Factors associated with psychotic symptoms in Alzheimer''s disease

BACKGROUND: The incidence of abdominal aortic aneurysm (AAA) has increased steadily during the past 30 years. METHODS: Trends in the incidence and surgical intervention for AAA in Western Australia were reviewed for the interval 1985-1994. A population-based health database was used to link morbidity and mortality records of all patients aged 55 years or more who died from rupture or were admitted and treated surgically for AAA. Three groups were separated for analysis: patients with a ruptured AAA, those admitted for elective repair and those admitted as an emergency with an acute (non-ruptured) aneurysm. RESULTS: There was a decline in the incidence of both emergency and elective procedures for AAA after 1992. While the mortality rate from ruptured AAA has also fallen since 1991, the overall case fatality rate for ruptured AAA has fallen by only 1.3 per cent (from 80.7 to 79.3 per cent). CONCLUSION: The decline in mortality rate and emergency procedures may result from a fall in the incidence of ruptured AAA, due to an increasing rate of elective surgery before 1992. The decline in elective procedures from 1992 may be due to a fall in the prevalence of AAA owing to high rates of elective surgery, or to a fall in the incidence of the disease itself.     

A 21-year experience of abdominal aortic aneurysm operations in Edinburgh

BACKGROUND: This study reviews the results of infrarenal abdominal aortic aneurysm (AAA) surgery over 21 years (1 January 1976 to 31 December 1996). METHODS: A prospectively gathered database was analysed. RESULTS: Infrarenal AAA repair was performed in 1515 patients: 492 (32.5 per cent) had elective repair of an asymptomatic AAA; 194 (12.8 per cent) had elective repair of a symptomatic AAA; 156 (10.3 per cent) had emergency repair of a symptomatic non-ruptured AAA; and 673 (44.4 per cent) had surgery for a ruptured AAA. The 30-day and/or same admission mortality rates were 6.1, 5.8, 14.1 and 37 per cent respectively. Operative mortality increased in all four groups over the study interval, although this only attained statistical significance in patients having elective repair of a symptomatic, non-ruptured AAA. There was a significant increase in the age of patients undergoing elective repair of an asymptomatic AAA, but not in the other three groups. There was also a significant increase in the proportion of straight 'tube' grafts inserted in all four groups. CONCLUSIONS: It remains the minority of patients who have elective operation before the onset of symptoms and/or rupture. Despite anaesthetic and surgical specialization, the results of AAA repair have not improved over the past two decades. Operative mortality may be increasing, possibly because of the increasing age and associated comorbidity of the patients presenting to this unit.     

Mortality following elective infrarenal aortic reconstruction: a Joint Vascular Research Group study

BACKGROUND: This study aimed to define the cause of death in patients undergoing elective infrarenal aortic reconstruction. METHODS: Members of the Joint Vascular Research Group who had collected details prospectively of patients undergoing elective aortic reconstruction provided information on those who died. RESULTS: Details of 3786 patients were obtained. Some 171 patients died (133 following abdominal aortic aneurysm (AAA) and 38 after aortofemoral bifurcation graft (AFBG) for occlusive disease). The mortality rate following AAA repair was 4.8 per cent, rising to 16 per cent if repair was combined with either renal or distal reconstruction (P < 0.001). Similar results were obtained with AFBG (3.4 and 11 per cent respectively, P < 0.001). The first major complication encountered was cardiac (39.8 per cent), followed by bleeding (20.5 per cent), respiratory (13.5), and gut (5.3 per cent), or limb ischaemia (6.4 per cent). Bleeding was commoner following reconstruction for aneurysm compared with that for occlusive disease (P < 0.05). Eighty-six patients (50.3 per cent) died from the first major complication. Of the remainder, 45 (53 per cent) developed multisystem organ failure (MSOF). The most commonly involved systems were cardiac, respiratory and renal. CONCLUSION: Cardiac problems were the major cause of death following infrarenal aortic reconstruction. MSOF is the 'final common pathway' in about half of the patients who survive the initial complication.     

