Natural conception resulting in a ruptured heterotopic pregnancy in a multiparous woman.

A 31-year-old multigravida woman 16 weeks pregnant by natural conception presented with right lower abdominal pain and bloody emesis. She was hypotensive and anemic with hemoperitoneum resulting from rupture of an ectopic pregnancy. At operation, she was found to have a right tubal heterotopic pregnancy with attachments to the appendix and omentum.

Deficiencies with current aortic endografts.

Endovascular aortic aneurysm repair (EVAR) has currently replaced open surgical repair as the primary method for treating aneurysm disease of the abdominal aorta and common iliac artery. Current EVAR devices, despite undergoing multiple improvement iterations, continue to have relatively high secondary intervention rates. Device migration, endoleak and limb occlusion continue to be challenges not completely met by any of the current devices. Investigational devices presently in clinical trials may provide significant resolution for many of the identified endograft deficiencies.

The 'propofol infusion syndrome': the facts, their interpretation and implications for patient care.

AstraZeneca (the manufacturer of Diprivan) presents its review of the history of the so-called 'propofol infusion syndrome', highlighting the difficulties in analysing the incomplete information available. Theories as to its causality are presented and discussed; these include mitochondrial toxicity, mitochondrial defects, impaired tissue oxygenation and carbohydrate deficiency. A review of published and confidential safety data is presented and discussed; it concludes that the major risk factors for its development appear to be poor oxygen delivery, sepsis, serious cerebral injury and high propofol dosage. In some reports an increasing lipaemia was noted and was likely to be due to a failure of hepatic lipid regulation, possibly related to poor oxygenation and/or possibly a lack of glucose. In some cases an increasing lipaemia was the first indication of impending 'propofol infusion syndrome' onset and it should not be viewed as a benign sign. The lipaemia can lead to sequestration of propofol into the lipid phase, leading to lowered free propofol levels and apparent insensitivity to propofol. In conclusion AstraZeneca advocates good haemodynamic and oxygen delivery management, adequate glucose provision, adherence to recommended propofol dosing regimes together with active management of lipaemias to both prevent and treat 'propofol infusion syndrome'.

Duration or disadvantage? Exploring nativity, ethnicity, and health in midlife.

OBJECTIVES: This study examined nativity as a risk factor for poor physical and emotional health for an ethnically diverse population making the transition into retirement. The authors addressed whether the health disadvantage observed for immigrants lessens with increased time spent in the country (supporting theories of assimilation) or increases with duration of residence (supporting theories of cumulative disadvantage). METHODS: The sample was drawn from Waves 1 and 2 of the Health and Retirement Study (HRS), an in-depth economic, social, and health database of persons in midlife and beyond. The analyses were restricted to 9,912 native-born and 1,031 foreign-born individuals. RESULTS: The data revealed that after socioeconomic factors were controlled, foreign-born individuals were at higher risk of poor emotional health than their native-born counterparts. Although aging immigrants displayed worse health than the native-born population, this disadvantage was mediated by duration of residence (young age at migration) and socioeconomic incorporation. DISCUSSION: These findings extend our understanding of nativity and duration as risk factors for poor physical and emotional health. Immigrants may overcome the nativity disadvantages found for emotional distress with increased duration of residence, but the pattern becomes more complicated with the inclusion of race and Hispanic ethnicity.

Quality vascular surgical care: the importance of innovation and change in an era of dwindling reimbursement.

BACKGROUND: Reductions in vascular surgery reimbursement emphasize the need to decrease cost while maintaining quality. Hospital solvency is essential if we are to preserve acceptable levels of nursing/support personnel and acquire new diagnostic and treatment programs. METHODS: Care processes for patients undergoing carotid, aortic, or dialysis access surgery were retrospectively analyzed and new quality- and cost-oriented treatment algorithms and clinical pathways were developed and implemented using case management principles. Preoperative risk stratification, length of stay, costs, complications, outcomes, and patient satisfaction were compared before and after these revisions in the care process. Statistical analyses were done using the Wilcoxon Rank sum test and Fisher exact test. RESULTS: Significant reductions in length of stay, intensive care use, and cost of treatment and diagnosis were achieved without adversely affecting morbidity, mortality, or patient satisfaction. CONCLUSION: Use of algorithm, clinical pathway, and case management principles resulted in a marked improvement in the "bottom line" for vascular surgical procedures in our academic medical center.

