimer's disease or something else?

The majority of mild cognitive impairment (MCI) studies use baseline and one follow-up measurement to determine the clinical course of the disorder. This report of MCI clinical course is based on the a statistical evaluation of multiple neurocognitive tests over a 60 month period in elderly normal and MCI cohorts. The data includes serial informant-based measures (Clinical Dementia Rating [CDR]) and a comprehensive battery of neuropsychological tests analyzed by two different regression methods. Twenty-nine elderly participants entered the study as neurocognitively normal; 26 remained normal, 2 progressed to MCI, and 1 progressed to dementia. Eighty-three participants entered the study as multiple domain MCI cases; 10 became normal, 46 remained MCI, and 27 progressed to dementia. Three of the 27 demented died with full necropsies performed (one case was progressive supranuclear palsy and two confirmed Alzheimer's disease with severe cerebral amyloid angiopathy (CAA)). Without serial measures, 1 in 8 MCI could be misclassified as "stable MCI" despite reverting to normal. The stable MCI cohorts did not benefit from practice effects though the normal subjects did. Applying Classification and Regression Tree (CART) analysis enabled prediction of the endpoint status of participants from baseline values with 78.6% accuracy. The fluctuating cognitive status of the multiple domain MCI cases implies a remitting pathologic process with elements of recovery consistent with a progressive microvasculopathy such as CAA.

Academic integrity violations: a national study of dental hygiene students.

The purpose of this study was to identify the prevalence of academic integrity violations reported by a national sample of dental hygiene students as compared to general undergraduate students. This study also examined the influence of student variables such as gender, age, and level of education, along with honor codes and other contextual factors, on academic integrity. A total of 2,050 surveys were mailed to a random selection of the schools with dental hygiene degree programs in each of the twelve American Dental Hygienists' Association (ADHA) districts. A total of 794 usable surveys were returned for an overall response rate of 39 percent. The respondents were predominantly twenty to twenty-nine years of age (85 percent), and 97.7 percent were female. The largest percentage of respondents (38.5 percent) had completed four or more years of undergraduate education at the time of the survey, with the majority of the coursework taken in a community college setting (39 percent). Approximately 53 percent were from associate programs and 47 percent from baccalaureate programs. Of those responding, 11.3 percent reported cheating during their dental hygiene program, and 30.2 percent were aware of someone cheating in their program. A comparison of academic violations for dental hygiene students to students in other undergraduate programs reveals that a smaller proportion of dental hygiene students report violations.

Serial susceptibility weighted MRI measures brain iron and microbleeds in dementia.

A new iron sensitive MR sequence (susceptibility weighted imaging - SWI) enabling the simultaneous quantitation of regional brain iron levels and brain microbleeds (BMB) has been acquired serially to study dementia. Cohorts of mildly cognitively impaired (MCI) elderly (n = 73) and cognitively normal participants (n = 33) have been serially evaluated for up to 50 months. SWI phase values (putative iron levels) in 14 brain regions were measured and the number of BMB were counted for each SWI study. SWI phase values showed a left putaminal mean increase of iron (decrease of phase values) over the study duration in 27 participants who progressed to dementia compared to Normals (p = 0.035) and stable MCI (p = 0.01). BMB were detected in 9 out of 26 (38%) MCI participants who progressed to dementia and are a significant risk factor for cognitive failure in MCI participants [risk ratio = 2.06 (95% confidence interval 1.37-3.12)]. SWI is useful to measure regional iron changes and presence of BMB, both of which may be important MR-based biomarkers for neurodegenerative diseases.

Efficacy of a self-study programme to teach spiritual care.

