Post-operative Venous Thromboembolism in Patients Operated on for Aorto-iliac Obstruction and Abdominal Aortic Aneurysm, and the Application of Pharmacological Thromboprophylaxis.

OBJECTIVE/BACKGROUND: In light of the methods generally used to assess the risk of venous thromboembolism (VTE), major vascular operations should be regarded as high risk procedures. Nevertheless, no principles for implementing and maintaining thromboprophylaxis have so far been developed. The aim of this study was to determine the frequency and nature of VTE occurrence in patients routinely applying pharmacological thromboprophylaxis following implantation of an aorto-bifemoral prosthesis. METHODS: The prospective non-randomized study included 105 patients with aortoiliac obstruction and 119 patients with abdominal aortic aneurysm (AAA) treated surgically. During hospitalization pharmacological thromboprophylactic procedures were observed. A duplex test was performed on the day before surgery, on the day of discharge, and 30 days after the patients had left the hospital. RESULTS: VTE was detected in 18.1% of the patients with aortoiliac obstruction (9.5% of patients during hospitalization and 8.6% of patients after discharge). VTE was diagnosed in 21.0% of patients with AAA (15.1% of patients during hospitalization and 5.9% of patients after discharge). The incidence of VTE was comparable in both groups, both during hospitalization (p = .51) and in the 30 day period following the end of hospitalization (p = .48). It is advisable that before hospital discharge routine duplex ultrasonography tests should be conducted on the venous systems of all patients who have undergone major vascular operations. CONCLUSIONS: It is likewise advisable to consider whether thromboprophylaxis for vascular patients should be extended beyond their discharge from hospital.

Interaction with gravitropism, reversibility and lateral movements of phototropically stimulated potato shoots.

Phototropic (PT) and gravitropic (GT) bending are the two major tropic movements that determine the spatial position of potato shoots. We studied PT bending of potato plantlets grown under long-day photoperiods in several prearranged position setups providing different interactions with the GT response. Starting with the standard PT stimulation setup composed of unilateral irradiation of vertically positioned shoots, experiments were also done in antagonistic and synergistic setups and in treatments with horizontal displacement of the light source. In the standard setup, PT bending suppressed the GT bending, which could occur only if the PT stimulation was cancelled. The antagonistic position, with phototropism and gravitropism attempting to bend shoots in opposite directions, showed phototropism and gravitropism as independent bending events with the outcome varying throughout the day reflecting diurnal changes in the competence of individual tropic components. Whilst gravitropism was constant, phototropism had a marked daily fluctuation of its magnitude with a prominent morning maximum starting an hour after the dawn in the growth room and lasting for the next 6 h. When phototropism and gravitropism were aligned in a synergistic position, stimulating shoot bending in the same direction, there was little quantitative addition of their individual effects. The long period of morning PT bending maximum enabled multiple PT bending events to be conducted in succession, each one preceded by a separate lag phase. Studies of secondary PT events showed that potato plantlets can follow and adjust their shoot position in response to both vertical and horizontal movements of a light source. PT bending was reversible, since the 180° horizontal change of a blue light (BL) source position resulted in reversal of bending direction after a 20-min-long lag phase.

Morphological and mechanical changes in juxtarenal aortic segment and aneurysm before and after open surgical repair of abdominal aortic aneurysms.