Retroperitoneal approach for aortic surgery: is it worth it?

BACKGROUND: Previous reports suggest that earlier hospital discharges and reduced postoperative complications occur when a retroperitoneal approach is used for aortic surgery. Other publications refute this concept. In an effort to determine the most cost efficient method for aortic surgery in our institution, while maintaining high standards of care and outcome, we compared the retroperitoneal approach to the conventional transperitoneal aortic operation. PATIENTS AND METHODS: Between December 1995 and April 1998, 120 patients underwent aortic surgery by either the transperitoneal (n=60) or retroperitoneal approach (n=60). All patients were enrolled prospectively in a vascular registry and retrospectively reviewed. Patients were randomly assigned to one of three vascular surgeons. A clinical pathway for elective aortic surgery was developed and applied to both groups. Patients were evaluated with respect to demographics, comorbidities, preoperative risk stratification, conduct of the operative procedure, length of stay, complications, cost, clinical outcomes and patient satisfaction. The indications for aortic surgery were similar in both groups - 64% for aneurysm disease and 36% for occlusive disease. Both symptomatic and asymptomatic aneurysms were included and size ranged from 4.4 to 14cm. All aortic reconstructions were done in the standard manner using knitted Dacron velour prostheses in either the aortic tube, bi-iliac or bi-femoral configuration. Statistical analysis of means and medians was accomplished using the Wilcoxin Rank-sum test and percentages were compared using Fisher's Exact test. P values less than 0.05 indicate statistical significance. RESULTS: There were no statistically significant differences in patient demographics. The incidence of atherosclerotic coronary artery disease, obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco abuse, distal lower extremity occlusive disease and the results of chemical myocardial stress evaluations were similar in both groups. Comorbidities of pre-existing renal insufficiency/failure and morbid obesity were increased in the retroperitoneal group. Five patients in the retroperitoneal group represented redo aortic surgery and there were no redo procedures in the transperitoneal group. Length of operative procedures and blood replacement requirements for both groups were similar. The transperitoneal group required 2-3l more intraoperative intravenous (IV) crystalloid than the retroperitoneal group (P<0.0001). Statistically significant reductions in ICU days, postoperative ileus and total lengths of stay were observed in the retroperitoneal group (P<0.0001). This resulted in substantial reductions in hospital costs for the retroperitoneal group (P<0.01). Postoperative complications were similar for both groups except for statistically significant increases in pulmonary edema (P<0.01) and pneumonia (P<0.001) in the transperitoneal group. Cardiac arrhythmias, primarily atrial dysrhythmias, were more frequent in the transperitoneal group but this failed to reach statistical significance (P<0.16). Combined thirty day mortality was 0.9%. Time of recovery to full activity and patient satisfaction substantially favored the retroperitoneal group. CONCLUSION: Our clinical pathway and algorithm for aortic surgery was easily followed by those patients in the retroperitoneal approach group and resulted in decreases in ICU time, postoperative ileus, volume of intraoperative crystalloid and total length of stay. The patients in the transperitoneal group often failed to progress appropriately on the pathway. Reduced hospital costs associated with aortic surgery using the retroperitoneal approach has increased the profitability for this surgery in our institution by an average of $4000 per case and has increased the value (quality/cost) of this surgery to our patients and our institution.

Suggested treatment protocol for improving patency of femoral-infrapopliteal cryopreserved saphenous vein allografts.

