Assessing the effect of different operation techniques on postoperative duplex ultrasound quality after carotid endarterectomy.

BACKGROUND: Duplex ultrasound is the first choice in diagnostics and surveillance of stenoses of the internal carotid arteries before and even after surgery. Therefore, the quality of duplex ultrasound is crucial to investigate these vascular pathologies. OBJECTIVE: Aim of this study was the evaluation whether different surgical techniques affect the postoperative quality of duplex ultrasound. METHODS: In a time period from January to May 2015 duplex ultrasound of the cervical vessels was performed in 75 patients after unilateral endarterectomy of the internal carotid artery at our department between 2006 and 2012. Thereby, the non-operated contralateral side served as a control. Study groups were defined by the surgical techniques of eversion- or thrombendarterectomy with patch plasty using different patch materials and/or a haemostatic sealant. Duplex ultrasound analysis included acoustic impedance, extinction of ultrasound, thickness of skin and individual anatomic aspects of the patients. RESULTS: Carotid endarterectomy itself reduced intravascular grey levels, skin thickness and increased extinction of duplex ultrasound when compared to the non-operated side of the neck. In contrast, neither the kind of chosen operative technique nor the use of different patch materials or the application of a haemostatic sealant showed an effect in this regards. CONCLUSIONS: Whereas carotid endarterectomy per se worsens the quality of postoperative duplex ultrasound, the different analysed surgical techniques as well as used patches and the application of a haemostatic sealant can be assumed to be equal regarding the quality of postoperative ultrasound.

Influence of local hemostatic and antiplatelet agents on the incidence of bleeding complications in carotid endarterectomies.

BACKGROUND: For the reduction of cardio- and cerebrovascular events in carotid endarterectomies continuation of antiplatelet medication is recommended perioperatively. As a result, this patient population is at increased risk for postoperative bleeding complications. Intraoperative application of local hemostatic agents might reduce the incidence of bleeding complications. MATERIAL AND METHODS: All 565 patients undergoing carotid endarterectomy between January 2005 and January 2011 were analysed retrospectively. Most patients in the earlier cohort years of the study had no perioperative antiplatelet medication. In contrast antiplatelet medication was usually continued perioperatively in the later cohort years. To reduce the risk of perioperative bleeding local hemostatic agents were applied increasingly. RESULTS: Revision surgery, due to postoperative bleeding or massive hematoma, was necessary in 20 cases (3.5 %). Overall, 383 carotid endarterectomies (67.8 %) were performed with perioperative antiplatelet medication. Local hemostatic agents were applied in 259 cases (45.8 %) intraoperatively. Initially, operations performed in patients taking antiplatelet medication resulted in an increased need for surgical revision. Following an accelerated practice of using local hemostatic agents, the need for revision surgeries fell. Nevertheless, when patients from all years were analysed together there was no significant benefit from the application of local hemostatic agents. CONCLUSION: Application of local hemostatic agents might have contributed to a reduction of bleeding complications in carotid endarterectomies. However, this could not be shown of statistical significance. Other confounding factors such as different operative techniques or forms of anesthesia might also have influenced this decline.

[Risk evaluation of type B aortic dissection: importance for treatment of acute aortic syndrome]. / Risikoevaluation der Aortendissektion Typ B: Bedeutung für die Behandlung des akuten Aortensyndroms.

Acute aortic syndrome (AAS) is a modern term used to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges including aortic dissection, intramural hematoma (IMH) and penetrating aortic ulcer (PAU). Population-based studies suggest that the incidence of aortic dissection ranges from 2.6 to 3.5 cases per 100,000 inhabitants per year; hypertension and a variety of genetic disorders with altered connective tissue are the most prevalent risk conditions. In general, open surgical repair is recommended when dissection involves the ascending aorta, whereas medical management and endovascular stent graft repair is the best option when the ascending aorta is spared. Pathological conditions involving the aortic arch may be treated using a hybrid approach combining debranching of supra-aortic vessels and stent graft placement. Stent graft-induced remodeling of a dissected aorta seems to have long-term benefits in complicated and so-called uncomplicated type B dissections as almost every case reveals a risk profile and one in eight patients diagnosed with acute type B aortic dissection has either an IMH or a PAU. Pain is the most commonly presenting symptom of AAS and should prompt immediate attention including diagnostic imaging modalities, such as multislice computed tomography, transesophageal ultrasound and magnetic resonance imaging. A specific therapeutic approach is necessary for IMH and PAU because without treatment they have a very poor outcome, are unpredictable in evolution and can be more severe than acute aortic dissection. All patients must receive the best medical treatment available at admission. High-risk but asymptomatic patients with IMH and PAU can probably be monitored without interventions. All symptomatic patients will need treatment. In many of these patients a direct surgical approach is often prohibitive due to age and multiple comorbidities. Endovascular treatment offers superior results and is becoming a recognized indication for such patients. Irrespective of the treatment modality close surveillance is mandatory in order to monitor disease progression.

