Association between inhibited binding of folic acid to folate receptor alpha in maternal serum and folate-related birth defects in Norway.

BACKGROUND: Folic acid intake during pregnancy can reduce the risk of neural tube defects (NTDs) and perhaps also oral facial clefts. Maternal autoantibodies to folate receptors can impair folic acid binding. We explored the relationship of these birth defects to inhibition of folic acid binding to folate receptor α (FRα), as well as possible effects of parental demographics or prenatal exposures. METHODS: We conducted a nested case-control study within the Norwegian Mother and Child Cohort Study. The study included mothers of children with an NTD (n = 11), cleft lip with or without cleft palate (CL/P, n= 72), or cleft palate only (CPO, n= 27), and randomly selected mothers of controls (n = 221). The inhibition of folic acid binding to FRα was measured in maternal plasma collected around 17 weeks of gestation. On the basis of prior literature, the maternal age, gravidity, education, smoking, periconception folic acid supplement use and milk consumption were considered as potential confounding factors. RESULTS: There was an increased risk of NTDs with increased binding inhibition [adjusted odds ratio (aOR) = 1.4, 95% confidence interval (CI) 1.0-1.8]. There was no increased risk of oral facial clefts from inhibited folic acid binding to FRα (CL/P aOR = 0.7, 95% CI 0.6-1.0; CPO aOR = 1.1, 95% CI 0.8-1.4). No association was seen between smoking, folate supplementation or other cofactors and inhibition of folic acid binding to FRα. CONCLUSIONS: Inhibition of folic acid binding to FRα in maternal plasma collected during pregnancy was associated with increased risk of NTDs but not oral facial clefts.

Major malformations in infants of IDDM women. Vasculopathy and early first-trimester poor glycemic control.

From animal and in vitro studies, it has been suggested that high environmental glucose, ketone, or insulin concentrations and low glucose or insulin concentrations may be etiologic factors for congenital malformations (CMs) in infants of diabetic mothers (IDMs). Transplacental passage of antibody-bound insulin has been demonstrated in humans. Controversy exists regarding the pathophysiology of CMs in human insulin-dependent diabetes mellitus (IDDM) pregnancies. We hypothesized that CMs in IDMs are associated with maternal vasculopathy, poor first-trimester glycemic control (i.e., hyper- and/or hypoglycemia), advanced White class, and high insulin requirements. We studied 165 first pregnancies of women with IDDM from 1978 to 1986. The goals of glucose control were a fasting blood glucose of less than 100 mg/dl and a 90-min postprandial blood glucose of less than 140 mg/dl. Insulin requirements, body weight, and pre- and postprandial blood glucose were recorded at weekly clinic visits. Maternal blood HbA1 was measured on entry and every 4 wk to confirm that adequate glycemic control was achieved. Women who enrolled in the project were interviewed during gestation by a geneticist/dysmorphologist who obtained genetic and environmental histories using a standard questionnaire. All live-born infants and stillbirths were examined. Each live-born infant was assessed systematically by two independent examiners, a neonatologist and a geneticist/dysmorphologist; examination with standardized checklists was performed in the newborn nursery as soon after birth as was practical. In first pregnancies in the study, there were 13 IDMs with major CMs (7.9%).(ABSTRACT TRUNCATED AT 250 WORDS)

Necrotizing tracheobronchitis: case report.

A 33-week-gestation infant with respiratory distress syndrome is reported. At five days of age, acute life-threatening tracheal obstruction occurred, which was relieved after removal of a plug during bronchoscopy. Histologic examination of the plug revealed partially necrotic tracheal mucosa, compatible with the diagnosis of necrotizing tracheobronchitis. At 31 days of age, obstruction recurred due to the development of a tracheal stricture, which resolved after tracheal reintubation (to maintain patency) and corticosteroid therapy. Tracheal stricture may be a long-term complication of necrotizing tracheobronchitis, when the initial episode does not lead to death from obstruction.

Gastric outlet obstruction caused by traumatic pseudoaneurysm of superior mesenteric artery.

