Outcomes of a Multidisciplinary Vascular Practice: 12-Month Amputation-Free Survival and Beyond in Patients With Chronic Limb-Threatening Ischemia.

OBJECTIVE: There is great variability in the treatment of chronic limb-threatening ischemia, including the practice paradigm, vascular provider specialty, devices utilized, and experience with advanced open and/or endovascular treatments, among other factors. Our unique practice consists of patient-centered, clinically oriented Interventional Radiologists and Vascular Surgeons, with treatments being performed in Office Interventional Suites (OIS), Ambulatory surgery center (ASC), and hospital inpatient/outpatient settings. We evaluate our results, centered on major amputation rates while comparing case complexity and rates with previously published data. METHODS: A retrospective review was performed of all Rutherford 4, 5, and 6 patients who underwent treatment in our practice from 2015 to 2021. Baseline patient characteristics, complexity of lesions, and major amputation rates were collected. Patients with more complex diseases or requiring re-interventions were openly discussed in multidisciplinary fashion to determine the group's approach to revascularization. Limb salvage, clinically driven target lesion revascularization (TLR), repeat interventions, length of follow-up, and mortality were assessed. RESULTS: Treatment was performed in 829 limbs in 351 females and 478 males, with chronic limb-threatening ischemia. Of the 829 cases, 541 cases had at least 1 chronic total occlusion (CTO), including 115 limbs with 2 CTOs and 24 limbs with 3 CTOs with 63.5% of cases requiring multilevel intervention. One year mortality rate was 6.2% with a major lower extremity amputation rate of 2.3% with a mean length of follow-up of 22.3 months. One-year freedom from clinically driven TLR rate was 78.7% with repeat intervention in 163 cases within 12 months. Over the course of the study, within the femoropopliteal stent subset, there was a significant increase in time to reintervention when newer stent technologies were utilized such as woven nitinol and drug-eluting technology (p=0.03). The overall 1-year amputation-free survival (AFS) was 91.5. CONCLUSIONS: Multidisciplinary approach with surgical and endovascular treatment may provide patients with the best chance of AFS. CLINICAL IMPACT: Real world practice of critical limb-threatening ischemia in a multidisciplinary practice demonstrates favorable outcomes for patients with the best reported one year major amputation free survival in a population this large. A strong clinical practice based on close routine follow up and arterial duplex monitoring is a major contributing factor, as well as utilization of the latest technology in drug eluting stents and drug coated balloons for best patient outcomes. We hope this study provides other practices with a guideline for establishing or modifying their practice to attain the best procedural and clinical outcomes.

Repeatability of anogenital distance measurements from birth to maturity and at different physiological states in female Holstein cattle.

The inverse association between anogenital distance (AGD; the distance from the center of the anus to the base of the clitoris) and fertility, its moderate heritability, and high variability reported in dairy cattle make AGD a promising candidate for further exploration as a reproductive phenotype. In addition to heritability, repeatability (i.e., consistency in measurements taken at different time points) is important for a reproductive phenotype to be considered useful in genetic selection. Therefore, our primary objective was to determine the repeatability of AGD from birth to breeding age (≈16 mo) in Holstein heifer calves, and during different stages of the estrous cycle, gestation, and lactation in Holstein cows. We also determined the associations among AGD, height (at the hip), and body weight (BW) at birth. In calves (n = 48), we recorded BW (kg) and height (cm) at birth and measured AGD (mm) at approximately 0, 2, 6, 9, 12, and 16 mo of age. In cows, AGD was measured at different stages of the estrous cycle (proestrus, estrus, metestrus and diestrus; n = 20), gestation (30, 90, 180, and 270 d; n = 78), and lactation (30-300 d in milk in 30-d increments; n = 30). Calf height and BW at birth had a weak positive association with AGD at birth. The AGD increased linearly from birth to breeding age, but there was no association between the AGD at birth and at breeding age in heifers. Although any 2 consecutive AGD measurements were correlated, 6 mo was the earliest age at which AGD was moderately correlated (r = 0.41) with that of breeding-age heifers. The AGD was neither influenced by the different stages of estrous cycle nor lactation and remained highly repeatable (r ≥ 0.95). Although AGD measurements at 30, 90, and 180 d of gestation (126.9, 126.7, and 127.7 mm, respectively) were strongly correlated (r ≥ 0.97) with each other, AGD at 270 d of gestation (142.8 mm) differed from AGD at all earlier stages of gestation. In summary, AGD measured at birth did not reflect AGD at breeding age in heifers, but AGD measurements in cows had high repeatability at all stages of the estrous cycle, gestation, and lactation, except at 270 d of gestation. Therefore, AGD could be measured reliably at any of the aforesaid physiological states in cows due to its high repeatability, except during late gestation. The earliest gestational stage when pregnancy-associated increase in AGD occurred, however, could not be definitively established in the present study.