[Postoperative long-term results in high-grade traumatic ruptures of the spleen in children]. / Postoperative Ergebnisse höhergradiger traumatischer Milzrupturen bei Kindern im Langzeitverlauf.

BACKGROUND: Splenic rupture is the most common injury in blunt abdominal trauma at any age. The grade of rupture, haemodynamic stability and, in the case of operative treatment, the experience of the surgeon all play an important role in preserving the spleen. Due to its important immunological function preservation of the spleen should be the goal. PATIENTS: From January 2000 to August 2009 five children (4 male/1 female) with isolated grade IV or V splenic rupture, according to the Organ Injury Score (OIS), were treated operatively. At the time of the trauma the patients were 8.8 ± 3.8 (mean ± standard deviation; range, 6­15) years old. Four patients with an OIS grade IV rupture were primarily treated with partially spleen-saving surgery: one resection of 2/3 of the spleen including the splenic vessels, one hemisplenectomy and two lower pole resections; in one patient with an OIS grade V rupture splenectomy was performed immediately. RESULTS: In one patient treated with a spleen-preserving approach (hemisplenectomy) the remainder of the spleen had to be removed due to acute bleeding on the first postoperative day. This patient needed two units of blood transfused following the second operation. There were no other complications. The two patients with splenectomy and resection of ⅔ of the spleen developed a transient thrombocytosis indicating impaired clearance of the spleen. In a follow-up involving ultrasonography (median 13, range 1-101 months) all patients managed with partially spleen-saving surgery showed a large remnant spleen with arterial perfusion. CONCLUSION: The majority of primarily partially spleen-preserving operations result from OIS grade IV ruptures of the spleen. Use of a partially spleen-saving surgical approach was successful in ¾ of these patients. Low morbidity and documented perfusion of the remnant spleen at long-term follow-up indicate that a spleen-preserving technique is warranted if an operative approach is required.

[Pancreas-preserving duodenectomy in acute situations. Surgical treatment of an iatrogenic hemorrhage in the duodenal wall]. / Pankreaserhaltende Duodenektomie in der Akutsituation.: Operative Therapie einer iatrogenen Einblutung in die Duodenalwand.

We report the case of a 24-year-old patient who underwent a duodenal biopsy due to the suspicion of graft-versus-host disease following allogeneic stem cell transplantation 3 months previously. The patient developed severe upper abdominal pain after the biopsy. A computed tomography scan revealed diffuse hemorrhaging in the duodenal wall and mesenteric root. Following supraselective angioembolization to stop the bleeding a control computed tomography scan was carried out the following day and revealed increasing destruction of the duodenal wall due to a dissecting aneurysm. A pancreas-preserving duodectomy was carried out.

Adaptive physical activity and back pain: a non-randomised community-based intervention trial.

BACKGROUND: Back pain is a significant problem due to the high healthcare utilization, rising costs of care and low effectiveness of many current treatments. AIM: Aim of this study was to determine the effects of a community-based Adapted Physical Activity (APA) program focused on chronic, non-specific back pain. DESIGN: Open-label intervention study. SETTING: Community. POPULATION: All patients admitted to Empoli Rehabilitation Department for non-specific back pain for at least three months, were considered for APA. Exclusion criteria were: "red flags", difficulty/disability in basic daily living activities, severe/acute medical conditions, acute pain, psychiatric disease or cognitive impairment, severe visuoauditory deficit. Overall, 650 persons were enrolled. METHODS: The APA program, including strength and flexibility training and exercises for improving posture was delivered for 12 months, with 1-hour group classes three times per week. RESULTS: Overall 261 (40.2%) subjects completed the 12-month APA program and were compared to the 310 (47.7%) who were screened but failed to initiate or complete the study. There were no significant differences in baseline demographic and clinical characteristics between groups. Patients who followed the APA program reported significantly improved health status and significant back pain improvement, compared with those who did not adhere to the program. In the logistic regression analysis adjusted for age and gender, a distance from home to gymnasium greater than the median for the study population (2.6 km) was the only baseline characteristic significantly associated with an increased risk of non-adherence (OR 1.44, 95%CI 1.01-2.13; P=0.04). CONCLUSION: This study suggests that a community-based APA program can improve back pain and health status in persons with chronic, non-specific low back pain. CLINICA REHABILITATION IMPACT: These findings highlight the potential for new approaches to manage chronic disease and disability by facilitating a healthy lifestyle and promoting physical activity through implementation of community-based exercise programs.