Traumatic pseudoaneurysms of the superior mesenteric artery (SMA) are extremely rare. We describe two cases of posttraumatic proximal SMA pseudoaneurysms with symptoms of gastric outlet obstruction. Repair was accomplished by aorta-SMA bypass with saphenous vein. Injuries to the proximal SMA are easily missed at laparotomy, especially if intestinal ischemia or hematomas are absent. Recognition and repair are stressed to avoid the complications associated with pseudoaneurysm formation.

Popliteal-tibial bypass grafts in the management of limb-threatening ischemia.

OBJECTIVES: To ascertain the cumulative rates of primary graft patency and limb salvage and the frequency of proximal arterial disease progression in patients with autologous saphenous vein bypass grafts that originate from the popliteal artery and whose operative indication was limb-threatening ischemia. DESIGN: Five-year retrospective study with follow-up that ranged from less than 1 month to 60 months. SETTING: Tertiary care center. PATIENTS: Twenty-four threatened limbs in 23 patients were reviewed. Surgical indications included gangrene in 15 limbs (63%), rest pain in seven limbs (29%), and a nonhealing ulcer in two limbs (8%). Patients with previous ipsilateral infrainguinal arterial reconstructive procedures were excluded. Mean patient age was 66 years, and 18 patients 78% had insulin-dependent diabetes mellitus. MAIN OUTCOME MEASURES: Percentages of primary graft patency and limb salvage were determined by the life-table method. Proximal arterial disease progression was assessed via follow-up arteriography or segmental limb pressures. RESULTS: The cumulative rates of primary graft patency and limb salvage at 1, 3, and 5 years were 73%, 59% and 59%, and 87%, 57%, and 57%, respectively. No patient developed proximal arterial disease progression that required intervention during the study period. CONCLUSIONS: The cumulative rates of primary graft patency and limb salvage were essentially the same, which indicated poorly collateralized limbs that are solely dependent on the graft. There did not appear to be a critical progression of proximal arterial disease that would warrant a more proximal graft origin. A short autologous saphenous vein graft that originates from the above-knee or below-knee popliteal artery is a durable bypass.

Vascular reconstruction and major resection for malignancy.

HYPOTHESIS: Complications of vascular procedures performed for tumor infiltration of major vessels or for the rescue of complex tumor resections may significantly affect perioperative patient outcome and long-term patient survival rate. DESIGN AND PATIENTS: Retrospective review of 39 patients undergoing major resection for malignancy between April 1980 and April 1998; 35 patients underwent major-vessel reconstruction, 3 patients underwent extra-anatomic bypass, and 1 patient underwent major venous thrombectomy. SETTING: University hospital tertiary referral center. MAIN OUTCOME MEASURES: Vascular complications and patient survival rate. RESULTS: Vascular complications included major stroke (3), carotid artery blowout (2), acute graft thrombosis (1), bowel infarction (1), and anastomotic disruption (1). Factors such as patient demographics, preoperative irradiation, tumor stage, resection for recurrent disease, and vessel or graft type had no bearing on the occurrence of a vascular complication (P>.05 in all cases). Eight patients (21%) died within 30 days of surgery, and 2 (5%) died after 30 days but before hospital discharge. Five of these deaths were directly related to vascular problems (P<.001). Cumulative patient survival rate was 44%, 26%, and 10% at 1, 3, and 5 years, respectively. CONCLUSIONS: The long-term patient survival rate is poor when resections for carcinoma are associated with maj or-vessel infiltration or a complication that necessitates an emergent vascular procedure. In this setting, in-hospital mortality is negatively affected by the incidence of a major vascular complication.

Cost-effective evaluation and treatment for carotid disease.