Effect of intraluminal thrombus on abdominal aortic aneurysm wall stress

PURPOSE: Abdominal aortic aneurysms (AAAs) rupture when the wall stress exceeds the strength of the vascular tissue. Intraluminal thrombus may absorb tension and reduce AAA wall stress. This study was performed to test the hypothesis that intraluminal thrombus can significantly reduce AAA wall stress. METHODS: AAA wall stresses were determined by axisymmetric finite element analysis. Model AAAs had external diameters ranging from 2.0 to 4.0 cm. Model parameters included: AAA length, 6 cm; wall thickness, 1.5 mm; Poisson's ratio, 0.49; Young's modulus, 1.0 MPa; and luminal pressure, 1.6 x 10(5) dyne/cm2. Stresses were calculated for each model without thrombus, and then were recalculated with thrombus filling 10% of the AAA cavity. Calculations were repeated as thrombus size was increased in 10% increments and as thrombus elastic modulus increased from 0.01 MPa to 1.0 MPa. Maximum wall stresses were compared between models that had intraluminal thrombus and the unmodified models. Stress reduction greater than 25% was considered significant. RESULTS: The maximum stress reduction of 51% occurred when thrombus with elastic modulus of 1.0 MPa filled the entire AAA cavity. Stresses were reduced by only 25% as modulus decreased to 0.2 MPa. Similarly, decreasing thrombus size by 70% resulted in stress reduction of only 28%. Large AAAs experienced greater stress reduction than small AAAs (48% vs 11%). CONCLUSION: Intraluminal thrombus can significantly reduce AAA wall stress.     

Cyanamide-induced granulocytopenia

BACKGROUND: The appropriate management of patients who are older than 80 years of age and who present with an abdominal aortic aneurysm (AAA) remains controversial. While it appears that elective repair can be performed safely, appropriate management of these patients in the emergency situation is unclear. The purpose of the present study was to examine the results obtained in treating this elderly group in the elective and emergency setting, by operation and conservative techniques at St George Hospital, Kogarah. METHODS: Between January 1987 and December 1994 85 patients older than 80 years of age were treated for AAA. These patients were divided into four groups: I, elective presentation/no surgery; II, elective presentation/elective surgical repair; III, emergency presentation/surgical repair; and IV, emergency presentation/conservative treatment. We examined age, sex, size of AAA, mode of presentation, type of treatment, length of survival and cause of death. RESULTS: The mean age of the total group (n = 85) of patients was 84 years (range: 80-94). The mean AAA diameter for this group was 5.6 cm (95% CI: 5.2-6 cm). The diameters for group I (n = 40), II (n = 22), III (n = 16) and IV (n = 7) were 4.9 cm (4.4-5.5, 95% CI), 5.7 (4.9-6.5 CI), 7.0 (6.1-7.7 CI) and 6.2 (5.2-7.2 CI), respectively. The median survival for groups I, II, III and IV was 18, 38.5, 0.25 and 0 months, respectively. Group II had a longer survival than any other group (P = 0.015), and group IV had a shorter survival than the total group (P = 0.001). However, the length of survival was no different for III versus IV (P = 0.146). Deaths in each group were due to the following reasons. I: cardiopulmonary events (14), rupture (3), malignancy/sepsis (3); II: cardiopulmonary events (3), rupture (thoracic aneurysm) (2), malignancy (I); III: rupture (10), malignancy (I); and (IV): rupture (6), malignancy (1). CONCLUSIONS: Elective surgical repair offers the best management option for AAA in patients older than 80 years of age. Death may still occur from progression of aneurysmal disease at other sites. An aggressive surgical approach to the management of haemodynamically unstable patients in this age group is of questionable benefit.     

Influence of birth weight on educational outcomes at age 9: the Miami site of the Infant Health and Development Program