OBJECTIVE: The aim of study was to assess how the ultrastructure of the wall of aortic aneurysms, sac and neck influences aortic wall distensibility and proximal dilatation 2 years after open repair. METHODS: Biopsies for electron microscopy were taken from aneurysmal sac and neck of 30 patients. Patients were assessed by computed tomography (CT) and ultrasound for aneurysm diameter and distensibility (M-mode ultrasonography). RESULTS: Postoperative CT of the aortic stump distinguished two groups. Group I (n = 11) with little enlargement, median 1 mm (1-3 mm) and group II (n = 19) with significant aortic enlargement, median 5.2 mm (4-12 mm). In group II, changes in elastic fibres in the aneurysm neck were comparable to, but as extreme as in the aneurysm sac. For group I, the distensibility of the aneurysmal sac was significantly lower than in the neck or at the renal arteries. For group II, the distensibility in both the neck and sac was significantly lower than at the juxtarenal segment (p = 0.01). The biopsies of group II patients showed the extensive degeneration of normal architecture, which was associated with altered wall distensibility in both the aneurysmal neck and sac. CONCLUSIONS: Disorganisation and destruction of normal aortic architecture at the ultrastructural level are associated with decreasing aortic distensibility. Low aortic neck distensibility is associated with proximal aortic dilatation at 2 years postoperatively.

The influence of elastic components of the venous wall on the biomechanical properties of different veins used for arterial reconstruction.

OBJECTIVE: To evaluate the relationship between the biomechanical properties and the structure of elastic components in different veins used for vascular reconstruction. DESIGN: In vitro experimental study. MATERIAL AND METHODS: Groups of 30 samples of incompetent saphenous veins (rSV), competent saphenous veins (cSV) and femoral veins (FVs) were compared following immunohistochemical staining for the presence of collagen types I, III and IV and elastin. The percentage area of transverse section of veins occupied by each type of collagen and elastin was measured using a computer-image-analysis system connected to a microscope. For all three groups of veins, the storage modulus, E', and the loss modulus, E'', were measured with a mechanical analyser, DMA-242, and changes in the function of temperature and frequency, and duration of exposure to the applied force were determined. RESULTS: The rSV showed the highest percentage share of collagen I and the lowest percentage share of collagen IV. These samples also showed the greatest expression of elastin and the highest elastin to collagen ratio. The rSV were also found to have the highest E' and E'', and during the long-term exposure achieved maximum stiffness in the least time as compared to cSV and FV. CONCLUSION: The histological structure directly influences the biomechanical properties of venous wall with rSV showing least compliance and cSV the greatest compliance.

Severe severe psychological repulsion reaction in patient with PAD resulted in natural lower extremity mummification.

This case report describes the very uncommon event of mummification of the lower limb occurring naturally in a patient with peripheral arterial occlusive disease aggravated by severe reactive aversion and serves as a warning that this can happen in cases of untreated advanced critical limb ischemia even in well developed countries.

Endovascular treatment of intramural hematoma of internal carotid artery after blunt trauma of neck inflicted with the seatbelt.

Blunt trauma of the neck caused by a seatbelt may cause dissection with intramural hematoma of the internal carotid artery. The following case report discusses the differential diagnosis and the potential of endovascular treatment of symptomatic intramural hematoma of the internal carotid artery.

The importance of ceruloplasmin oxidase activity in patients with chronic lower limb atherosclerotic ischemia.

AIM: Inflammatory reactions accompanying ischemia increase the cytokine synthesis what leads to the increase in serum ceruloplasmin (Cp) concentration and activity. The aim of the study was to evaluate the association between serum Cp oxidase concentration and activity and the grade of lower extremity ischemia. Moreover, the correlation of Cp concentration and activity with the levels of interleukin 6 (IL-6), C-reacting protein (CRP), and a-1-acid glycoprotein (AGP) in serum was studied. METHODS: Two groups of patients were examined: 15 patients with moderate (MI) and 32 patients with critical ischemia (CI) of the lower extremities. Cp oxidase activity was measured spectrophotometrically, after incubation with o-dianisidine. The concentration of IL-6 was measured with the ELISA method, and Cp, CRP and AGP concentration by rocket immunoelectrophoresis. RESULTS: Significant increase in Cp oxidase concentration and activity was observed in patients with critical limb ischemia (median: 164.8 U/L), especially in patients with necrotic changes (median: 216.6 U/L). Cp oxidase activity was dependent on its concentration in patients with critical limb ischemia with necrotic changes (r=0.56; P<0.01). In patients with critical limb ischemia, the increase in Cp concentration and activity correlated significantly with CRP concentration (r=0.46; P=0.0007) (r=0.62; P=0.0001), respectively. CONCLUSION: Concentration and the oxidase activity of Cp depend of the degree of lower extremity ischemia and correlates with the major markers of inflammation, such as CRP. Critical limb ischemia induces the inflammatory reaction triggering the increase in IL-6 and of acute phase protein production. These processes lead to the increase in Cp oxidase activity dependent of Cp and CRP concentration.