AIM AND OBJECTIVES: This study investigated the efficacy of a self study programme designed to teach nurses about how to talk with patients about spirituality, and to identify factors predicting this learning. Furthermore, the study investigated whether there were differences in learning between students and practicing clinicians, and between those in a religious or non-religious institution. BACKGROUND: Although USA and UK accrediting bodies mandate nurses learn how to assess and support patient spiritual health, there is a paucity of evidence to guide educators regarding how to teach spiritual care to nurses. Indeed, it is unknown if aspects of spiritual care can be taught using formal approaches. DESIGN: A pretest-posttest pre-experimental design was used to study how attitude toward spiritual care, ability to create empathic verbal responses to expressed spiritual pain, personal spiritual experience, and knowledge about communication for spiritual caregiving changed from before to after programme completion. METHODS: Study participants, 201 nursing students and RNs, independently completed the mailed self-study programme (i.e. workbook with supplemental DVD) and self-report study instruments (i.e. Daily Spiritual Experience Scale, Spiritual Care Perspective Scale-Revised, Response Empathy Scale, Communicating for Spiritual Care Test, and Information about You form). RESULTS: Significant differences were seen between the before and after scores measuring attitude, ability, spiritual experience, and knowledge. An interaction effect of time between students and registered nurses for both spiritual care attitude and personal spiritual experience was observed. CONCLUSIONS: Findings suggest learning occurred for both students and RNs, regardless of whether they were at a religious institution or not. Relevance to clinical practice. These data indicate that this self-study programme was an effective approach to teach nurses about how to converse with patients about spirituality.

Longitudinal metabolic and cognitive changes in mild cognitive impairment patients.

Advancements in clinical therapies have identified the need for biomarkers of early Alzheimer disease that distinguish the earliest stages of pathology and target those patients who are likely to gain the most benefit. The aim of this study was to characterize the longitudinal metabolic changes measured by 1H magnetic resonance spectroscopy in correlation to neuropsychologic indices of episodic memory, attention and mental processing speed, language facility, and executive function in subjects with mild cognitive impairment (MCI). Quantitative 1H magnetic resonance spectroscopy of the posterior cingulate gyrus was performed and repeated at 11.56+/-4.3 months. N-acetyl aspartate (NAA), total choline (Cho), total creatine (Cr), myo-inositol (mI), and glutamate/glutamine (Glx) metabolite levels were measured, corrected for cerebrospinal fluid dilution, and ratios calculated in MCI and cognitively normal subjects. In the first study, MCI subjects showed lower NAA levels, NAA/Cho, and NAA/mI ratios and increased Cho/Cr and mI/Cr compared with controls. In the follow-up study, 36% of the MCI subjects [atypical MCI (atMCI)] showed interval increases in NAA, Cr, and Glx levels compared with 64% of MCI subjects (typical MCI) who showed an interval decrease in NAA, Cr, and Glx. Both MCI subgroups had higher Clinical Dementia Rating scores and lower scores on episodic memory, phonemic, and semantic word fluency tasks, compared with controls. The annualized rate of change in metabolic and cognitive status did not differ between normal aging and MCI subjects. atMCI subjects showed significant negative correlations between metabolite levels and executive function task scores, with NAA/mI showing a significant positive correlation with phonemic and semantic word fluency. There were no significant correlations between metabolite levels and cognitive performance in tMCI subjects; however, NAA/mI and mI/Cr were negatively correlated with executive function tasks. These results indicate 2 distinct evolving metabolite profiles that correlate with changes in executive function and can be used to differentiate MCI from normal aging.

Variability in pediatric brain death determination and documentation in southern California.

OBJECTIVES: Because the concept of brain death is difficult to define and to apply, we hypothesized that significant variability exists in pediatric brain death determination and documentation. METHODS: Children (0-18 years of age) for whom death was determined with neurologic criteria between January 2000 and December 2004, in southern California, were included. Medical charts were reviewed for documented performance of 14 specific elements derived from the 1987 brain death guidelines and confirmatory testing. RESULTS: A total of 51.2% of children (142 of 277 children) referred to OneLegacy became organ donors. Care locations varied, including PICUs (68%), adult ICUs (29%), and other (3%). One patient was <7 days, 6 were 7 days to 2 months, 22 were 2 months to 1 year, and 113 were >1 year of age. The number of brain death examinations performed was 0 (4 patients), 2 (122 patients), 3 (14 patients), or 4 (2 patients). Recommended intervals between examinations were followed for 18% of patients >1 year of age and for no younger patients. A mean of only 5.5 of 14 examination elements were completed by neurologists and pediatric intensivists and 5.8 by neurosurgeons. No apnea testing was recorded in 60% of cases, and inadequate PaCO(2) increase occurred in more than one half. Cerebral blood flow determination was performed as a confirmatory test 74% of the time (83 of 112 cases), compared with 26% (29 of 112 cases) for electroencephalography alone. CONCLUSIONS: Children suffering brain death are cared for in various locations by a diverse group of specialists. Clinical practice varies greatly from established guidelines, and documentation is incomplete for most patients. Physicians rely on cerebral blood flow measurements more than electroencephalography for confirmatory testing. Codifying clinical and testing criteria into a checklist could lend uniformity and enhance the quality and rigor of this crucial determination.