PURPOSE: Cryopreserved saphenous vein allografts are used for femoral-infrapopliteal bypass graft purposes when adequate autogenous vein is unavailable. Anticoagulation, immunosuppression therapy, or both have been suggested means for improving allograft patency. Immunosuppression has significant cost and morbidity and has produced variable results. Our successful treatment of luminal surface hypercoagulability associated with certain endovascular procedures prompted the use of an anticoagulation protocol prospectively to improve graft patency and limb salvage for patients receiving femoral-infrapopliteal cryopreserved saphenous vein allografts. METHODS: Between September 1995 and October 1999, 24 patients (15 men and nine women) were enrolled in a prospective clinical trial for salvage of 26 severely ischemic lower limbs with femoral-infrapopliteal cryopreserved saphenous vein allograft bypass grafts. All patients were treated with a protocol (aspirin, low-dose heparin, low molecular weight dextran 40, dipyridamole, and warfarin), and no immunosuppressive agents were used. The cryopreserved saphenous vein allografts were matched to patients by ABO and Rh compatibility. Indications for revascularization were ischemic rest pain (n = 8), nonhealing ulcer (n = 13), or focal gangrene (n = 5), and no usable autogenous vein was available. Follow-up ranged from 2 to 35 months (mean, 19 months). We studied the location and type of outflow anastomosis, specific outflow vessel, morbidity, death, secondary procedures (digital/transmetatarsal amputation), and complications related to the treatment protocol. Life table analyses of primary graft patency and limb salvage were compared with other current reported data. RESULTS: Primary graft patency with Kaplan-Meier life table analysis was 96% at 6 months, 87% at 12 months, and 82% at 18 and 24 months. There were no reoperations for acute graft occlusion. One graft underwent late segmental aneurysmal degeneration and rupture. There were no procedure-related deaths or bleeding complications. During late follow-up, anticoagulation was discontinued in three patients (12%) because of gastrointestinal bleeding. Limb salvage was 88% at 6 months and 80% at 12, 18, and 24 months. Patients returned to ambulatory status that was limited only by their other comorbidities. CONCLUSION: Femoral-infrapopliteal bypass graft for limb salvage with a cryopreserved saphenous vein allograft can be an acceptable alternative when autogenous vein is not available. Our treatment protocol substantially improved allograft patency and limb salvage when compared with current published data.

Transesophageal atrial pacing reduces phenylephrine needed for blood pressure support during carotid endarterectomy.

OBJECTIVE: To determine whether transesophageal atrial pacing reduces phenylephrine requirement for blood pressure support during general anesthesia for carotid endarterectomy. DESIGN: Prospective randomized clinical study. SETTING: University hospital. PARTICIPANTS: Thirty-six patients undergoing elective carotid endarterectomy under general anesthesia. INTERVENTIONS: Adults of either sex (n = 36) received general anesthesia using a standardized anesthetic regimen for elective carotid endarterectomy. Phenylephrine requirements were measured in patients having carotid endarterectomy and randomized to phenylephrine infusion (group 1, 19 patients) or phenylephrine infusion plus transesophageal atrial pacing (group 2, 17 patients) to maintain systolic blood pressure within +/-20% of baseline systolic blood pressure. MEASUREMENTS AND MAIN RESULTS: Measurements included (1) the amount of phenylephrine required in each group, (2) the variance of systolic blood pressure outside the desired range, and (3) the occurrence of postoperative electrocardiogram or myocardial enzyme changes suggesting myocardial ischemia. The average requirement for phenylephrine was less for group 2 (0.28+/-0.16 microg/kg/min) than for group 1 patients (0.46+/-0.23 microg/kg/min) (p = 0.02 by t-test). CONCLUSIONS: Under controlled conditions of general anesthesia for carotid endarterectomy, transesophageal atrial pacing reduced by 40% the amount of phenylephrine needed for blood pressure support and helped in the treatment of disadvantageous sinus bradycardia.

Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels.