OBJECTIVE: To compare carotid endarterectomy (CEA) based solely on Duplex ultrasonography (DU) with CEA based on DU and arteriography. DESIGN AND SETTING: Retrospective case series analysis in a regional tertiary care center. PATIENTS: Consecutive sample of 194 patients undergoing 218 CEAs from January 1, 1993, through June 30, 1995, with either preoperative DU plus arteriography (165 CEAs) or DU only (53 CEAs). MAIN OUTCOME MEASURES: Concordance of the 2 diagnostic imaging techniques and influence of these on the conduct of surgery, surgical outcome, and resource cost. RESULTS: There was agreement (kappa = 0.85) between DU and arteriography in the detection of a carotid occlusion or a stenosis greater than 45%. Arteriography demonstrated 26 aortic arch branch lesions (15.8%), 22 intracranial abnormalities (13.3%), and 6 type C ulcers (3.6%), in addition to 1 nonoccluded internal carotid artery (ICA) (0.61%) and 1 contralateral severe ICA stenosis (0.61%) inaccurately estimated by Duplex. These findings prompted 3 changes (1.8%) in surgical therapy, including 2 decisions in favor of CEA and 1 subclavian-carotid bypass added to CEA. There was no difference in the stroke and death rate for CEA based solely on DU compared with CEA based on DU and arteriography (P = .43). The mean total hospital cost was $5,534 for DU only CEA vs $7,608 for DU plus arteriogram CEA (mean difference = $2,074, P < .01). CONCLUSIONS: The addition of carotid arteriography to a diagnostic Duplex ultrasound study that already suggested the need for CEA did not change the operative plan in 98% (162/165) of the cases. Carotid endarterectomy based solely on DU is appropriate and cost-effective.

Cervical-to-petrous internal carotid artery bypass procedure. Technical note.

The technique for cervical-to-petrous internal carotid artery saphenous vein bypass is described. This procedure was used in the treatment of three patients with high cervical or skull base vascular injuries. All grafts were patent on follow-up angiography.

The diagnostic accuracy of duplex ultrasonography for evaluating carotid bifurcation.

BACKGROUND: In many medical centers the standard preoperative study for patients undergoing carotid endarterectomy is four-vessel carotid arteriography, but duplex scanning of the carotid bifurcation is also reported to be highly accurate for detecting stenotic or occluded carotid arteries. METHODS: The diagnostic accuracy of duplex ultrasonography was evaluated in a study of 774 carotid bifurcations, in 400 patients comparing the degree of predicted internal carotid artery (ICA) stenosis found using that technique, with that found by contrast arteriography. Agreement between the predicted degree of ICA stenosis and the arteriographic measurement was evaluated using the Spearman rank order correlation. Accuracy statistics for duplex scanning as a diagnostic modality were assessed using 2 x 2 tables. RESULTS: The Spearman rank order correlation coefficient was 0.74 (P = 0) for the symptomatic group, 0.65 (P = 0) for the asymptomatic group, and 0.68 (P = 0) for the total group. The accuracy of duplex ultrasonography for detecting all grades of ICA stenosis ranged from 80% to 97%. CONCLUSIONS: Duplex ultrasonography of the carotid bifurcation is a reliable diagnostic tool and can be used as the sole preoperative study for selected patients with extracranial cerebrovascular disease. Our current algorithm is discussed in conjunction with a critical analysis of this large database.

Major complications of angioaccess surgery.

Angioaccess procedures at one institution over a 4-year period were retrospectively reviewed to ascertain the frequency of major limb- or life-threatening complications. A total of 435 angioaccess procedures were performed, including 81 Cimino-Brescia fistulas, 166 polytetrafluoroethylene grafts, and 111 thrombectomy/revisions. There were 77 operations for major complications in 53 patients. In addition, five patients required major vascular repair or emergency thoracotomy for complications of central hemodialysis line placement. A significant portion (18% of this series) of the total angioaccess caseload of a vascular surgeon will be utilized in the repair of major complications. The in-hospital (6 patients, or 11%) and long-term (12 patients, or 23%) mortality rates are significant. Although most complications can be repaired without limb loss and with shunt salvage, a small percentage (in our study three patients, or 4%) will have debilitating long-term symptoms.

Management of small artery vascular trauma.