Exposure to environmental tobacco smoke in the nonsmoking population of Cambodia.

OBJECTIVE: To estimate the extent of environmental tobacco smoke (ETS) exposure among nonsmokers in the adult population of Cambodia. METHODS: A cross-sectional survey was conducted on a nationally representative sample of 13,988 Cambodian adults in 2005. Information on smoking and exposure to ETS was obtained by trained interviewers using a standard questionnaire. RESULTS: Overall, 37.4% of the 10,263 nonsmoking responders, or an estimated 1,629,700 nonsmoking Cambodians, were exposed to ETS. One third of pregnant women (31.4%) were exposed to ETS at home. In both unadjusted and adjusted models, men were less likely to be exposed to ETS at home (OR=0.34; 95% CI=0.29-0.41) and more likely to be exposed to ETS at work and in public places (OR=3.08; 95% CI=2.14-4.43 and OR=2.17; 95% CI=1.82-2.59, respectively). Education was inversely related to ETS exposure at home (OR=0.51; 95% CI=0.27-0.96 for 10 years of education vs 5 years or less). Legislators, senior officials, and managers were less likely to be exposed to ETS at home than professionals (OR=0.13; 95% CI=0.04-0.46), but more likely to be exposed at work or in public places. Rural residence was associated with higher ETS exposure in the home (OR=2.52; 95% CI=1.71-3.71) and lower ETS exposure at work (OR=0.42; 95% CI=0.24-0.76) compared to urban residence. CONCLUSIONS: The high prevalence of ETS exposure among adult Cambodians indicates an urgent need for specific measures such as public awareness campaigns, policies, and regulations to protect nonsmokers in Cambodia.

Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: a systematic review.

STATEMENT OF PROBLEM: Dentists and patients are regularly confronted by a difficult treatment question: should a tooth be saved through root canal treatment and restoration (RCT), be extracted without any tooth replacement, be replaced with a fixed partial denture (FPD) or an implant-supported single crown (ISC)? PURPOSE: The purpose of this systematic review was to compare the outcomes, benefits, and harms of endodontic care and restoration compared to extraction and placement of ISCs, FPDs, or extraction without tooth replacement. MATERIAL AND METHODS: Searches performed in MEDLINE, Cochrane, and EMBASE databases were enriched by hand searches, citation mining, and expert recommendation. Evidence tables were developed following quality and inclusion criteria assessment. Pooled and weighted mean success and survival rates, with associated confidence intervals, were calculated for single implant crowns, fixed partial dentures, and initial nonsurgical root canal treatments. Data related to extraction without tooth replacement and psychosocial outcomes were evaluated by a narrative review due to literature limitations. RESULTS: The 143 selected studies varied considerably in design, success definition, assessment methods, operator type, and sample size. Direct comparison of treatment types was extremely rare. Limited psychosocial data revealed the traumatic effect of loss of visible teeth. Economic data were largely absent. Success rates for ISCs were higher than for RCTs and FPDs, respectively; however, success criteria differed greatly among treatment types, rendering direct comparison of success rates futile. Long-term survival rates for ISCs and RCTs were similar and superior to those for FPDs. CONCLUSIONS: Lack of comparative studies with similar outcomes criteria with comparable time intervals limited comparison of these treatments. ISC and RCT treatments resulted in superior long-term survival, compared to FPDs. Limited data suggested that extraction without replacement resulted in inferior psychosocial outcomes compared to alternatives. Long-term, prospective clinical trials with large sample sizes and clearly defined outcomes criteria are needed.