BACKGROUND: Carotid endarterectomy (CEA) is the standard of care for patients with high-grade carotid artery stenosis who are acceptable surgical candidates. Focal occlusive lesions of the origin of aortic arch vessels can be effectively and safely treated with balloon angioplasty and primary stenting. The purpose of this study was to retrospectively review results of carotid endarterectomy for high-grade carotid bifurcation stenosis combined with intraoperative retrograde transluminal angioplasty and primary stenting of a hemodynamically significant stenosis at the origin of a proximal ipsilateral aortic arch vessel. METHODS: Between October 1994 and August 1998, 592 patients underwent CEA. Six patients were found to have hemodynamically significant tandem lesions affecting one of the aortic arch vessels and the ipsilateral ICA for an overall incidence of 1%. Age ranged from 63 to 78 years (mean 74.7). Four of 6 (67%) patients had asymptomatic lesions, and 2 of 6 (33%) had symptoms of cerebral ischemia. Five patients had tandem lesions affecting the proximal left common carotid artery and the left ICA. One patient had a tandem lesion affecting the innominate artery and the right ICA. Carotid duplex imaging and arch and cerebral arteriography was performed in all six patients. Arteriography confirmed high-grade stenoses in both the ICA and ipsilateral proximal aortic arch vessel. The range of stenoses in the ICA was 70 to 95% (mean 80.8%) measured arteriographically. The range of stenoses at the origin of the aortic arch vessels was 75-90% (mean 79.2%). All six patients underwent combined retrograde transluminal balloon angioplasty and primary stenting of the ipsilateral CCA or innominate artery with temporary occlusion of the ICA for cerebral protection. The endovascular procedure was then followed with standard surgical endarterectomy using an inline shunt. RESULTS: All six procedures were successfully completed. There were no periprocedural strokes or other morbidities. Follow-up ranged from 6 to 43 months (mean 23.6) and showed no evidence of recurrent stenosis by carotid duplex imaging. No TIAs or strokes related to the surgically corrected lesions were noted during the follow-up period. One patient suffered a right hemispheric stroke secondary to a high-grade right carotid stenosis which occurred two months after her procedure surgically correcting tandem lesions on the opposite side. CONCLUSIONS: Carotid endarterectomy with balloon angioplasty and primary stenting of an ipsilateral hemodynamically significant aortic arch trunk vessel stenosis can be safely and successfully accomplished and avoids the need for an intra/extrathoracic bypass procedure.

Economic considerations for aortic surgery: retroperitoneal approach--is it worth it?

