Cognitive impairment in asymptomatic carotid artery stenosis is associated with abnormal segments in the Circle of Willis.

OBJECTIVE: Our group has previously demonstrated that patients with asymptomatic carotid artery stenosis (ACAS) demonstrate cognitive impairment. One proposed mechanism for cognitive impairment in patients with ACAS is cerebral hypoperfusion due to flow-restriction. We tested whether the combination of a high-grade carotid stenosis and inadequate cross-collateralization in the Circle of Willis (CoW) resulted in worsened cognitive impairment. METHODS: Twenty-four patients with high-grade (≥70% diameter-reducing) ACAS underwent carotid duplex ultrasound, cognitive assessment, and 3D time-of-flight magnetic resonance angiography. The cognitive battery consisted of nine neuropsychological tests assessing four cognitive domains: learning and recall, attention and working memory, motor and processing speed, and executive function. Raw cognitive scores were converted into standardized T-scores. A structured interpretation of the magnetic resonance angiography images was performed with each segment of the CoW categorized as being either normal or abnormal. Abnormal segments of the CoW were defined as segments characterized as narrowed or occluded due to congenital aplasia or hypoplasia, or acquired atherosclerotic stenosis or occlusion. Linear regression was used to estimate the association between the number of abnormal segments in the CoW, and individual cognitive domain scores. Significance was set to P < .05. RESULTS: The mean age of the patients was 66.1 ± 9.6 years, and 79.2% (n = 19) were male. A significant negative association was found between the number of abnormal segments in the CoW and cognitive scores in the learning and recall (ß = -6.5; P = .01), and attention and working memory (ß = -7.0; P = .02) domains. There was a trend suggesting a negative association in the motor and processing speed (ß = -2.4; P = .35) and executive function (ß = -4.5; P = .06) domains that did not reach significance. CONCLUSIONS: In patients with high-grade ACAS, the concomitant presence of increasing occlusive disease in the CoW correlates with worse cognitive function. This association was significant in the learning and recall and attention and working memory domains. Although motor and processing speed and executive function also declined numerically with increasing abnormal segments in the CoW, the relationship was not significant. Since flow restriction at a carotid stenosis compounded by inadequate collateral compensation across a diseased CoW worsens cerebral perfusion, our findings support the hypothesis that cerebral hypoperfusion underlies the observed cognitive impairment in patients with ACAS.

Platelet function testing and clinical outcomes in peripheral arterial disease: Systematic review and narrative synthesis.

OBJECTIVE: This systematic review aims to comprehensively assess the contemporary literature on platelet function testing (PFT) in individuals undergoing revascularization therapy for peripheral arterial disease (PAD). The goal is to identify whether PFT can aid in detecting antiplatelet resistance, predicting post-procedural thrombotic complications, and informing tailored treatment strategies. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature review was conducted using PubMed databases. Search terms included relevant medical subject headings (MeSH) terms. Eligible articles published in English between 1990 and 2023 were analyzed. Studies that examined PFT outcomes in patients with PAD after lower extremity revascularization were included. RESULTS: Ten studies met the inclusion criteria. Various PFT methods were used, including thromboelastography with platelet mapping, multiplate analyzer, Cytochrome P450 2C19 testing, VerifyNow, corrected whole blood aggregometry, platelet function analyzer-100, and light transmission aggregometry. PFT identified individuals who were resistant or non-sensitive to antiplatelet therapy, with such patients facing increased risks of graft/stent thrombosis, amputation, and reintervention. However, substantial heterogeneity in surgical procedures, drug regimens, and testing methods was observed among the studies. CONCLUSIONS: PFTs can play a crucial role in detecting resistance and non-sensitivity to antiplatelet drugs in patients with PAD post-revascularization. However, heterogeneity of data and methods underlines the need for standardized protocols and consensus-building among PFTs. Enhancing clinical utility and reliability could help optimize antiplatelet thromboprophylaxis, minimize thrombotic complications, and improve treatment strategies in vascular surgery. Further research is necessary to solidify the role of PFTs in guiding antiplatelet therapy post-revascularization in patients with PAD.

Diameter and depth of femoral vessels by duplex ultrasound.