This 11-year retrospective study reviewed 99 arterial injuries distal to the brachial bifurcation or popliteal trifurcation in 89 extremities in 88 patients. Associated injuries occurred in 78 of 88 (89%) patients, including 10 fractures or dislocations, 66 nerve injuries, and 59 single or multiple tendon injuries. Fasciotomy was performed in 9 upper extremities and 11 lower extremities (23% of patients). The selection of operative treatment by arterial repair or ligation was by surgeon choice (52% repair and 48% ligation). Postoperative patency was found in 45 of 47 (96%) repaired arteries. In cases of isolated single arterial injuries (10), there were excellent results, and there was no difference in the results between repair and ligation. In cases of nonisolated single arterial injuries (69), there were 46% and 36% nonvascular complications in the repaired and ligated groups, respectively. In 10 patients with nonisolated multiple arterial injuries in the same extremity, the results of repair of one artery with ligation of the other artery versus repair of both arteries were identical, and there were no vascular complications. Operative exploration was the key to complete evaluation of vascular and neuro/musculoskeletal injuries. The data suggest that one functional artery distal to the elbow or knee is sufficient for limb viability and vascular function (follow-up range: 0 to 110 months; mean: 12 months). Nerve injury was the single most important factor of extremity injury in terms of the degree of functional loss.

Autologous saphenous vein popliteal-tibial artery bypass for limb-threatening ischemia: a reassessment.

BACKGROUND: The purpose of this review was to ascertain the cumulative primary and secondary graft patency rates, the cumulative limb salvage rate, and the frequency of atherosclerotic disease progression proximal to the graft origin, in patients with autologous saphenous vein popliteal-tibial artery bypass grafts whose operative indication was limb-threatening ischemia. PATIENTS AND METHODS: Forty-three short autologous saphenous vein grafts originating from the popliteal artery were retrospectively reviewed. The life-table method was used to determine primary and secondary graft patency and limb salvage rates. Atherosclerotic disease progression proximal to the graft origin was assessed via follow-up arteriography, segmental limb pressures, or pulse-volume recordings. All other data were compared by chi-square analysis. RESULTS: The cumulative primary graft patency rate at 1, 3, and 5 years (86%, 66%, 58%) was similar to the cumulative secondary patency rate (90%, 70%, 62%) and the cumulative limb salvage rate (80%, 55%, 55%). No patient developed hemo-dynamically significant atherosclerotic disease proximal to the graft origin during the follow-up period. CONCLUSIONS: The similarity of the life-table data suggests graft-dependent, poorly collateralized limbs; it is therefore not uncommon for these patients to require major amputations shortly after bypass failure. There was no evidence of critical proximal disease progression that might warrant a more proximal graft origin. Poplitealtibial artery bypass grafts are durable, with acceptable graft patency and limb salvage rates.

Extracorporeal techniques in thoracoabdominal aortic surgery.

Most complications related to thoracoabdominal aortic reconstruction stem from ischemia-induced injury to the viscera, kidneys, and spinal cord. In addition to adjunctive methods designed to minimize metabolic demands of the spinal cord during aortic cross-clamping, a variety of extracorporeal techniques have been developed that provide supplemental blood flow to vital end organs during the period of clamp-induced ischemia. These techniques represent a broad range of design complexities and command significant operator expertise to optimize their benefit. This section briefly describes commonly used extracorporeal circulation methods in thoracoabdominal aortic surgery.

Cervicothoracic vascular injuries.

Arterial and venous trauma of the cervicothoracic region continues to present challenging problems for the surgeon, despite advances in vascular diagnostics and surgical technique. Whether due to penetrating or blunt mechanisms, overall incidence of these injuries is low, whereas morbidity and mortality remain high. Despite collective experience from busy trauma centers, there still remain controversies regarding diagnostic evaluation, operative approach, and surgical treatment of these potentially devastating injuries. Therefore, this article compares and contrasts recent literature and controversies surrounding the treatment of cervicothoracic trauma. Pros and cons of duplex ultrasonography and angiography in the diagnosis of carotid and vertebral artery injury are highlighted, and selective versus mandatory neck exploration for zone II penetrating injuries are discussed. Increasing awareness of blunt carotid artery injury is emphasized, including management dilemmas that frequently accompany this type of injury. In addition, we review interventional radiological techniques for the management of vertebral artery injury and surgical approaches for aortic arch branch vessel or major cervicothoracic vein injury.

Management of sterile para-anastomotic aneurysms of the aorta.