Influence of bleeding on haemorheology and haemostasis in surgery.

Changes in haemorheology and haemostasis may contribute to bleeding or thrombosis, which is of concern particularly in surgery. Blood loss itself has a major influence on both parameters being closely involved in the clinical outcome. In order to analyze the underlying interrelations, a prospective study with 122 patients (64 females, 58 males) aged between 18 and 83 years (mean: 51.8 years) was conducted. All patients were electively submitted to orthopaedic surgery. Haemorheological parameters included measurements of plasma viscosity, red body cell (RBC) and platelet aggregation index preoperatively, as well as by day 1 and day 7 after surgery. Additionally hematological and haemostaseological parameters including leukocyte and platelet counts, haematocrit and fibrinogen were investigated. Bleeding was defined as high (>500 ml) or low blood loss (≤500 ml) according to the drainage volume. High but not low blood loss was associated with an increase of RBC aggregation by day 1 and 7 after surgery. Plasma viscosity decreased significantly by day 1, returning to normal 7 days after surgery. Platelet count decreased significantly, concurrent with the haematocrit, by day 1 postoperatively, whereas by day 7 a significant increase was observed, being more distinct in high blood loss. Platelet aggregation index did not change under the influence of blood loss. Plasma fibrinogen, clearly corresponding to the extend of blood loss, showed a continuous postoperative increase, which was significantly higher at day 7. Leukocytes increased moderately but significantly in particular in high blood loss. In conclusion, the postoperative decrease of plasma viscosity and of platelet counts, concurrent with the haematocrit, provides evidence of being clearly dependent on blood loss which is regarded as a dilution effect corresponding with the haemorrhagic risk. The increase of RBC aggregation at the early postoperative stage is solely observed in high blood loss and is esteemed as a result of volume therapy. The marked increase of platelet counts and plasma fibrinogen at the late postoperative stage, being more pronounced in high blood loss, might contribute to an elevated prothrombotic risk and is ascribed to an inflammatory response to surgery. In summary, it is concluded, that bleeding tendency corresponding with haemorheologic parameters is enhanced in the early, whereas the prothrombotic risk, well correlating with haemostaseologic parameters, is elevated in the later stage after surgery.

Fibrinolytic and procoagulant activity in septic and haemorrhagic shock.

Septic and haemorhagic shock carry the risk of high mortality. Failure of microcirculation secondary to alterations of haemostasis and fibrinolysis play a major role in the pathogenesis of shock. The aim of this study was to evaluate the clinical relevance of procoagulatory and fibrinolytic activities referring to survival. Therefore, 39 patients (23 to 80 yrs, 16 females, 23 males) suffering from haemorrhagic (n = 21) and septic shock (n = 18) were screened prospectively for plasmatic coagulation and fibrinolysis parameters. Thirteen patients (33.3%) developed lethal outcome. Concerning fibrinolysis, plasminogen was significantly lower in non-survivors by day 1 and plasmin-antiplasmin complex significantly higher by day 4 compared to survivors. Consecutive increase of plasminogen over day 4 and 7 was significantly stronger in survivors. Concerning haemostasis activation, thrombin-antithrombin complex was higher and D-dimers or fibrinogen levels were lower, but not significantly different, in non-survivors compared to survivors. We conclude from these data, that procoagulant activities are increased, but not significantly predictive for the clinical outcome in septic and haemorrhagic shock. By contrast, fibrinolysis, as measured by enhanced capacity and responsiveness, is clearly predictive and plays a significant role for survival, possibly due to its clearing function in microcirculation.

[Anatomic and atypical resections of the gallbladder bed in patients with gallbladder carcinoma]. / Anatomische und atypische Resektionen des Gallenblasenbetts beim Gallenblasenkarzinom.