BACKGROUND: Planned reductions in reimbursement for all forms of vascular surgery dictate a need for the development of more cost efficient, yet quality oriented, treatment programs. We are faced with an increasingly older patient population with multiple comorbidities. In this environment it will become extremely difficult to accomplish aortic surgery in a way which will be profitable for our hospitals. More than 100,000 aortic surgeries are performed annually in the United States. Previous reports suggest that earlier hospital discharges and reduced postoperative complications occur when a retroperitoneal approach is used for aortic surgery. Other publications refute this concept. In an effort to determine the most cost efficient method for aortic surgery in our institution, while maintaining high standards of care and outcome, we compared the retroperitoneal approach to the conventional transperitoneal aortic operation. PATIENTS AND METHODS: Between December 1995 and April 1998, 120 patients underwent aortic surgery by either the transperitoneal (n = 60) or retroperitoneal approach (n = 60). All patients were enrolled prospectively in a vascular registry and retrospectively reviewed. Patients were randomly assigned to one of three vascular surgeons. A clinical pathway for elective aortic surgery was developed and applied to both groups. Patients were evaluated with respect to demographics, comorbidities, preoperative risk stratification, conduct of the operative procedure, length of stay, complications, cost, clinical outcomes and patient satisfaction. The indications for aortic surgery were similar in both groups--64% for aneurysm disease and 36% for occlusive disease. Both symptomatic and asymptomatic aneurysms were included and size ranged from 4.4 cm to 14 cm. All aortic reconstructions were done in the standard manner using knitted Dacron velour prostheses in either the aortic tube, bi-iliac or bi-femoral configuration. Statistical analysis of means and medians was accomplished using the Wilcoxin Rank-sum test and percentages were compared using Fisher's Exact test. P values less than 0.05 indicate statistical significance. RESULTS: There were no statistically significant differences in patient demographics. The incidence of atherosclerotic coronary artery disease, obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco abuse, distal lower extremity occlusive disease and the results of chemical myocardial stress evaluations were similar in both groups. Comorbidities of preexisting renal insufficiency/failure and morbid obesity were increased in the retroperitoneal group. Five patients in the retroperitoneal group represented redo aortic surgery and there were no redo procedures in the transperitoneal group. Length of operative procedures and blood replacement requirements for both groups were similar. The transperitoneal group required 2-3 liters more intraoperative intravenous (i.v.) crystalloid than the retroperitoneal group (p < 0.0001). Statistically significant reductions in ICU days, postoperative ileus and total lengths of stay were observed in the retroperitoneal group (p < 0.0001). This resulted in substantial reductions in hospital costs for the retroperitoneal group (p < 0.01). Postoperative complications were similar for both groups except for statistically significant increases in pulmonary edema (p < 0.01) and pneumonia (p < 0.001) in the transperitoneal group. Cardiac arrhythmias, primarily atrial dysrhythmias, were more frequent in the transperitoneal group but this failed to reach statistical significance (p < 0.16). Combined thirty day mortality was 0.9%. Time of recovery to full activity and patient satisfaction substantially favored the retroperitoneal group. CONCLUSION: Our clinical pathway and algorithm for aortic surgery was easily followed by those patients in the retroperitoneal approach group and resulted in decreases in ICU time, postoperative ileus, volume of intraoperative crystalloid and total length of stay. The patients in the transperitoneal group often failed to progress appropriately on the pathway. Reduced hospital costs associated with aortic surgery using the retroperitoneal approach has increased the profitability for this surgery in our institution by an average of $4000 per case and has increased the value (quality/cost) of this surgery to our patients and our institution. This was accomplished in an academic environment with surgical residency training where cost containment has historically been difficult.

Clinical application of perioperative evidence-based practice.

Practitioners today are seeing changes in our health care system, economic pressures related to decreased reimbursement, and the growth of managed care that are producing major adjustments in health professions' education, patient care, and research. Evidence-based practice (EBP) is considered by many to be the way of the future. This article describes factors affecting implementation of EBP in the clinical arena. It also gives some practical applications found when implementing EBP at one hospital.

Mobile atheroma of the aortic arch and the risk of carotid artery disease.

BACKGROUND: Mobile atheromas of the aortic arch are associated with otherwise unexplained strokes and transient ischemic attacks (TIA). They are associated with increased perioperative strokes in patients undergoing coronary artery bypass surgery. Peripheral embolization is an additional risk. Transesophageal echocardiography (TEE) accurately identifies mobile atheroma. Anticoagulant therapy may have therapeutic considerations in the management of this condition. However, the risk of significant carotid artery disease associated with mobile atheromas is unknown. METHODS: Between March 1994 and July 1998, 40 patients with mobile atheromas by TEE and evidence of embolization were studied. All patients were captured prospectively in a vascular registry and were retrospectively reviewed. Carotid artery disease was evaluated using carotid duplex imaging in an accredited vascular laboratory. All patients with significant carotid disease, 70% or greater stenosis, underwent arteriography. Patients with significant carotid artery stenosis then underwent carotid endarterectomy. All patients with mobile atheromas were maintained on anticoagulation. RESULTS: Forty patients with mobile atheromas of the aortic arch were diagnosed with TEE. All 40 patients had evidence of embolization. Patient age ranged from 57 to 73 years (mean 68.4). There were 22 men and 18 women. Twenty of 40 (50%) patients presented with symptoms of TIA. Eleven of 40 (28%) patients presented with diffuse atheroembolization (lower extremity embolization and renal insufficiency). Six of 40 (15%) patients presented with a completed stroke. Three of 20 (7%) patients presented with acute extremity ischemia secondary to a peripheral embolus. Twenty-three of 40 (58%) of patients had significant carotid artery stenosis, 70% or greater stenosis. These 23 patients underwent both arteriography and carotid endarterectomy without complication. All patients were treated with anticoagulation and have remained anticoagulated. Clinical follow-up between 2 to 48 months (mean 18) has demonstrated no further evidence of systemic embolization in these 40 patients. Repeat TEE was performed in 6 of 40 patients. These follow-up studies no longer visualized mobile atheromas. CONCLUSIONS: Mobile atheromas are recognized sources for embolization. Routine carotid duplex imaging should be performed in patients found to have mobile atheromas of the aortic arch. Carotid endarterectomy appears to be safe in patients who have combined carotid artery stenosis and mobile atheromas. Anticoagulation may have therapeutic considerations in the management of this condition.