Establishing a baseline phase behavior in magnetic resonance imaging to determine normal vs. abnormal iron content in the brain.

PURPOSE: To establish a baseline of phase differences between tissues in a number of regions of the human brain as a means of detecting iron abnormalities using magnetic resonance imaging (MRI). MATERIALS AND METHODS: A fully flow-compensated, three-dimensional (3D), high-resolution, gradient-echo (GRE) susceptibility-weighted imaging (SWI) sequence was used to collect magnitude and phase data at 1.5 T. The phase images were high-pass-filtered and processed region by region with hand-drawn areas. The regions evaluated included the motor cortex (MC), putamen (PUT), globus pallidus (GP), caudate nucleus (CN), substantia nigra (SN), and red nucleus (RN). A total of 75 subjects, ranging in age from 55 to 89 years, were analyzed. RESULTS: The phase was found to have a Gaussian-like distribution with a standard deviation (SD) of 0.046 radians on a pixel-by-pixel basis. Most regions of interest (ROIs) contained at least 100 pixels, giving a standard error of the mean (SEM) of 0.0046 radians or less. In the MC, phase differences were found to be roughly 0.273 radians between CSF and gray matter (GM), and 0.083 radians between CSF and white matter (WM). The difference between CSF and the GP was 0.201 radians, and between CSF and the CN (head) it was 0.213 radians. For CSF and the PUT (the lower outer part) the difference was 0.449 radians, and between CSF and the RN (third slice vascularized region) it was 0.353 radians. Finally, the phase difference between CSF and SN was 0.345 radians. CONCLUSION: The Gaussian-like distributions in phase make it possible to predict deviations from normal phase behavior for tissues in the brain. Using phase as an iron marker may be useful for studying absorption of iron in diseases such as Parkinson's, Huntington's, neurodegeneration with brain iron accumulation (NBIA), Alzheimer's, and multiple sclerosis (MS), and other iron-related diseases. The phases quoted here will serve as a baseline for future studies that look for changes in iron content.

Increased intraabdominal pressure in abdominoplasty: delineation of risk factors.

BACKGROUND: Abdominoplasty is associated with a 1.1 percent risk of deep venous thrombosis. This has been attributed to rectus plication causing intraabdominal hypertension, known to effect decreased venous return, venous stasis, and thus thrombosis. The authors conducted a pilot study to determine which components of the abdominoplasty procedure (i.e., general anesthesia, flexion of the bed, plication, and/or binder placement) may elevate intraabdominal pressures and whether this was clinically relevant. METHODS: Twelve abdominoplasty and 10 breast reduction (control) patients were enrolled prospectively. Intraabdominal pressure was transduced through the bladder before plication in the supine and flexed positions, after plication in both positions, after skin closure in the flexed position, and on postoperative day 1 with and without a binder in the flexed position. RESULTS: All intraabdominal pressures measured were clinically insignificant (<20 mm Hg). A statistically significant increase was found from flexion of the bed (mean difference, 3.80 +/- 2.0, p < 0.001, in the control group; and 4.39 +/- 1.68, p < 0.001, in the study group); rectus plication (mean difference, 2.78 +/- 2.11, p = 0.001, in the supine position; and 2.03 +/- 2.48, p = 0.016, in the flexed position); and binder placement (2.63 mm Hg for no binder versus 4.5 mm Hg with binder, p = 0.004). Both groups also showed an increase from preoperative to skin closure (mean difference, 2.03 +/- 6.7, p = 0.035, for the control group; and 2.83 +/- 3.97, p = 0.031, for the study group), suggesting general anesthesia as a risk factor. CONCLUSIONS: This study confirms the effect of rectus plication on increasing intraabdominal pressures but also implicates bed position, binder placement, and general anesthetic as risk factors. A larger study is needed to clarify the role of these variables in elevating intraabdominal pressure during abdominoplasty.

Preliminary demonstration of an allelic association of the IREB2 gene with Alzheimer's disease.