BACKGROUND: At present, atypical as well as anatomic liver resections are recommended as the surgical therapy for gallbladder cancer (GC) at stages > or = T 2. The aim of this study was to compare atypical with anatomic resections (mostly resections of segments IV b / V with selective vascular occlusion using the round ligament approach). PATIENTS AND METHODS: Between November 1994 and January 2007, n = 56 patients were treated for GC. The staging, operative and histological results and the postoperative course were recorded. In addition, the survivals at a mean follow-up of 13 (range: 3-54) months were estimated and compared between the two study groups. RESULTS: We performed 28 liver resections for GC (n = 14 atypical and n = 14 anatomic resections). In the anatomic resection group, there was one extended right hepatectomy as well as thirteen segment IV b / V resections. The volume of the resected liver specimen, the frequency of the Pringle manoeuvre, the transfusion requirements, and the duration of the operation did not differ between the two study groups. However, in only 64 % of the atypical resections, the recommended resection margin of at least 3 cm could be achieved. One patient died after extended hepatectomy. There were no other major complications. The mean follow-up was 16 +/- 5 months in the anatomic and 22 +/- 7 months in the atypical resection group. Survival was not statistically different between the two study groups. CONCLUSION: Segment IV b / V resections are attractive procedures to treat GC due to their lower invasiveness in spite oncological adequacy. However, we could not demonstrate any superiority in terms of survival for the segment IV b / V liver resections. Nevertheless, extended liver resections are rarely necessary in the operative treatment of GC.

[Intraarterial thrombolysis in acute limb ischaemia: alternative treatment and basic principles of further interventions]. / Lokale Lyse bei akuter peripherer Extremitätenischämie: Therapiealternative und Grundlage weiterer Interventionen.

INTRODUCTION: Intraarterial thrombolysis of acute arterial occlusions in the lower limbs is an established therapeutic procedure. However, its value as a primary treatment is discussed controversially and it is mostly seen as a competing procedure to primary vascular surgical interventions. METHODS: From January 2001 to December 2004, we performed a total of 132 intraarterial thrombolysis procedures in 112 patients with acute or subacute ischaemia of the lower limbs. In the majority of the cases, there was an ischaemia of stage I or II a according to Rutherford, a few further cases were in stage II b at the start of treatment. The patients' ages at the time of thrombolysis was 64.7+/-11.3 years (mean value+/-standard deviation, range: 27-91 years). There were 46 female and 86 male patients. RESULTS: The average duration of thrombolysis was 35.2+/-20.8 hours (mean+/-standard deviation, range: 6-142 hours). As median 2 (range: 0-8) angiographic controls were performed. In 100 cases (75.8%), an operation could be avoided by thrombolysis alone or in combination with an supplementary intervention. On the other hand, in 32 cases (24.2%) a subsequent operative therapy including 10 major amputations (7.6%) was necessary. Because of hemorrhagic complications, 15 thrombolysis procedures (11.4%) had to be terminated prematurely but only 2 patients required an inguinal revision. Therapy-related mortality was 0.8% (1 patient). CONCLUSION: In the majority of our patients, primary intraarterial thrombolysis was successful and often led to the discovery of the underlying vascular lesion. It can serve both as a therapeutic alternative to a primary vascular surgical intervention and as the foundation further interventional or vascular surgical therapies although this cannot always be predicted for individual cases.

[Chronic back pain resulting from a retroperitoneal lymphangioma]. / Chronische Rückenschmerzen als Folge eines retroperitonealen Lymphangioms.

A 39-year-old female patient presented with a 3-year history of lower back pain which had not been alleviated by pain treatment combined with physiotherapy. Radiological findings were normal with the exception of a cystic paravertebral tumor in the left retroperitoneum. The cyst was primarily regarded as a coincidental finding because no criteria for malignancy were present. Magnetic resonance tomography, however, the cyst showed a progressive increase in size and the pain remained unchanged so that surgical resection was performed. The histopathological examination showed a lymphangioma and the pain was nearly completely resolved after surgery.

[An adrenal pseudocyst as the cause of chronic back pain]. / Eine adrenale Pseudozyste als Ursache chronischer Rückenschmerzen.

We present the case of a 36 year old female patient with a 3 month history of severe lower back pain without improvement after physiotherapy and analgesic drug therapy. X-rays of the spine were normal except for a calcified paravertebral lesion on the right side. A cystic tumor projecting on the posterior area of the right liver lobe was seen using ultrasound. MRI-scan showed an extrahepatic localization of the tumor. Intraoperatively, the tumor was located in the right adrenal gland which was then removed. Histopathology revealed an adrenal pseudocyst, and the pain was gone immediately after surgery.