Use of intravascular ultrasound improves long-term clinical outcome in the endovascular management of atherosclerotic aortoiliac occlusive disease.

PURPOSE: This study was undertaken to determine whether the use of intravascular ultrasound (IVUS) during balloon angioplasty and stenting of atherosclerotic aortoiliac occlusive lesions improved long-term clinical outcome. IVUS has been previously shown to be more accurate than arteriography in evaluating the deployment of stents in both peripheral and coronary arteries. Incomplete stent deployment has been anecdotally identified as a cause of restenosis or occlusion of a treated lesion. To our knowledge, there have been no previous studies that demonstrate whether the use of IVUS will affect the long-term patency rate of stented arterial lesions. METHODS: Between March 1992 and October 1995, 52 patients with symptomatic aortoiliac occlusive disease underwent balloon angioplasty and stenting of their lesions. We retrospectively reviewed these cases to determine whether the use of IVUS influenced the long-term patency rate of these interventions. Follow-up ranged from 1 to 4 years with a mean of 28 months. RESULTS: Fifty-two patients had confirmation of adequate stent deployment by arteriography. IVUS was used in conjunction with arteriography in 36 patients to evaluate stent deployment. Patients in the IVUS-assisted group were slightly younger than those patients who were evaluated solely by arteriography (p < 0.01). No statistical differences were noted between the two groups with respect to coronary artery disease, diabetes mellitus, obstructive pulmonary disease, hypertension, or obesity. Length of hospital stay, number of stents used, and preoperative ankle brachial indexes were comparable in both groups. In the arteriography plus IVUS group, 40% of patients had underdeployed stents by IVUS evaluation, though they appeared adequately expanded by arteriography. No restenoses or occlusions were seen in the arteriography plus IVUS group. Restenosis or occlusion of the stented lesion occurred in 25% of patients evaluated by arteriography alone (p < 0.01). These failures were treated by either thrombolysis or catheter thrombectomy and were then evaluated with IVUS. All were found to have underdeployed stents. Subsequent treatment consisted of adequate redeployment of existing stents using IVUS criteria. These salvaged reconstructions have continued to remain patent. CONCLUSIONS: The use of IVUS may be the best means for assessing adequacy of arterial stent deployment. Our study suggests that the use of IVUS improves the long-term clinical outcome of balloon angioplasty and stented aortoiliac occlusive lesions.

Impact of intravascular ultrasonography in the endovascular management of aortoiliac occlusive disease.

Intravascular ultrasonography (IVUS) is one of several new imaging technologies that have been applied in the treatment of arterial occlusive disease. Endovascular procedures are increasing annually, and arteriography, which is thought to be the "gold standard" for assessing adequacy of endovascular therapy, appears to have flaws. IVUS, a new imaging technique that expands the understanding of atherosclerotic lesions, images a vessel in a cross-sectional plane and provides information about the morphology of the lesion and the vessel wall. IVUS clearly visualizes the spatial relationship between a deployed stent and the vessel wall; this information is not usually obtainable with arteriography. We conducted 2 studies at our institution to evaluate the use of IVUS in the endovascular treatment of atherosclerotic aortoiliac occlusive disease. The first study showed that actual vessel size and lumen diameter were underestimated 62% of the time by arteriography and that 40% of stents (P < .01) placed in the iliac arterial system were underdeployed, which might be related to treatment failure. The second study showed that the use of IVUS had a positive effect on the long-term patency of angioplastied and stented iliac lesions--all of these reconstructions have remained patent to date. IVUS appears to be the best means of assessing morphology of the arterial occlusive lesions and the results of endovascular intervention. IVUS provides valuable information related to diagnosis and treatment that can alter the conduct of endovascular procedures.