Correlative histological and ultrastructural study of unusual changes in human tracheobronchial epithelium.

In tracheostomy patients with chronic bronchitis, scanning electron microscopy reveals detailed surface changes in the tracheobronchial mucosa. The principle of intermicroscopic correlation, i.e., the sequential examination of a specimen by different microscopic procedures, is illustrated with giant cilia. After re-embedding the scanning electron microscopic specimens and precisely locating a ciliary convolution by light microscopy in semithin section, the giant cilia were studied in ultrathin sections by transmission electron microscopy. The cilia were shown to be at least 9 microns long (normal ciliary length = 4-6 microns). Central and peripheral microtubular axonemal structures with a 9 + 2 arrangement were clearly shown in both longitudinal and cross section. Giant cilia, thus, most closely resemble outgrowths of normal cilia. If they are motile at all, they seem unlikely to effect a transport function coordinated in direction and time.

Attitude towards one's illness vs. attitude towards a surgical operation, displayed by patients diagnosed with asymptomatic abdominal aortic aneurysm and asymptomatic internal carotid artery stenosis.

AIM: Two most frequent asymptomatic diseases qualifying for vascular surgery are abdominal aortic aneurysm (AAA) and internal carotid artery stenosis (ICAS). Emotions experienced by the patient activate processes of dealing with the cognitive dissonance of asymptomatic disease. The aim of this paper was to compare the reasons involved in decision making on surgery in two asymptomatic vascular pathologies. METHODS: Fifty patients were divided into two groups: the ICAS group-27 (CAS or CEA) and the AAA group-23 (EVAR or open surgical operation (OSR). Specific questionnaire regarding: 1) self-image; 2) attitude to one's illness; 3) reasons for decision on surgery was applied for the study. The χ² test was used to for the analysis. RESULTS: The AAA patients reacted emotionally (88.2%) comparing to ICAS patients reacting "rationally" (59.3%) (α=0.05). In AAA patients attitude towards themselves had worsened (α=0.001) AAA patients were less likely to seek support in decision on surgery (α=0.01). ICAS patients are internally motivated (78.7%), whereas AAA patients are externally motivated (63.9%) (α=0.001). Reasons underlying the decision on surgery, were predominantly rational (55.8%). CONCLUSION: In the process of decision-making on surgery by asymptomatic patients, evolutionary transformation takes place - the emotional attitude to one's illness leads to rationally evaluated decision. Regardless of the causes the process of making a decision on surgical operation tended to run more smoothly in ICAS patients. The ICAS patients tended to display a rational attitude to their illness. AAA patients displayed a distinctly emotional attitude towards their illness.

Intensive decongestive treatment restores ability to work in patients with advanced forms of primary and secondary lower extremity lymphoedema.

OBJECTIVE: To show that adequate therapy for lymphoedema is able to restore ability to work. MATERIALS AND METHODS: The population of patients with primary lymphoedema registered in the university clinical centre diagnosed with primary or secondary lymphoedema and presumed by the national social institution as completely unable to work was selected for the retrospective analysis and divided into two groups. Group 1 consisted of 25 patients treated with a complex decongestive therapy programme daily for 3-6 weeks. The study population comprised 19 women and six men from 14 to 61 years of age (mean 31.5). In all 25 patients, complete inability to work was certified by the social institution before the treatment started. Group 2 consisted of 47 patients, 14 men and 33 women, aged from 26 to 71 years (mean 39 years) treated by so-called standard methods, who resigned from the proposed intensive treatment. In all 47 patients, complete inability to work was declared by the social institution before the treatment. Ability to work and oedema reduction were assessed by the treating physician. RESULTS: The intensive phase of treatment succeeded in 3870-15,330 mL oedema reduction in Group 1. After the end of therapy, 21 patients were able to work or study without any limitation and patients returned to their regular professional activity. Among four others, two were on welfare for at least 10 years, for another one welfare was their only income and one person was receiving a social pension. In none of the patients from group 2 was any significant oedema reduction observed. Every patient from group 2 maintained the social pension due to ineffective treatment. CONCLUSIONS: Complex decongestive therapy is a very efficient form of treatment in advanced primary and secondary lymphoedema. It allows returning to work after a short period of temporary disability without the necessity of a social pension.