The role of iron metabolism in Alzheimer's disease (AD) is well documented. Regulation of the proteins that maintain cellular iron metabolism is mediated by two cytoplasmic RNA-binding proteins, the Iron Regulatory Proteins (IRP1 and IRP2), that function through post-transcriptional interactions with RNA stem loop structures called iron-responsive elements. As the primary mediator of iron homeostasis in neuronal cells, IRP2 is a strong candidate for polymorphisms that could impact AD pathogenesis. Thus, we performed a pilot study to assess polymorphisms in the gene encoding IRP2 (IREB2) on clinically well-characterized, post-mortem samples (50 AD and 50 controls). DNA sequence analysis of the IREB2 gene region revealed 14 polymorphisms. Two (rs2656070 and rs13180) showed statistically significant skewing of allelic and genotypic distributions between AD patients and controls. In silico analyses revealed that rs2656070 lies within a probable promoter and disrupts the binding sites of at least two known transcription factors. Though silent and likely not functionally relevant, rs13180 is in complete LD with rs2656070 (D' > 0.999), creating an IREB2-haplotype that is significantly associated with AD. Confirmation of this association in a larger cohort of cases and controls would further support the role of iron regulation in the pathogenesis of this catastrophic and increasingly common neurodegenerative disorder.

The association between fatal coronary heart disease and ambient particulate air pollution: Are females at greater risk?

The purpose of this study was to assess the effect of long-term ambient particulate matter (PM) on risk of fatal coronary heart disease (CHD). A cohort of 3,239 nonsmoking, non-Hispanic white adults was followed for 22 years. Monthly concentrations of ambient air pollutants were obtained from monitoring stations [PM < 10 microm in aerodynamic diameter (PM10), ozone, sulfur dioxide, nitrogen dioxide] or airport visibility data [PM < 2.5 microm in aerodynamic diameter (PM2.5)] and interpolated to ZIP code centroids of work and residence locations. All participants had completed a detailed lifestyle questionnaire at baseline (1976), and follow-up information on environmental tobacco smoke and other personal sources of air pollution were available from four subsequent questionnaires from 1977 through 2000. Persons with prevalent CHD, stroke, or diabetes at baseline (1976) were excluded, and analyses were controlled for a number of potential confounders, including lifestyle. In females, the relative risk (RR) for fatal CHD with each 10-microg/m3 increase in PM2.5 was 1.42 [95% confidence interval (CI), 1.06-1.90] in the single-pollutant model and 2.00 (95% CI, 1.51-2.64) in the two-pollutant model with O3. Corresponding RRs for a 10-microg/m3 increase in PM(10-2.5) and PM10 were 1.62 and 1.45, respectively, in all females and 1.85 and 1.52 in postmenopausal females. No associations were found in males. A positive association with fatal CHD was found with all three PM fractions in females but not in males. The risk estimates were strengthened when adjusting for gaseous pollutants, especially O3, and were highest for PM2.5. These findings could have great implications for policy regulations.

The Gail model predicts breast cancer in women with suspicious radiographic lesions.

BACKGROUND: We sought to evaluate whether a woman's 5-year Gail risk adds to the predictive value of the Breast Imaging Reporting and Data System (BI-RADS) classification for the detection of breast cancer. METHODS: We performed a retrospective review of the BI-RADS classifications and pathology results for all image-guided needle breast biopsy examinations over a 3-year period at our institution. The 5-year Gail risk was calculated for eligible patients. Chi-square analysis was used to compare rates of malignancy based on Gail and BI-RADS scores. RESULTS: A total of 632 image-guided needle biopsy examinations were performed in 609 women. A total of 414 women had suspicious (BI-RADS 4) lesions and underwent 424 biopsy examinations. For this subset, women with a Gail risk of less than 1.7% had 21% malignant results, whereas those with a Gail risk of 1.7% or greater had 42% malignant results (relative risk, 1.94; 95% confidence interval, 1.45-2.66). CONCLUSIONS: The Gail model can stratify further the risk for breast cancer in women with suspicious breast imaging reports.

Quality of life before and after endovascular and retroperitoneal abdominal aortic aneurysm repair.