Associations between anogenital distance and measures of fertility in lactating North American Holstein cows: A validation study.

Anogenital distance (AGD) has been defined in dairy cows as the distance from the center of the anus to the base of the clitoris. Initial reports on nulliparous Holstein heifers and first- and second-parity Holstein cows have found inverse relationships between AGD and measures of fertility. Our primary objective was to determine the relationship between AGD and measures of fertility in a larger population of North American Holstein cows to validate our previous finding that AGD is inversely related to fertility. Secondary objectives were to determine the associations between AGD and parity, and milk yield. Using digital calipers, we measured AGD in 4,709 Holstein cows [mean ± standard deviation (SD); parity 2.3 ± 1.4; days in milk (DIM) 154 ± 94; 305-d mature equivalent (ME) milk yield 13,759 ± 2,188 kg] from 18 herds in Western Canada and 1 herd in the USA. Anogenital distance (mm) was normally distributed with a mean (±SD) of 132 ± 12, ranging from 95 to 177, and a median of 133. Anogenital distance was linearly but inversely associated with pregnancy to first artificial insemination (P/AI1). For every 1-mm increase in AGD, the estimated probability of P/AI1 decreased by 0.8%. The optimum AGD cut-point that predicted probability of P/AI1 with sensitivity and specificity of 45 and 55%, respectively, was 129 mm. Consequently, data were categorized into either short (≤129) or long (>129) AGD groups across parities, and associations between AGD, parity (first, second, and third+), and fertility measures were determined. Rates of P/AI1 were greater (36 vs. 30%) in short- than in long-AGD cows; short-AGD cows required fewer AI per conception (2.3 vs. 2.4) and had fewer days open (137 vs. 142), and a greater proportion of short-AGD cows (67 vs. 64%) was pregnant by 150 DIM compared with long-AGD cows. The rates of pregnancy up to 150 (hazard ratio of 0.91) and 250 DIM (hazard ratio of 0.93) were smaller in long- than in short-AGD cows. Anogenital distance had a weak positive association with both parity (r = 0.22) and 305-d ME milk yield (r = 0.04). Results indicate an inverse relationship between AGD and measures of fertility in lactating cows, validating our earlier report. We infer that although selecting cows for short AGD is expected to have an adverse effect on milk yield, the anticipated gain in fertility will outweigh the small decline in milk yield, strengthening the potential of AGD as a novel reproductive phenotype for use in future breeding programs to improve fertility.

Relationship of anogenital distance with fertility in nulliparous Holstein heifers.