Endovascular surgery: past, present, future.

In the 33 years since Dotter described his innovative treatment of an arterial obstruction using transluminal dilatation, endovascular therapy has developed into an important and necessary part of the treatment of occlusive vascular diseases. Today, three major endovascular therapies: balloon dilatation, intraluminal stenting, and athrectomy have earned full FDA approval and have predictable and acceptable short- and long-term outcomes. These procedures may be used as "stand alone" therapies or in conjunction with standard vascular surgical reconstructions to provide the best outcome for each patient. In general, endovascular treatment can be expected to result in lower morbidity and mortality than traditional vascular surgical interventions. However, the long-term outcome of these therapies is often less durable. Both the standard and endovascular therapies will likely be performed into the 21st century; so an appropriate treatment program specific for an individual patient can be developed. This program should balance risks of treatment with anticipated benefits when considering the expected longevity and comorbid conditions of the patient. A new technology with limited FDA approval is the technique of endovascular grafting. This technology and the development of new treatments to minimize or prevent restenosis should revolutionize the practice of vascular surgery in the future.

Extended wear disposable soft contact lenses as an alternative to photorefractive keratectomy: report of 4 years experience.

PURPOSE: To establish whether, in a well-informed population, the use of extended wear disposable soft contact lenses (EWDSCL) poses an unacceptable risk to vision and corneal health due to complications associated with their use. METHODS: A 4 year retrospective review of EWDSCL, involving 371 patients in Melbourne from a single general ophthalmology practice. The important aspects of this group were that all patients were given written instructions about the methods of ensuring initial and ongoing cleanliness of lenses, no lenses were cleaned and reinserted, and no solutions other than the saline in the original packaging, and comfort crops, were used. Two types of EWDSCL were used in powers from -9.0 to +6.0 D, and with an initial aim of 4 weeks uninterrupted extended wear. Follow-up was from 2 to 52 months, with an average of 24 months. RESULTS: Of the 354 patients followed up, 236 (66%) regularly wore them on an extended overnight basis, and of these 180 (76%) wore them for the suggested 4 week period before renewal of lenses. In the 471 eyes of 236 patients, adverse reactions occurred at the following rates, marginal infiltrates (12 cases, 2.5%); corneal oedema (10 cases, 2%) peripheral corneal vascularization (2 cases, 0.4%); and presumed infective keratitis (1 case, 0.2%). No eyes lost one or more lines of Snellen acuity. CONCLUSIONS: When disposable soft contact lenses do not come into contact with cleaning solutions, saline from bottles or aerosol cans, or storage cases, their use on an extended wear basis (up to 4 weeks continuous) appears to be associated with a low risk of minor or major complications. The results of this review indicate that controlled usage of EWDSCL is safer than previous reports have indicated.

Gender, age and the marriage market: evidence on marriage in late adulthood in Russia.

"In this paper I explore one specific type of informal support, marital unions, and the ways in which patterns suggest differential access to this support mechanism based on age and sex. Through an examination of marriage patterns in the Russian Federation I show that women may be disadvantaged by low levels of access to marital unions past the age of 50 due to high differential mortality and age differentials at marriage. For both sexes, the probability of marital entrance is negatively related to age, but the negative influence of age follows different paths for men and women. In spite of high sex differentials in mortality, findings indicate that men, over 50 and outside of marital unions, are far more likely to marry than their female counterparts regardless of residence or age."