BACKGROUND: The Quality of Surgical Care Project (QSCP) was established in May 1996, to evaluate surgical outcomes and where indicated, recommend changes to improve the quality of surgical care in Western Australia (WA). The purpose of this study is to establish benchmark standards in WA for operative mortality, 5-year survival and length of stay in all patients who were surgically treated for aneurysm of the abdominal aorta (AAA) in WA. METHODS: The WA Linked Database was used to link the morbidity and mortality records of all patients admitted and surgically treated for AAA in WA from 1985 to 1994. The linked chains of de-identified hospital morbidity and death records were selected using diagnostic and procedure codes pertaining to AAA. Three groups were separated for analysis: those admitted for rupture, those admitted for elective repair, and those who were admitted to hospital as an emergency without mention of rupture but who underwent repair for AAA. Independent analysis for gender and patients 80 years or more were included in the study. Patients were excluded from the study if they were less than 55 years of age. RESULTS: A total of 1475 cases (1257 males, 218 females) were identified. The mean age in elective cases was 70.4 years in males and 72.4 years in females, and for rupture the mean ages were 71.9 and 74.8 years, respectively. Median length of stay for males was 12 days for elective cases. Admission type or age did not significantly influence length of stay. Thirty-day mortality in males was 4.4% for elective repair and 36.7% for ruptured AAA and 5-year survival was 71.7 and 47.7%, respectively. The overall case fatality rate for ruptured AAA was 79.3% which included those cases who died from rupture without being admitted to hospital. CONCLUSIONS: These community-wide data provide a realistic measure of surgical performance for open repair of AAA. The outcomes for elective and rupture repair for AAA compare favourably with standards reported by international centres of excellence. They also support the use of this procedure in patients over 80 years of age with rupture. This information can be used for ongoing audit purposes and as a benchmark for the introduction of new treatment modalities.     

Screening for abdominal aortic aneurysm

In spite of increasing number of elective resections of abdominal aortic aneurysms (AAA) the mortality or ruptured AAA is increasing. The advantages of elective operations are obvious; the lethality is 2-6% while the lethality of ruptured AAA is 75-95%. However, AAA seldom causes symptoms before rupture. Ultrasonographic screening for AAA takes 10 minutes per scan, and the sensitivity and specificity are high. Ultrasonographic screening for AAA is a reliable, safe and inexpensive method for screening, and screening for AAA is discussed worldwide. One point four percent of deaths among men from 65 to 80 year of age are caused by ruptured AAA. Screening men over 65 for AAA can theoretically prevent a substantial number of deaths. Our calculations predict one prevented AAA-death per 200-300 scans for a cost of about 4000 DKK per saved year of life. However, cost-benefit analyses are based on uncertain assumptions concerning prevalence, incidence and risk of rupture. Therefore a randomized trial screening of 65-73 year old males is taking place in the County of Viborg in Denmark.     

Ruptured abdominal aortic aneurysm: the internist as diagnostician

PURPOSE: To define the clinical features and assess the frequency and causes of missed diagnoses of ruptured abdominal aortic aneurysm (AAA) in patients initially presenting to internists. PATIENTS: All identified patients with ruptured AAA presenting to internists during a 7 1/2-year period at a large academic medical center. METHOD: Chart review. RESULTS: We identified 23 patients with a ruptured AAA presenting to internists. Most had abdominal pain and tenderness, back or flank pain, and leukocytosis, whereas anemia and profound hypotension (systolic blood pressure below 90 mm Hg) were uncommon at presentation. In 14 cases (61%), the diagnosis of ruptured AAA was initially missed. Nine patients had an interval of 24 hours or more between presentation to the internist and surgery or death. The diagnosis was not made until after shock developed in nine patients who were hemodynamically stable at presentation. Of 17 patients who underwent surgery, 7 of 8 with preoperative shock died, compared with 2 deaths in 9 patients (p < .02) without shock. All six patients who did not have surgery died, yielding an overall mortality of 65% for the series. Ruptured AAAs were most frequently misdiagnosed as urinary tract obstruction or infection, spinal disease, and diverticulitis. Chart review revealed a general lack of physician awareness of the syndromes of contained rupture of AAA and symptomatic unruptured AAA. CONCLUSIONS: In patients with ruptured AAA who present to internists, the diagnosis is often delayed or missed and this appears to adversely effect survival. Internists should familiarize themselves with the presentation and management of ruptured AAA.     