IL-6, TNF-alpha, IL-1-beta arterial wall expression is independent of serum concentration in patients sustaining primary or secondary open vascular reconstructions.

AIM: The aim of this study was to assess morphological and immunohistochemical differences in arterial wall inflammation during primary and secondary vascular reconstructions. METHODS: Forty patients with lower extremities ischemia underwent vascular reconstruction: Group I included patients undergoing primary vascular reconstruction with 25 minor arterial reconstructive procedures; Group II included patients undergoing secondary reconstruction due to limb ischemia after at least 12 months since first operation (15). Immunohistochemical expression of IL-1-BETA,IL-6,and TNF-alpha in arterial wall was correlated with serum concentration. RESULTS: No differences were observed in IL-1-beta, IL-6, TNF-alpha expression among groups (P=0.06, P=0.13, P=0.9). Cytokines expression was not accompanied by the growth of its serum concentrations (P=0.8, P=0.9). IL-6 serum concentration depended on the degree of limb ischemia and was very high in case of critical limb ischemia (P=0.006). Arterial morphology was comparable among the groups. CONCLUSION: IL-6, IL-1-BETA, TNF-alpha expression in the arterial wall is comparable in primary and secondary lesions. Serum concentrations of IL-6, IL-1-BETA, TNF-alpha are independent of its arterial wall expression.

[Percutaneous transluminal angioplasty of radiotherapy induced carotid stenosis--case report].

Frequent delayed effect of radiation therapy in the region of neck is stenosis of carotid arteries. We report the case of 32 years old man with history of radiation therapy due to Hodgkin lymphoma, and severe stenosis of the right common carotid artery. Stenosis was succesfuly treated by percutaneous transluminal angioplasty with implantation of two bare-metal stents.

Association between intracranial pulse pressure levels and brain energy metabolism in a patient with an aneurysmal subarachnoid haemorrhage.

This report addresses whether intracranial pulse pressure amplitudes are associated with brain energy metabolism, examined by intracerebral microdialysis. We present a 65-year-old female with an aneurysmal subarachnoid haemorrhage (SAH) from a left posterior communicating artery (PCOM) aneurysm. She underwent simultaneous intracranial pressure (ICP) monitoring and microdialysis (MD) as part of a diagnostic workout because of a lack of clinical improvement after long-term intensive care management. Over a 4-day period, a total of 128 samples of metabolites (glutamate, glycerol, lactate and pyruvate) were gathered, allowing retrospective comparisons with the levels of intracranial pulse pressure amplitudes (the mean ICP wave amplitude). During this 4-day period, mean ICP was normal (<15 mmHg), while mean ICP wave amplitude was high (>/=5 mmHg) in 47% of the recording time. There was a highly significant relationship between the levels of the mean ICP wave amplitude and the levels of glutamate, glycerol and lactate/pyruvate ratio. The levels of metabolites were increased when the mean ICP wave amplitude was >/=5 mmHg as compared with mean ICP wave amplitude levels <5 mmHg. We tentatively suggest that increased mean ICP wave amplitudes indicative of reduced intracranial compliance can be associated with brain ischaemia.

Treatment of chronic subdural hematoma by burr-hole craniostomy in adults: influence of some factors on postoperative recurrence.