BACKGROUND: The anatomy of the femoral artery and vein plays an integral role in vascular access. Both technical feasibility and complication rates are associated with femoral vessel diameter and depth. The goal of this study is to establish normative values for common femoral artery (CFA) and vein (CFV) depth and diameter using a large, diverse patient population. METHODS: A retrospective review of all patients undergoing lower extremity venous duplex imaging over a 1 year period were reviewed. Patients with inadequate imaging or with evidence of deep vein thrombosis were excluded. The index image of all studies was a non-compressed view of the common femoral vein at the saphenous-femoral junction. All measurements were taken from this still. Vessel diameters were measured from intima to intima. Depth was measured from skin to intima. BMI and BSA were calculated using standard formulas. Chi square was used for univariate analysis. Linear regression was used to establish correlation. RESULTS: Over the 1 year period, 983 patients met criteria for inclusion. The majority were male (53%) with a mean age of 55. The patients were 47% white and 44% black. The majority had hypertension (53%). The mean BMI and BSA were 29 and 2, respectively. Mean CFA depth was 1.7 cm, while mean CFV depth was 1.8 cm. The mean CFA and CFV diameters were 0.9 and 1.1 cm, respectively. Amongst height, weight, BMI, and BSA, weight correlated best with CFA (R = 0.548) and CFV (R = 0.552) depth, while BSA correlated best for diameter for both CFA (R = 0.390) and CFV (R = 0.440). CONCLUSIONS: This study establishes mean diameters and depths for the common femoral artery and vein using a large, diverse patient group. BSA was most closely associated with vessel diameter, while weight was correlated with depth. This study provides normative diameter and depth values for the common femoral vasculature, which may assist in vascular access planning for providers.

Prediction of bleeding in patients being considered for venous thromboembolism prophylaxis.

BACKGROUND: Venous thromboembolism (pulmonary embolism and deep vein thrombosis) is an important preventable cause of in-hospital death. Prophylaxis with low doses of anticoagulants reduces the incidence of venous thromboembolism but can also cause bleeding. It is, therefore, important to stratify the risk of bleeding for hospitalized patients when considering pharmacologic prophylaxis. The IMPROVE (international medical prevention registry on venous thromboembolism) and Consensus risk assessment models (RAMs) are the two tools available for such patients. Few studies have evaluated their ability to predict bleeding in a large, unselected cohort of patients. We assessed the ability of the IMPROVE and Consensus bleeding RAMs to predict bleeding within 90 days of hospitalization in a comprehensive analysis encompassing all hospitalized patients, regardless of surgical vs nonsurgical status. METHODS: We analyzed consecutive first hospital admissions of 1,228,448 unique surgical and nonsurgical patients to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. IMPROVE and Consensus scores were generated using data from a repository of their common electronic medical records. We assessed the ability of the two RAMs to predict bleeding within 90 days of admission. We used area under the receiver operating characteristic curves to determine the prediction of bleeding by each RAM. RESULTS: Of 1,228,448 hospitalized patients, 324,959 (26.5%) were surgical and 903,489 (73.5%) were nonsurgical. Of these patients, 68,372 (5.6%) had a bleeding event within 90 days of admission. The Consensus RAM scores ranged from -5.60 to -1.21 (median, -4.93; interquartile range, -5.60 to -4.93). The IMPROVE RAM scores ranged from 0 to 22 (median, 3.5; interquartile range, 2.5-5). Both showed good calibration, with higher scores associated with higher bleeding rates. The ability of both RAMs to predict 90-day bleeding was low (area under the receiver operating characteristic curve 0.61 for the IMPROVE RAM and 0.59 for the Consensus RAM). The predictive ability was also low at 30 and 60 days for surgical and nonsurgical patients, patients receiving prophylactic, therapeutic, or no anticoagulation, and patients hospitalized for ≥72 hours. Prediction was also low across different bleeding outcomes (ie, any bleeding, gastrointestinal bleeding, nongastrointestinal bleeding, and bleeding or death). CONCLUSIONS: In this large, unselected, nationwide cohort of surgical and nonsurgical hospital admissions, increasing IMPROVE and Consensus bleeding RAM scores were associated with increasing bleeding rates. However, both RAMs had low ability to predict bleeding at 0 to 90 days after admission. Thus, the currently available RAMs require modification and rigorous reevaluation before they can be applied universally.