Colonic ischemia: the Achilles heel of ruptured aortic aneurysm repair

Colonic ischemia is an often fatal complication of abdominal aortic aneurysm (AAA) repair. In elective AAA repair, patency of the inferior mesenteric artery (IMA) has been shown to be an important contributing factor. The purpose of this study was to determine which clinical and operative factors are important in the development of colonic ischemia in ruptured AAA repair. A retrospective review of all patients treated for ruptured AAA over a 7-year period was performed. Of 101 patients who were treated for ruptured AAA, 71 (70 per cent) survived for longer than 24 hours postoperatively, and these patients are the basis for this study. Colonic ischemia, primarily left sided, was a common perioperative complication (n = 24; 35 per cent) requiring colectomy in 11 patients (44 per cent). It carried a 44 per cent mortality compared to 20 per cent in patients without this complication (P = 0.07). Colonic ischemia occurred more frequently in patients with preoperative shock (P = 0.01) and a greater intraoperative blood loss (P = 0.003), but showed no correlation with patient age, co-morbid medical conditions, laboratory values, time to operation, or treatment of the IMA. Most patients with postoperative bowel ischemia were found to have chronic IMA occlusion, including 8 of the 11 patients requiring colectomy. Revascularization would not be feasible in this group. Revascularization of patent IMAs had little effect on outcome. Of the 17 patent IMAs, 9 were reimplanted and 5 (55 per cent) developed bowel ischemia, two of which required colectomy. Eight were ligated and 3 (38 per cent) developed bowel ischemia, one requiring colectomy. The presence of preoperative shock is the most important factor predicting the development of colonic ischemia following ruptured AAA. The incidence of ischemia is not altered by the presence of a patent IMA or with attempts at IMA revascularization. Colonic ischemia remains a significant source of morbidity and mortality in these patients.     

Natural history of abdominal aortic aneurysm detected by screening

A group of 88 patients with abdominal aortic dilation found in four ultrasonographic screening studies was followed prospectively by repeated ultrasonography. The initial aortic diameter ranged between 18 and 70 mm. In 19 patients (22 per cent) the aortic diameter exceeded 39 mm. The mean (s.e.m.) annual expansion rate of dilatations < 40 mm in diameter was 0.8 (1.2) mm; among those > or = 40 mm it was 3.3 (1.2) mm. The expansion rate increased with increasing initial diameter. Thirty-eight patients died; the overall mortality rate in the group was high in comparison with an age- and sex-matched population. One patient died after elective aneurysm surgery but none died from a ruptured aneurysm. In conclusion, in about 80 per cent of dilatations found in screening studies the aortic diameter was < 40 mm, with a low risk of rupture. One annual rescanning of an aneurysm < 35 mm in diameter is sufficient; a high overall mortality rate must be expected.     

High-speed, three-dimensional kinematic analysis of the normal wrist

PURPOSE: To identify the predictive risk factors for rupture of thoracoabdominal aortic aneurysms (TAA). METHODS: Thirty-one patients with TAA who did not have the indications for surgical repair of the aneurysm were selected. Inclusion criteria were maximum diameter less than 60 mm, refusal of surgical treatment, and high surgical risk. The selected patients participated in a prospective follow-up study for a median period of 47 months and underwent at least two thoracoabdominal computed tomographic scans a year to measure transverse and anteroposterior diameters. Identification of the predictive factors associated with rupture was undertaken with multivariate analysis by means of Cox regression model. RESULTS: During the study period five patients underwent elective repair, six died of unrelated causes, nine had aneurysms that ruptured (all with diameters greater than 50 mm), and 11 reached the end of the study without rupture or surgical management. Initial anteroposterior diameter and annual growth rate of the anteroposterior diameter were the variables associated with rupture of the TAA according to the multivariate statistical analysis by means of Cox regression model. CONCLUSION: We recommend elective repair for a fit patient with asymptomatic TAA with an initial anteroposterior diameter of 50 mm only when there is an annual growth rate of at least 10 mm. Patients with similar diameters but with smaller annual growth rates should be treated conservatively and undergo thoracoabdominal computed tomography every 6 months. Patients with an initial anteroposterior diameter of 60 mm and an annual growth rate of 6 mm should undergo surgical treatment. These guidelines for elective repair of TAA are based on the results of a relatively small series and have to be carefully individualized for each patient.     