Anogenital distance (AGD), defined as the distance from the center of the anus to the base of the clitoris, in lactating dairy cows of first and second parity, has been reported to be inversely related to fertility and moderately heritable. Thus, AGD may be a useful reproductive phenotype for future genetic selection to improve fertility. The objectives of this study were to (1) characterize AGD in nulliparous dairy heifers; and (2) determine if the inverse relationship between AGD and fertility, found in lactating dairy cows, is also evident in nulliparous heifers. We measured AGD in 1,692 Holstein heifers from 16 herds in Western Canada (Alberta and British Columbia) and one herd in the United States (Washington State). Data were analyzed using MEANS, UNIVARIATE, LOGISTIC, ROC, GLIMMIX, and LIFETEST procedures of SAS (SAS Institute Inc.). Mean (±standard deviation) age at AGD measurement was 13.9 ± 1.5 mo, and AGD was normally distributed with a mean of 107.3 ± 10.5 mm, ranging from 69 to 142 mm. With every 1-mm increase in AGD, the predicted probability of pregnancy was reduced by 1.9%. Receiver operating characteristic curve analysis was used to determine the optimum threshold AGD that predicted the probability of pregnancy. Based on the optimum threshold AGD, data from heifers were categorized into short (≤110 mm) and long (>110 mm) AGD groups, and associations between AGD groups and fertility measures were determined. Heifers with short AGD required fewer services per conception (1.5 vs. 1.7) than heifers with long AGD. Consequently, heifers with short AGD conceived earlier (448.4 vs. 454.3 d) and had greater pregnancy to first AI than those with long AGD (58.3 vs. 49.6%). Moreover, heifers with long AGD had reduced hazard (hazard ratio of 0.59) for pregnancy up to 450 d of life compared with those with short AGD. In summary, AGD was normally distributed and highly variable in the population. In addition, an inverse relationship between AGD and fertility measures in nulliparous heifers was evident, confirming an earlier report of a similar relationship in lactating dairy cows. These findings strengthen the potential for AGD to be used as a fertility trait and management tool in future selection programs.

Functional and metabolic effects of omega-3 polyunsaturated fatty acid supplementation and the role of ß-hydroxy-ß-methylbutyrate addition in chronic obstructive pulmonary disease: A randomized clinical trial.

INTRODUCTION: Short-term (4 weeks) supplementation with n-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) has recently been shown to improve protein metabolism in a dose dependent way in normal weight patients with Chronic Obstructive Pulmonary Disease (COPD). Furthermore, EPA/DHA supplementation was able to increase extremity lean soft tissue but not muscle function. No studies are available combining n-3 PUFAs and the leucine metabolite ß-hydroxy-ß-methylbutyrate (HMB) supplementation in chronic clinical conditions. Whether adding HMB to daily EPA/DHA supplementation for 10 weeks enhances muscle and brain health, daily functional performance, and quality of life of patients with COPD by further improving their protein and amino acid homeostasis remains unknown. METHODS: Patients with COPD (GOLD: II-IV, n = 46) received daily for 10 weeks, according to a randomized double-blind placebo-controlled three-group design, EPA/DHA (n = 16), EPA/DHA to which HMB was added (n = 14), or placebo (n = 16). The daily dose of 2.0 g of EPA/DHA or soy + corn oil as the placebo was provided via gel capsules, and 3.0 g of Ca-HMB or maltodextrin as placebo as powders. At pre- and post-intervention, a pulse mixture of multiple amino acids was administered to measure postabsorptive net protein breakdown (netPB as primary endpoint) and whole body production (WBP) and conversion rates of the amino acids. As secondary endpoints, lean soft tissue and fat mass were assessed by dual-energy X-ray absorptiometry, upper and lower muscle function by handgrip and single leg isokinetic dynamometry, brain (cognitive, wellbeing) health by assessments, daily functional performance by measuring 6-min walk distance, 4-m gait speed, and postural balance, and quality of life by questionnaire. Plasma enrichments and concentrations were analyzed by LC-MS/MS, and systemic inflammatory profile and metabolic hormones by Luminex. RESULTS: HMB + EPA/DHA but not EPA/DHA supplementation increased postabsorptive netPB (p = 0.028), and WBPs of glutamine (p = 0.024), taurine (p = 0.039), and tyrosine (p = 0.036). Both EPA/DHA and HMB + EPA/DHA supplementation resulted in increased WBP of phenylalanine (p < 0.05). EPA/DHA but not HMB + EPA/DHA was able to increase WBP of arginine (p = 0.030), citrulline (p = 0.008), valine (p = 0.038), and conversion of citrulline to arginine (p = 0.009). Whole body and extremity fat mass were reduced after HMB + EPA/DHA supplementation only, whereas lean soft tissue was increased after EPA/DHA (p = 0.049) and HMB + EPA/DHA (p = 0.073). No other significant findings were observed. Reductions in several proinflammatory cytokines were observed in the HMB + EPA/DHA group including IL-2, IL-17, IL-6, IL-12P40, and TNF-ß (p < 0.05). CONCLUSIONS: Ten weeks of supplementation with 2 g of EPA/DHA daily is sufficient to induce muscle gain in COPD but HMB is needed to induce fat loss. Whether HMB is solely responsible for the fat mass loss or has a synergistic effect with EPA/DHA remains unclear. The increase in net protein breakdown observed with HMB + EPA/DHA supplementation may indicate a beneficial enhanced protein turnover cycling associated with increased lean soft tissue. CLINICAL TRIAL REGISTRY: ClinicalTrials.gov; NCT03796455.