PURPOSE: This study was undertaken to evaluate changes in quality of life and to compare conventional outcomes in patients undergoing endovascular and open retroperitoneal abdominal aortic aneurysm (AAA) repair. METHODS: Between October 2000 and May 2003, 129 patients underwent elective AAA repair, endovascular repair in 22 patients and open retroperitoneal repair in 107 patients. The Short-Form Health Survey, 12 items (SF-12) was administered preoperatively and at 3 weeks, 4 months, and 1 year after discharge. Quality of life, hospital and intensive care unit stay, perioperative complications, discharge disposition, readmission, and hospital cost were statistically evaluated. RESULTS: For the total group, significant differences were observed for both Physical Component Summary scores (P<.001) and Mental Component Summary scores (P=.001) between time points. There were no significant differences for either Component Summary score between open and endovascular procedures for any time period. Number of weeks required to return to baseline functional status was similar after either open or endovascular repair (7.22 vs 5.47 weeks, respectively; P=.09). Mean hospital and intensive care unit stay was 4.4 and 1 days, respectively, for open repair versus 1.9 and 0 days, respectively, for endovascular repair (P<.0001). No significant difference between groups was observed in terms of perioperative complications, discharge disposition, or hospital readmission (P> or =.54). Mean total hospital cost for endovascular repair was 1.60 times that for open repair (mean difference, $11,662; P<.0001; 95% confidence interval, $17,799-$5525). CONCLUSIONS: Hospital stay is significantly shorter after endovascular AAA repair. However, hospital cost is almost twice that for open retroperitoneal repair. Perioperative complications, discharge disposition, and hospital readmission are not statistically different between the two groups. Effect on health-related quality of life is similar after either open retroperitoneal or endovascular AAA repair.

Duration of residence in the United States as a new risk factor for coronary artery disease (The Konkani Heart Study).

A survey conducted in a relatively homogeneous group of 527 Konkani subjects revealed a high prevalence of coronary artery disease (CAD) despite a lack of smoking and significant obesity. Traditional risk factors (age, gender, high cholesterol, hypertension, and diabetes) were significant predictors of CAD. In addition, duration of residence in the United States (US) emerged as a new independent risk factor. Independent predictors of CAD included age, gender, ever smoking, and duration of residence in the US. We conclude that acculturation may be a major risk factor for CAD in immigrant populations.

A multicenter study of permanent hemodialysis access patency: beneficial effect of clipped vascular anastomotic technique.

OBJECTIVE: There is an urgent and compelling need to reduce the morbidity and expense of maintaining hemodialysis vascular access patency. This large, long-term, retrospective, multicenter study, which compared access patency of autogenous arteriovenous fistulas (AVF) and synthetic bridge grafts (AVG) created with conventional sutures or nonpenetrating clips, was undertaken to resolve conflicting results from previous smaller studies. DESIGN: Patency data for 1385 vascular access anastomoses (clipped or sutured) was obtained from 17 hospitals and dialysis centers (Appendix). Five hundred eighteen AVF (242 clip, 276 suture) and 827 AVG (440 clip, 384 suture) were analyzed. Statistical comparisons were made with Kaplan-Meier survival analysis, log-rank test, two-sample t test, and X(2) test. The Cox proportional hazards model was used to confirm Kaplan-Meier analysis. RESULTS: Access patency (primary, secondary, overall, and intention to treat) was significantly improved in access anastomoses constructed with clips. In the intention-to-treat group, primary patency at 24 months was 0.54 for clipped AVF and 0.34 for sutured AVF, and was 0.36 for clipped AVG and 0.17 for sutured AVG. At 24 months, primary patency rate for AVF successfully used for dialysis was 0.67 for clips and 0.48 for sutures, and for AVG was 0.39 for clips and 0.19 for sutured constructs. Interventions necessary to maintain patency were significantly fewer in clipped anastomoses. CONCLUSION: Replacing conventional suture with clips significantly reduces morbidity associated with maintaining permanent hemodialysis vascular access. This beneficial effect may be due to the biologic superiority of interrupted, nonpenetrating vascular anastomoses.