Review of Tretinoin-Benzoyl Peroxide in The Treatment of Acne Vulgaris.

BACKGROUND: Acne vulgaris has a multifactorial pathogenesis, and combination therapy is recommended in most patients. A tretinoin 0.1%/benzoyl peroxide 3% (Tret-BPO) cream which uses a core-shell encapsulation system to enhance the stability of both active ingredients recently received approval from the Food and Drug Administration (FDA). OBJECTIVE: To review the pharmacokinetics, efficacy, and safety of recently approved Tret-BPO. METHODS: A review of literature was conducted using the EMBASE, MEDLINE (Pubmed), and Clinicaltrials.gov databases in December 2021. Articles in English discussing the use of Tret-BPO in the treatment of acne vulgaris were included. RESULTS: In a phase 2 trial, Tret-BPO achieved Investigators Global Assessment (IGA) success more often (39.7%) than vehicle (12.3%; P<0.001). In 2 phase 3 trials, Tret-BPO had a higher success rate (Trial 1: 38.5% and Trial 2: 25.4%) when compared with vehicle (Trial 1: 11.5% and Trial 2: 14.7%; P<0.001 and P=0.017). LIMITATION: This review was limited by the lack of clinical trials assessing the efficacy and safety of Tret-BPO compared with other acne treatments. CONCLUSIONS: Tret-BPO is a safe and effective novel therapy for acne vulgaris. Poor adherence is a major hurdle in management; the combination of two separate first-line drugs may address this hurdle by decreasing the complexity of treatment regimens. J Drugs Dermatol. 2022;21(10):1098-1103. doi:10.36849/JDD.6808.

Robotic-assisted colorectal surgery in obese patients: a case-matched series.

BACKGROUND: Reports demonstrate laparoscopic colorectal surgery in obese patients is associated with higher conversion to laparotomy and complication rates. While several advantages of robotic-assisted surgery have been reported, outcomes in obese patients have not been adequately studied. Therefore, this study compares outcomes of robotic-assisted surgery in non-obese and obese patients. METHODS: A retrospective review of 331 consecutive robotic procedures performed at a single institution between 2009 and 2015 was performed. Patients were divided into non-obese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2) groups, and were clinically matched by gender, age, and procedure performed. Intraoperative and postoperative complications, operative time, estimated blood loss, and length of stay were examined. RESULTS: Following matching, each group included 108 patients comprised of 50 men and 58 women. Mean BMI was 24.6 ± 3.15 and 36.2 ± 5.67 kg/m2 (p < 0.0001), and the mean age was 59.2 ± 11.28 years for non-obese patients and 57.1 ± 12.44 for obese patients (p = 0.18). Surgeries included low anterior resection, right colectomy, left colectomy, sigmoid colectomy, excision of rectal endometriosis, total proctocolectomy, APR, subtotal colectomy, ileocecectomy, proctectomy, rectopexy, transanal excision of rectal mass, and colostomy site hernia repair. The mean operative time was 272.69 ± 115.43 and 282.42 ± 120.51 min (p = 0.55), estimated blood loss 195.23 ± 230.37 and 289.19 ± 509.27 mL (p = 0.08), conversion to laparotomy 6.48 and 9.26 % (p = 0.45), and length of stay 5.38 ± 4.94 and 4.56 ± 4.04 days (p = 0.18) for the non-obese and obese groups, respectively. Twenty of the non-obese patients had postoperative complications as compared to 27 of the obese patients (p = 0.30). However, the prevalence of wound complications was higher in obese patients (1.9 vs 9.3 %; p = 0.03). CONCLUSION: There is no difference in conversion to laparotomy and overall complication rates in non-obese and obese patients undergoing robotic-assisted colorectal surgery. However, obesity is associated with a higher prevalence of wound complications. Robotic-assisted surgery may minimize conversion to laparotomy and complications typically seen in obese patients due to improved visualization, instrumentation, and ergonomics.