Superovulatory response, anti-Müllerian hormone concentration and antral follicle count in Holstein cattle with short or long anogenital distance.

To understand the mechanisms underlying the inverse relationship between anogenital distance (AGD) and fertility in dairy cattle, we determined if embryo yield and quality differed between cattle of short- and long-AGD (Study 1), and whether anti-Müllerian hormone (AMH), antral follicle count (AFC) and superovulation responses differed by AGD group (Study 2). In Study 1, records of embryo yield and quality in Holstein heifers (n = 43) and cows (n = 14) from two commercial dairy herds were analyzed, retrospectively. Short- and long-AGD groups were based on the median AGD cut-points of 113 and 134 mm, for heifers and cows, respectively. The mean numbers of total (7.4 vs. 9.0; 9.4 vs.12.9), fertilized ova (5.6 vs. 6.2; 6.6 vs. 6.9), and viable embryos (4.4 vs. 4.8; 5.9 vs. 5.3) per heifer and cow did not differ between cattle of short vs. long AGD. Short-AGD cows, however, had greater proportions of fertilized ova (69.7 vs. 53.3%; P = 0.07) and viable embryos (62.1 vs. 41.1%; P = 0.03) than long-AGD cows. The odds of short-AGD cows yielding fertilized ova and viable embryos were 2.0 and 4.0 times greater, respectively, than the odds of long-AGD cows. In Study 2, lactating cows (n = 24) of a research herd had their AGD categorized as in Study 1, and AFC, AMH, and superovulation responses (i.e., no. of preovulatory follicles [≥ 10 mm] and CL) were determined. Mean AFC (27 ± 4.5 vs. 21 ± 4.0) and CL (9 ± 1.6 vs. 7 ± 1.4) per cow did not differ between short- and long-AGD groups. Serum AMH concentration (pg/mL) was lesser in short-AGD cows compared with long-AGD cows (114 ± 30.4 vs. 200 ± 26.8; P = 0.05), but the no. of preovulatory follicles was greater (15 ± 1.9 vs. 8 ± 1.7; P = 0.01) in short-AGD than in long-AGD cows. The overall proportion of follicles ≥10 mm was also greater in short-AGD cows than in long-AGD cows (56 vs 44%; P = 0.03). Preovulatory follicle number was affected by a parity x AGD group interaction (P = 0.04), with multiparous short-AGD cows accounting for the largest number of follicles. No associations were found among AGD, AFC and AMH. The associations between AFC and superovulation responses (follicles: r = 0.67, and CL: 0.58; P < 0.01) were moderate but AMH was not associated with superovulation responses. In summary, whereas AGD-associated differences in the yield and quality of embryos were not evident in heifers, the proportions of fertilized ova and viable embryos were greater in short-AGD than in long-AGD cows. In addition, the proportion of preovulatory follicles, an indicator of superovulatory response, was greater in short-AGD cows than in long-AGD cows.

Leveraging the virtual learning environment to enhance medical student engagement with interventional radiology.