A prospective study to define the optimum rescreening interval for small abdominal aortic aneurysm

A prospective study of 99 patients with small abdominal aortic aneurysms was undertaken using serial ultrasound to assess the optimum screening interval. Fifty-three patients had aneurysms measuring 2.5-3.9 cm and 46 patients aneurysms of 4.0-4.9 cm. Aneurysms measuring 2.5-3.9 cm were screened annually and those > 4.0 cm every 6 months. There were eight deaths in the 2.5-3.9 cm group, none attributable to a ruptured aneurysm and five patients have had their aneurysm repaired. Nine patients died in the 4.0-4.9 cm group, one with a ruptured aneurysm measuring 5.6 cm at her previous screening visit and who was unfit for operation. No other patient had an aneurysm which ruptured between scans. There were seven elective repairs in this group. No patient died following elective operation in either group. The mean growth rate of aneurysms in the 2.5-3.9 cm group was 2.2 mm in the first year, 2.8 mm in the second and 1.8 mm in the third. Corresponding growth rates in the 4.0-4.9 cm group were 2.7 mm, 4.2 mm and 2.2 mm. This study supports a policy of annual screening for aneurysms measuring 2.5-3.9 cm and 6-monthly screening for those > or = 4.0 cm.     

Carotid endarterectomy and abdominal aoritc aneurysm repair: are these reasonable treatments for patients over age 80?

Due to the aging of America, increased numbers of very elderly patients require peripheral vascular surgery. From April 1980 to November 1997, 191 patients age 80 years or older had carotid endarterectomy (CEA) and/or abdominal aortic aneurysm (AAA) repair at Loma Linda University Medical Center. The total perioperative stroke and death rate in the CEA group was 2.9 per cent. Mean postoperative cumulative survival in this group was 8.4 years. The cumulative stroke-free survival rate was 95.5 per cent for all yearly postoperative intervals up to 12 years. The perioperative mortality rate was 10.7 per cent in the nonruptured AAA group and 53.8 per cent in the ruptured AAA group (P < 0.00001). Mean cumulative survival was 8.6 years in the nonruptured AAA group and 1.1 years in the ruptured AAA group (P = 0.0001). These data support the conclusion that CEA and nonemergent AAA repair in octo- and nonagenarians are safe and effective in prolonging stroke-free and rupture-free survival. The utility of ruptured AAA repair in this age-group is less clear.     

The influence of shape on the stresses in model abdominal aortic aneurysms

Presence of a small abdominal aortic aneurysm (AAA) often presents a difficult clinical dilemma--a reparative operation with its inherent risks versus monitoring the growth of the aneurysm, with the accompanying risk of rupture. The risk of rupture is conventionally believed to be a function of the AAA bulge diameter. In this work, we hypothesized that the risk of rupture depends on AAA shape. Because rupture is inevitably linked to stress, membrane theory was used to predict the stresses in the walls of an idealized AAA, using a model which was axisymmetric and fusiform, with the ends merged into straight opened-ended tubes. When the stresses for many different shapes of model AAAs were examined, a number of conclusions became evident: (i) maximum hoop stress typically exceeded maximum meridional stress by a factor of 2 to 3 (ii) the shape of an AAA had a small effect on the meridional stresses and a rather dramatic effect on the hoop stresses, (iii) maximum stress typically occurred near the inflection point of a curve drawn coincident with the AAA wall, and (iv) the maximum stress was a function--not of the bulge diameter---but of the curvatures (i.e. shape) of the AAA wall. This last result suggested that rupture probability should be based on wall curvatures, not on AAA bulge diameter. Because curvatures are not much harder to measure than bulge diameter, this concept may be useful in a clinical setting in order to improve prediction of the likelihood of AAA rupture.     