[Cystic lesion of the dorsal mediastinum]. / Zystische Raumforderung im hinteren Mediastinum.

We present the case of a 52-year-old male who underwent thoracotomy for resection of a suspected bronchogenic cyst in the right posterior mediastinum. The size of the tumor had increased over years, according to repeated X-rays, and the cyst became symptomatic with obstruction of the right subclavian and jugular veins. To our surprise, histopathology revealed a hydatid cyst.

The effect of differential reproductive success on population genetic structure: correlations of life history with matrilines in humpback whales of the gulf of maine.

To examine whether demographic and life-history traits are correlated with genetic structure, we contrasted mtDNA lineages of individual humpback whales (Megaptera novaeangliae) with sighting and reproductive histories of female humpback whales between 1979 and 1995. Maternal lineage haplotypes were obtained for 323 whales, either from direct sequencing of the mtDNA control region (n = 159) or inferred from known relationships along matrilines from the sequenced sample of individuals (n = 164). Sequence variation in the 550 bp of the control region defined a total of 19 maternal lineage haplotypes that formed two main clades. Fecundity increased significantly over the study period among females of several lineages among the two clades. Individual maternal lineages and other clades were characterized by significant variation in fecundity. The detected heterogeneity of reproductive success has the potential to substantially affect the frequency and distribution of maternal lineages found in this population over time. There were significant yearly effects on adult resighting rates and calf survivorship based on examination of sighting histories with varying capture-recapture probability models. These results indicate that population structure can be influenced by interactions or associations between reproductive success, genetic structure, and environmental factors in a natural population of long-lived mammals.

Cues to participation in prostate cancer screening: a theory for practice.

PURPOSE/OBJECTIVES: To develop and test the Cues to Participation in Prostate Cancer Screening Theory, which proposes that exposure to information from certain sources cues or triggers screening. DESIGN: Descriptive correlational. SETTING: 11 counties of a southeastern state. SAMPLE: Convenience sample of 1,867 men at risk for prostate cancer (72% African American; 28% Caucasian). METHODS: Recent exposure to prostate cancer information was measured. Men were offered free screening by prostate specific antigen (PSA) and digital rectal exam (DRE). MAIN RESEARCH VARIABLES: Demographic variables (race, age, education, income, and marital status), exposure (electronic media, print media, healthcare provider recommendation, and interpersonal interactions), and screening as measured by PSA and DRE. FINDINGS: Several major propositions of the Cues to Participation Theory were supported. General exposure to prostate cancer information significantly predicted screening participation. Hearing about prostate cancer from a healthcare provider was the best predictor of screening. CONCLUSIONS: Men's demographic characteristics should be considered when providing information about prostate cancer. Hearing about prostate cancer from family and friends was not significantly related to screening behavior. IMPLICATIONS FOR NURSING PRACTICE: The importance of recommendations for prostate cancer screening is underscored.

Home- and community-based long-term care: lessons from Denmark.

PURPOSE: Denmark is cited as a model in the development of home- and community-based systems for the frail elderly population. We examined the results of this natural experiment and considered implications for U.S. policy. DESIGN AND METHODS: We used international comparative policy analysis, including site visits and semistructured interviews with Danish leadership in conjunction with a review of published literature, reports, and administrative data from Denmark and the United States. RESULTS: After 12 years of implementing integrated systems for home- and community-based services in 275 municipalities, growth in Danish long-term care expenditures has leveled off; expenditures appear to be decreasing for the over-80 population and have dropped as a percentage of the gross domestic product. Access to and quality of long-term care services appear to remain generally satisfactory. During this period, comparable expenditures in the United States have increased, and deficits in access and quality persist. IMPLICATIONS: These findings should be of interest to state and federal policy makers considering strategies to reduce the rate of growth in Medicaid and Medicare expenditures for elders and to expand home- and community-based services.

Training agrammatic subjects on passive sentences: implications for syntactic deficit theories.

We trained two subjects with chronic agrammatic aphasia on production of passive sentences using a computerized, iconic-based communication system. After training, one of the subjects demonstrated significant improvements in his abilities to comprehend and verbally produce English passive voiced sentences, including sentences with conjoined subjects and objects. These results suggest that agrammatism does not represent a fixed syntactic deficit.