PURPOSE: To evaluate medical student engagement with Interventional Radiology (IR) before and after a virtual elective course. METHODS: The elective was nine, one-hour lectures over ten weeks. An anonymous pre and post-course survey was administered to students. The hypothesis was that this course would increase student engagement with IR. Respondents answered nine questions to score their interest in, exposure to, familiarity with, and understanding of IR using a five-point Likert scale. Demographics were reported for the pre-course group only. A Wilcoxon signed-ranked test was performed to assess for significant mean change in pre and post-course responses. Among the 276 registered students, there were 144 individual, complete responses for the pre-course survey, and 60 paired responses for both surveys. RESULTS: Thirty-seven percent of respondents were first or second year medical students. Thirty percent of participants were enrolled at an institution outside of the United States, 26% are the first in their family to attend college, and 41% identified as female. Thirty-six percent reported this virtual course was one of their earliest experiences with IR. There was a significant increase in student exposure to IR generally, familiarity with IR compared to other specialties, familiarity with the IR training pathway(s), understanding of what an Interventional Radiologist does, understanding of the difference between IR and Diagnostic Radiology, and understanding of when to consult IR for patient care after completion of the course. CONCLUSION: A virtual IR elective is an effective means to increase exposure to, familiarity with, and understanding of IR.

Abdominal obesity in COPD is associated with specific metabolic and functional phenotypes.

BACKGROUND: Abdominal obesity (AO) is linked to reduced health status and mortality. While it is known that AO is prevalent in chronic obstructive pulmonary disease (AO-COPD), the specific metabolic and functional consequences associated with AO-COPD remain understudied. METHODS: We studied 199 older adults with COPD and 168 control subjects with and without AO and assessed visceral adipose tissue (VAT) by dual-energy X-ray absorptiometry. VAT > 70th percentile of the control group qualified a subject as AO in a sex specific manner. We measured plasma concentrations and whole body production (WBP) rates of multiple amino acids to assess the metabolic profile. We assessed medical history, body composition by Dual-Energy X-ray Absorptiometry, muscle strength, and cognitive function. We performed statistics by analysis of covariance (p) and FDR (q) for multiple comparisons. RESULTS: AO-COPD subjects had 27% more VAT (q < 0.01) than AO-Control subjects despite correction for BMI. Branched-chain amino acid concentrations and WBP rates were generally elevated in AO-COPD but whole body clearance rate was only elevated in COPD. Metabolic syndrome comorbidities (p < 0.01) and systemic inflammation (P < 0.05) were most prevalent in the AO-COPD group. Muscle strength was reduced in COPD subjects (p < 0.001), but partially preserved when combined with AO. Cognitive dysfunction and mood disturbances were present in COPD subjects (p < 0.001) with worst performers in AO-COPD (q < 0.05). CONCLUSION: The presence of AO is associated with specific metabolic and functional phenotypes in COPD. Clinical trial registry Trial registration ClinicalTrials.gov. In the present paper, we report an analysis of the baseline measurements of COPD subjects and healthy controls from the study numbers: NCT01787682, NCT01787682, NCT02157844, NCT02082418, NCT02065141, NCT02770092, NCT02908425, NCT03159390, NCT02780219, NCT03327181, NCT03796455, NCT04928872, NCT04461236, NCT01173354, NCT01154400.

Intestinal function is impaired in patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND & AIMS: Gastrointestinal symptoms are prevalent extrapulmonary systemic manifestations of Chronic Obstructive Pulmonary Disease (COPD), but have been rarely studied. We dissected the perturbations in intestinal function in human patients with COPD using comprehensive metabolic and physiological approaches. METHODS: In this observational study, small intestinal membrane integrity and active carrier-mediated glucose transport were quantified by sugar permeability test in 21 clinically stable patients with moderate to severe COPD (mean FEV1, 41.2 (3.2) % of predicted) and 16 healthy control subjects. Protein digestion and absorption was analyzed using stable tracer kinetic methods. Plasma acetate, propionate, and butyrate concentrations were measured as markers of intestinal microbial metabolism. RESULTS: Compared with healthy controls, non carrier-mediated permeability was higher (0.062 (95% CI [0.046, 0.078]) vs. 0.037 (95% CI [0.029, 0.045]), P = 0.009) and active glucose transport lower in COPD (31.4 (95% CI [23.4, 39.4])% vs. 48.0 (95% CI [37.8, 58.3])%, P = 0.010). Protein digestion and absorption was lower in COPD (0.647 (95% CI [0.588, 0.705]) vs. 0.823 (95% CI [0.737, 0.909]), P = 0007), and impairment greater in patients with dyspnea (P = 0.038), exacerbations in preceding year (P = 0.052), and reduced transcutaneous oxygen saturation (P = 0.051), and was associated with reduced physical activity score (P = 0.016) and lower quality of life (P = 0.0007). Plasma acetate concentration was reduced in COPD (41.54 (95% CI [35.17, 47.91]) vs. 80.44 (95% CI [54.59, 106.30]) µmol/L, P = 0.001) suggesting perturbed intestinal microbial metabolism. CONCLUSIONS: We conclude that intestinal dysfunction is present in COPD, worsens with increasing disease severity, and is associated with reduced quality of life.