BACKGROUND: The study was conducted to determine the causative factors in the postoperative recurrence (PR) of chronic subdural haematomas (CSDHs) and to evaluate the efficacy of surgery in adults enrolled in this trial. METHODS: 99 patients with 121 CSDHs, who were operated on between January 1999 and December 2001, were studied. We evaluated the PR rate related to anamnestic, clinical, surgical and neuroradiological imaging variables. In addition, we reviewed the number and the type of repeated operations, complications of surgery and the outcomes at one, three and 12 months. FINDINGS: 82.6% of lesions were successfully treated following the initial evacuation, and 95.9% of lesions following a second procedure. The PR rate was 14.9%. A significantly high PR rate was found to be associated with separated type, frontal base type, a midline displacement >5 mm and the presence of acute subdural clots in cranial base type on CT scans obtained within four days postsurgery. The interval from head trauma to initial surgery <60 days, the maximum width of subdural space >10 mm and massive collection of air in the subdural space tended to give a high PR rate. The PR rate associated with the homogeneous type of CSDHs was significantly low.Age, sex, cause of CSDH, anticoagulant therapy, preoperative neurological presentation, concomitant disease, variables on preoperative CT scans, and surgical factors such as the extent of the surgical procedure, use of drainage, duration and volume of drainage were not significantly associated with PR rate. CONCLUSIONS: It is important to identify factors leading to a high or a low PR rate in the treatment of CSDHs because this may help to select appropriate surgical procedures and postoperative management to treat this condition efficiently.

[South American blastomycosis (paracoccidioidomycosis) in Switzerland. Clinical course and morphological findings in a case following long-term therapy]. / Südamerikanische Blastomykose (Parakokzidioidomykose) in der Schweiz. Klinischer Verlauf und morphologische Befunde bei einem Fall nach Langzeittherapie.

The clinical course and morphological findings are reported of visceral paracoccidioidomycosis or South American blastomycosis with lung involvement in a 47-year-old male after specific antimycotic treatment for 11 years. The patient had been infected during a stay in São Paulo, Brazil, from 1950 to 1954. The diagnosis was established in 1959 after his return to St. Gall, Switzerland, in tissue from buccal mucosa and cervical lymph node biopsy and in fungus cultures. The patient was treated with Fungizone (amphotericin B) and with the sulfonamide Fanasil. He died in 1970 from acute right heart failure. Autopsy revealed multiple encapsulated mycotic foci in both lungs, together with healed foci and pulmonary fibrosis. Histological examination showed a large amount of Paracoccidioides brasiliensis in the mycotic foci, but cultural proof was no longer possible. In the buccal mucosa and lymph nodes, only fungus-free scars were observed. There are only a few effective antimycotic agents. With a thorough knowledge of their side effects and dosage modalities, it is possible to achieve highly satisfactory results.

[Granulomatous cytomegalovirus hepatitis]. / Granulomatöse Zytomegalievirus-Hepatitis.

Four primarily healthy patients with granulomatous hepatitis during acute cytomegalovirus infection are described. Granulomatous hepatitis associated with cytomegalovirus infection has been described previously in only 7 patients. As the authors have observed 4 such cases within a period of one year, this disease pattern may occur more frequently than was formerly assumed.

[The carpal tunnel syndrome. Indication, technic and results following epineural and interfascicular neurolysis]. / Das Karpaltunnel-syndrom. Indikation, Technik und Resultate nach epineuraler und interfaszikulärer Neurolyse.

In the advanced stage of the carpal tunnel syndrome with apparently "irreversible" loss of motor function and sensibility, epineural and interfascicular neurolysis has been recommended as an idjunct to the conventional decompression of the median nerve. Nevertheless the literature is lacking in data concerning recovery of motor function after operation. In addition to clinical examination, histological and electromyographic data are proveded to demonstrate the histo-pathological changes and the late results after neurolysis. Indications for the technique of this more radical operative procedure as well as late results are described.