Splenic complications in chronic pancreatitis: prevalence and risk factors in a medical-surgical series of 500 patients

BACKGROUND: The prevalence, course, treatment, outcome and risk factors of splenic complications in chronic pancreatitis are poorly documented. METHODS: Patients with splenic complications in a medical-surgical series of 500 consecutive patients with proven chronic pancreatitis prospectively followed up for a mean of 7.0 years were compared with patients without splenic complications. RESULTS: Eleven men (2.2 per cent) with alcoholic chronic pancreatitis (median duration 2 (range 0-5) years) had a splenic complication: intrasplenic pseudocyst (n=5), subcapsular haematoma (n=2) or splenic rupture (n=4). All patients except one underwent splenectomy, five of whom also underwent distal pancreatectomy. There were no deaths. Patients with splenic complications had pancreatic tail necrosis (six of 11 versus 17.4 per cent; P=0.007), distal pseudocyst (six of 11 versus 11.7 per cent; P=0.0009) or splenic vein occlusion (seven of 11 versus 10.8 per cent; P< 0.0001) more frequently than those without. In the 22 patients with distal pseudocyst and splenic vein occlusion, the prevalence of splenic complications was 18 per cent (odds ratio 15.0 (95 per cent confidence interval 4.0-55.7). CONCLUSION: Splenic complications occur early in the course of chronic pancreatitis, are rare and are favoured by splenic vein occlusion and pseudocyst or necrosis of the pancreatic tail. Surgical treatment is usually required.     

Simultaneous coronary artery bypass grafting and abdominal aneurysm repair decreases stay and costs

BACKGROUND: Patients with large (> or = 5.0 cm) abdominal aortic aneurysms (AAA) frequently have marked associated coronary artery disease. We hypothesized that a single operation for coronary artery bypass grafting (CABG)/AAA would provide equivalent, if not improved, patient care while decreasing postoperative length of stay and hospital costs compared with staged procedures. METHODS: Eleven patients to date have undergone a combined procedure at our institution. Ten underwent CABG followed by AAA repair, whereas one patient received an aortic valve replacement before aneurysm repair. We performed a retrospective analysis comparing the postoperative length of stay and hospital costs for this single procedure to a combined cohort of 20 randomly selected patients who either received AAA repair (n = 10) or standard CABG (n = 10) during the same time period. RESULTS: No operative mortality has been reported. There were no episodes of neurologic deficit or cardiac complication after these procedures. The postoperative length of stay was significantly decreased for the CABG/AAA group compared with the combined postoperative length of stay for the AAA plus CABG group (7.44+/-0.88 days versus 14.10+/-2.00; p = 0.012). Total hospital costs were also significantly decreased for the CABG/AAA group compared with total hospital costs for the AAA plus CABG group ($22,941+/-$1,933 versus $34,076+/-$2,534; p = 0.003). CONCLUSIONS: A single operation for coronary revascularization and AAA repair is safe and effective. Simultaneous CABG and AAA repair substantially decreases postoperative length of stay and hospital costs while avoiding possible interim aneurysm rupture and repeat anesthesia.     

Similarities between pleuropulmonary blastoma and Askin tumor

AIM: The purpose of the study was to determine the risk of postoperative complications and the functional outcome after a hand-sewn ileal pouch-anal anastomosis (IPAA) for ulcerative colitis using a single J-shaped pouch design. METHODS: Preoperative function, operative morbidity and long-term functional outcome were assessed prospectively in 1310 patients who underwent IPAA between 1981 and 1994 for ulcerative colitis. RESULTS: Three patients died after operation. Postoperative pelvic sepsis rates decreased from 7 per cent in 1981-1985 to 3 per cent in 1991-1994 (P = 0.02). After mean follow-up of 6.5 (range 2-15) years, the mean number of stools was 5 per day and 1 per night. Frequent daytime and nighttime incontinence occurred in 7 and 12 per cent of patients respectively, and did not change over a 10-year period. The cumulative probability of suffering at least one episode of 'clinical' pouchitis was 18 and 48 per cent at 1 and 10 years and the cumulative probability of pouch failure at 1 and 10 years was 2 and 9 per cent respectively. CONCLUSION: These results indicate that increased experience decreases the risk of pouch-related complications and that with time the functional results remain stable, but the failure rate increases.     

Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms

PURPOSE: To determine whether gender distinction influence the cardiac risk or survival rates associated with surgical treatment of infrarenal abdominal aortic aneurysms (AAAs). METHODS: From 1983 to 1988, graft replacement of intact AAAs was performed in 490 men (84%) and in 92 women (16%) who had no history of myocardial revascularization before the discovery of their AAAs. Patients of both genders were comparable with respect to mean age (68 years) and the prevalence of coronary artery disease (CAD) by standard clinical criteria (men, 73%; women, 65%). Preoperative coronary angiography was obtained in 471 of the 582 patients (men, 81%; women, 80%) during this particular study period. Preliminary coronary bypass was warranted on the basis of existing indications in 111 (24%) of these 471 patients (men, 25%; women, 18%), including 104 (31%) of the 337 who had clinical indications of CAD (men, 32%; women, 26%) but only 7 (5.2%) of the 134 who did not (men, 6%; women, 4%). Follow-up data were collected during a mean interval of 53 months (men, 54 months; women, 48 months) and were analyzed by Kaplan-Meier survival analysis and Cox proportional hazards models. RESULTS: Twenty-nine perioperative deaths (5.0%) occurred in conjunction with AAA repair (men, 5.1%; women, 4.3%), and 126 early and late deaths have occurred (men, 22%; women, 22%). Survival rates for the series were found to correlate with age (p < 0.001), the serum creatinine level (p < 0.001), and the coronary angiographic classification (p < 0.001). No significant differences were identified between the gender cohorts. The cardiac mortality rate for AAA resection was only 1.8% in the 111 patients who had preliminary coronary bypass, but five additional perioperative deaths (4.5%) related to renal failure or sepsis occurred in this group. However, 5-year survival rates for patients receiving preliminary bypass (men, 82%; women, 75%) were closely comparable with those for patients found to have only mild to moderate CAD by angiography (men, 86%; women, 82%). CONCLUSION: We conclude that men and women with AAAs have similar cardiac risks and survival rates associated with surgical treatment. Our results also illustrate that the potential benefit of coronary intervention for severe CAD in patients of either gender must be considered in the context of long-term outcome and the early mortality rate of AAA repair.     

The key informant technique

The clinical outcome of 152 patients aged 65 years or over who were referred to the author's institute between August 1990 and August 1991 with certain specified gastrointestinal malignancies and acute, life-threatening abdominal conditions, were audited concurrently. Two groups were considered: patients aged 65-79 years and those over 80 years. The mortality rate within 30 days of surgery was 14 per cent in both age groups, although significantly fewer patients aged over 80 years (35 of 54) were considered suitable for surgery than in the 65-79 years age group (84 of 98) (0.01 > P > 0.001). Morbidity after operation and cost of treatment were not significantly different between the two groups. Two years after surgery 40 per cent of the patients aged over 80 years and 58 per cent of those aged 65-79 years were alive. Quality of life in these survivors was good with 85 per cent of those aged over 80 years living at home and 72 per cent fit enough to undertake light work.     

Third-degree obstetric perineal tear: long-term clinical and functional results after primary repair

BACKGROUND: This study was designed to investigate the long-term clinical and anorectal functional results after primary repair of a third-degree obstetrical perineal rupture. METHODS: One hundred and fifty-six consecutive women who had a primary repair of a third-degree perineal rupture were sent a questionnaire and asked to undergo anorectal function testing (anal manometry, anorectal sensitivity, anal endosonography and pudendal nerve terminal motor latency (PNTML)) RESULTS: Some 117 women (75 per cent) responded. Anal incontinence was present in 47 women (40 per cent); however, in most cases only mild symptoms were present. In 40 women additional anorectal function tests were performed and compared with findings in normal controls. Mean(s.d.) maximum squeeze pressure (31(15) versus 63(17) mmHg, P< 0.001) was decreased and first sensation to filling of the rectum (88(47) versus 66(33) ml, P=0.03) and anal mucosal electrosensitivity (4.7(1.7) versus 2.5(0.8) mA, P=0.003) were increased compared with values in normal controls. In 35 women (88 per cent) a sphincter defect was found with anal endosonography. Factors related to anal incontinence were the presence of a combined anal sphincter defect (relative risk (RR) 1.7 (95 per cent confidence interval (c.i.) 1.1-2.8)) or subsequent vaginal delivery (RR 1.6 (95 per cent c.i. 1.1-2.5)). CONCLUSION: Anal incontinence prevails in 40 per cent of women 5 years after primary repair of a third-degree perineal rupture. The presence of a combined sphincter defect or subsequent vaginal delivery increase the risk of anal incontinence.