Thermal infrared imaging: a novel method to monitor airflow during polysomnography.

STUDY OBJECTIVES: This is a feasibility study designed to evaluate the accuracy of thermal infrared imaging (TIRI) as a noncontact method to monitor airflow during polysomnography and to ascertain the chance-corrected agreement (K) between TIRI and conventional airflow channels (nasal pressure [Pn], oronasal thermistor and expired CO2 [P(E)CO2]) in the detection of apnea and hypopnea. DESIGN: Subjects were recruited to undergo polysomnography for 1 to 2 hours, during which simultaneous recordings from electroencephalography, electrooculography, electromyography, respiratory impedance plethysmography, conventional airflow channels, and TIRI were obtained. SETTING: University-affiliated, American Academy of Sleep Medicine-accredited sleep disorders center. PATIENTS OR PARTICIPANTS: Fourteen volunteers without a history of sleep disordered breathing and 13 patients with a history of obstructive sleep apnea were recruited. MEASUREMENTS AND RESULTS: In the detection of apnea and hypopnea, excellent agreement was noted between TIRI and thermistor (kappa = 0.92, Bayesian Credible Interval [BCI] 0.86, 0.96; pkappa = 0.99). Good agreement was noted between TIRI and Pn (kappa = 0.83, BCI 0.70, 0.90; pkappa = 0.98) and between TIRI and P(E)CO2 (kappa = 0.80, BCI 0.66, 0.89; pkappa = 0.94). CONCLUSIONS: TIRI is a feasible noncontact technology to monitor airflow during polysomnography. In its current methodologic incarnation, it demonstrates a high degree of chance-corrected agreement with the oronasal thermistor in the detection of apnea and hypopneas but demonstrates a lesser degree of chance-corrected agreement with Pn. Further overnight validation studies must be performed to evaluate its potential in clinical sleep medicine.

Safety and Feasibility of Ultrasound-Guided Gastric Access for Percutaneous Transabdominal Gastrostomy Tube Placement.

BACKGROUND: The aim of the study was to evaluate the safety and feasibility of ultrasound guidance gastric access for percutaneous retrograde transabdominal gastrostomy (G)-tube placement. METHODS: Twenty-eight patients undergoing 31 percutaneous retrograde transabdominal G-tube placements utilizing ultrasound-guided gastric accesses were retrospectively identified. RESULTS: All patients had successful placement of G tubes with ultrasound-guided gastric access. There were no cases of aspiration or peritonitis. Average fluoroscopy time was 2.7 ± 1.4 min and average radiation dose was 220 ± 202 µGym2. CONCLUSIONS: Ultrasound-guided access for gastrostomy placement is safe and feasible and can be performed with minimal fluoroscopy times resulting in low patient and operator radiation dose.

Gastric Perforation Following Prophylactic Embolization of Right Gastric and Gastroduodenal Arteries Prior to Selective Internal Radiation Therapy.

Prophylactic gastroduodenal artery (GDA) and right gastric artery (RGA) embolization for prevention of gastric ulceration in patients with hepatic metastases from colorectal cancer undergoing Selective Internal Radiation Therapy (SIRT) are relatively safe. Herein, we present a case of gastric perforation following prophylactic embolization of the GDA and RGA for SIRT in a 43-year-old male with sigmoid colon adenocarcinoma and multiple hepatic metastases.

Tube cholecystostomy before cholecystectomy for the treatment of acute cholecystitis.