The history of surgical reconstruction of the aorta for aneurysmal and occlusive disease now spans over 50 years. The continued performance of these operations with minor modifications attests to their durability and efficacy. Despite this, some late complications do occur. One such complication is the development of a sterile para-anastomotic aneurysm. This has been reported in 1% to 4% of patients; however, the true incidence of para-anastomotic aneurysms of the aorta (PAAA) may be closer to 25% as evidenced by studies with standardized long-term surveillance. PAAA include true and false aneurysms, which occur in the absence of infection. Computed tomography (CT), magnetic resonance imaging (MRI), and labeled white blood cell scans are vital in excluding the presence of infection and differentiating PAAA from infected false aneurysm, aortic graft infection, and aorto-enteric fistula. The surgical approach to PAAA may require complex reconstruction of the suprarenal or supraceliac aorta similar to thoracoabdominal aortic aneurysm repair. Results of surgery are improved with asymptomatic detection and elective repair of PAAA. Methods of prevention rely mainly on technical perfection, but even with this PAAA likely will never be eliminated. This review will cover the incidence, pathophysiology, presentation, diagnosis and operative treatment of sterile para-anastomotic aneurysms of the aorta. Implications for prevention and the role of surveillance will also be discussed.

Wrist squareness and median nerve impairment.

Previous research indicated that a wrist-squareness ratio (thickness/width) greater than .7 is likely to indicate a median nerve sensory latency greater than 3.7 ms, usually a predictor of carpal tunnel syndrome (CTS). In this study, wrist thicknesses and widths were measured and wrist-squareness ratios were calculated for a sample of 417 railroad maintenance workers. Electrodiagnostic testing, in accordance with American Academy of Electrodiagnostics Medicine guidelines, was performed on both motor and sensory fibers of the median nerve to evaluate subjects for the presence of median nerve impairment typical of CTS. Results of this study indicate that wrist squareness is not a useful predictor of median nerve impairment typical of CTS in the railroad maintenance workers tested.

Carotid endarterectomy and abdominal aoritc aneurysm repair: are these reasonable treatments for patients over age 80?

Due to the aging of America, increased numbers of very elderly patients require peripheral vascular surgery. From April 1980 to November 1997, 191 patients age 80 years or older had carotid endarterectomy (CEA) and/or abdominal aortic aneurysm (AAA) repair at Loma Linda University Medical Center. The total perioperative stroke and death rate in the CEA group was 2.9 per cent. Mean postoperative cumulative survival in this group was 8.4 years. The cumulative stroke-free survival rate was 95.5 per cent for all yearly postoperative intervals up to 12 years. The perioperative mortality rate was 10.7 per cent in the nonruptured AAA group and 53.8 per cent in the ruptured AAA group (P < 0.00001). Mean cumulative survival was 8.6 years in the nonruptured AAA group and 1.1 years in the ruptured AAA group (P = 0.0001). These data support the conclusion that CEA and nonemergent AAA repair in octo- and nonagenarians are safe and effective in prolonging stroke-free and rupture-free survival. The utility of ruptured AAA repair in this age-group is less clear.

Ureteroinguinal hernia: a rare companion of sliding inguinal hernias.

Ureteroinguinal herniation is a rare occurrence with only 54 reported cases in the English literature. This article reviews the literature and reports on a case that typifies the problems posed by ureteroinguinal herniation. General surgeons should be aware of the potential of this condition so that they can prevent ligation or severance of the involved ureter.

A critical analysis of adjuvant techniques used to assess bowel viability in acute mesenteric ischemia.

Delayed revascularization and inaccurate assessment of bowel viability in acute mesenteric ischemia can be catastrophic. We reviewed the outcome of three popular adjuvant techniques used to evaluate bowel viability in all 16 patients who had second-look abdominal explorations following revascularization for acute mesenteric ischemia from 1984 to 1989. Each adjuvant technique was reviewed separately and compared with the unequivocal end points of viable or nonviable bowel. The sensitivity (percentage of nonviable bowel correctly identified), specificity (percentage of viable bowel identified), predictive value (percentage of bowel identified as "nonviable" that proved to be so), and overall accuracy (percentage of correct evaluations) were determined for each method. The overall accuracy of clinical judgment, fluorescein fluorescence, and Doppler was 50 per cent, 56 per cent, and 0 per cent, respectively. Based on this critical review, we recommend routine second-look explorations in patients with acute mesenteric ischemia to reassess bowel that has been predicted to be viable or to resect bowel that has progressed to infarction.