BACKGROUND AND OBJECTIVES: Percutaneous cholecystostomy is currently indicated for patients with cholecystitis who might be poor candidates for operative cholecystectomy. We performed a study to evaluate the long-term outcome of patients undergoing emergent tube cholecystostomy. METHODS: This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005, to July 1, 2012. RESULTS: During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients (5%) died during the year after tube placement. The mean hospital length of stay for survivors was 8.8 days (range, 1-59 days). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1-6) for gallbladder drainage. Twenty-nine patients (34%) ultimately underwent cholecystectomy. Surgery was performed a mean of 7 weeks after cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in 25 operative patients but required conversion to an open approach in 8 cases (32%). In another 4 cases, planned open cholecystectomy was performed. Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring endoscopic retrograde cholangiopancreatography, 1 patient requiring a return to the operating room for hemoperitoneum, and 2 patients with bile leak from the cystic duct stump. CONCLUSIONS: In high-risk patients receiving cholecystostomy tubes for acute cholecystitis, only about one third will undergo surgical cholecystectomy. Laparoscopic cholecystectomy performed in this circumstance has a higher rate of conversion to open surgery and higher hepatobiliary morbidity rate.

Rare Cause of Stricture Esophagus-Sarcoma: A Case Report and Review of the literature.

Adenocarcinoma and squamous cell carcinoma account for the vast majority of oesophageal malignancies. Other malignancies known to occur in the oesophagus include melanoma, sarcoma, and lymphoma. Among the sarcomas, carcinosarcoma is the commonest with both carcinomatous and sarcomatous elements followed by leiomyosarcoma of mesenchymal origin. Other sarcomas reported in the literature are liposarcoma, synovial sarcoma, myxofibrosarcoma, Ewing's sarcoma, granulocytic sarcoma, histiocytic sarcoma, schwannoma rhabdomyosarcoma, and epithelioid sarcoma. We report a case of malignant spindle cell tumour of oesophagus. Sarcomas of esophagus present as a polypoid exophytic soft tissue mass. Our patient presented with a stricture which is a rare presentation. Locally aggressive treatment with surgery is beneficial, and local palliative treatment including radiotherapy is worthwhile.

Sickle cell trait and fatal rhabdomyolysis in football training: a case study.

We report the athletic, the clinical, and the pathological details of a case of fatal rhabdomyolysis during training in a college football player with sickle cell trait (SCT) who collapsed minutes after running 16 successive sprints of 100 yd each. The player, 19 yr old, African American, was apparently healthy when he took the field for the conditioning run. No exertional heat illness was present. After collapsing on-field, the player soon went into coma and developed fulminant rhabdomyolysis, profound lactic acidosis, acute myoglobinuric renal failure, refractory hyperkalemia, and disseminated intravascular coagulation. Despite intensive care in the hospital, he died about 15 h after admission, likely from a hyperkalemic cardiac arrhythmia; the terminal rhythm was pulseless electrical activity. The forensic autopsy confirmed that the cause of death was acute exertional rhabdomyolysis associated with SCT. Counting this case, at least 15 college football players with SCT have died from complications of exertional sickling, as have younger football players and other athletes. In SCT, maximal, sustained exercise evokes four forces that can foster sickling: hypoxemia, acidosis, hyperthermia, and red cell dehydration. The setting, the clinical and laboratory features, and the clinicopathological correlation here suggest that the fulminant rhabdomyolysis and its fatal sequelae were from exertional sickling. These data suggest that screening and simple precautions for SCT may be warranted to prevent tragedies like this and enable all athletes with SCT to thrive in their sports.

Transient asymptomatic bradycardia in patients on infusional 5-fluorouracil.

The incidence of 5-fluorouracil (5-FU)-related cardiotoxicity seems to be dosage and schedule dependent. Although various other cardiac events have been reported in literature, a series of patients having transient asymptomatic bradycardia has not been reported in the literature as yet. We report such a series of patients who had transient asymptomatic bradycardia after being treated with continuous infusion 5-FU. We plan to do a Holter study during the period of bradycardia in subsequent patients and this may throw more light on the issue.