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.     

Current status of the use of retroperitoneal approach for reconstructions of the aorta and its branches

OBJECTIVE: The objective of this article is to determine whether retroperitoneal approach for aortic surgery has certain physiologic, technical advantages. SUMMARY BACKGROUND DATA: The retroperitoneal approach for abdominal aortic reconstruction classically had been reserved for select patients with either high-risk comorbid disease or specific anatomic problems that preclude the transabdominal approach. With increasing appreciation of the physiologic, anatomic, and technical advantages of the extended posterolateral retroperitoneal approach, the authors have expanded its use for repair of all types of aortic visceral and renal artery disease as well as ruptured abdominal aortic aneurysm and infected aortic grafts. METHODS: From January 1981 to September 1995, 2340 retroperitoneal aortoiliac reconstructions were performed in 2243 patients. Aortic reconstructions accounted for 1756 cases: 1109 for elective abdominal aortic aneurysms, 210 for ruptured and symptomatic aortic aneurysms, 399 for occlusive disease, 18 for infected aortic grafts, and 20 for other indications. Iliofemoral disease was the indication for 584 procedures. As experience was gained, this approach also was used for 417 renal and 50 celiac and superior mesenteric artery reconstructions. RESULTS: The mean age was 67 years with 1590 men and 653 women. Overall mortality was 5.2% for all aortic cases: 2.4% for elective, 12.6% for symptomatic, and 29.0% for ruptured aortic aneurysms. Major complications occurred in 12.5% of the elective procedures and in 38.3% of emergency procedures. Over the past 5 years, the average length of hospital for uncomplicated elective abdominal aortic aneurysms was 6.1 days, intensive care unit stay was 0.7 day, and diet was resumed by postoperative day 1. Five-year graft patency was 99% for aneurysms and 95% for occlusive disease. CONCLUSIONS: The retroperitoneal approach offers certain physiologic advantages associated with minimal disturbance of gastrointestinal and respiratory function, thereby reducing the length of intensive care unit and hospital stay. In addition, its technical advantages and flexibility facilitates visceral and juxtarenal aortic reconstructions without the need for thoracotomy.     

Continuous spinal analgesia. Comparison between patient-controlled and bolus administration of plain bupivacaine for postoperative pain relief

The purpose of this study was to examine the changing trends in surgical management of patients with abdominal aortic aneurysms at a tertiary care teaching hospital over the past 40 years, by analysis of demographic data, perioperative variables and outcomes on all patients having abdominal aortic aneurysm surgery between 1955 and 1993. Some 1604 abdominal aortic aneurysms were assessed. The annual rate of abdominal aortic aneurysm surgery increased from 17.6 to 67.8 cases per year. The non-ruptured to ruptured abdominal aortic aneurysm ratio increased from 2.4:1 in the first decade to 3.4:1 in the last 5 years. In non-ruptured abdominal aortic aneurysm repairs, the following variables changed over the four decades: patients age over 80 years increased (2.4% to 8.0%; P<0.04), concomitant lower-limb occlusive disease increased (12.2% to 23.7%; P<0.02), prevalence of smaller aneurysms (4-6 cm) increased (16.0% to 54.2%; P<0.0001); intraoperative hypotension decreased (9.0% to 0.7%; P<0.0001), postoperative hemorrhage decreased (8.2% to 0.0%, P<0.0001), postoperative leg ischemia decreased (5.7% to 1.1%; P<0.02) and postoperative amputation rate decreased (3.2% to 0.0%; P<0.03). There was a significant decrease in perioperative mortality (17.0% to 3.4%; P<0.0001). For ruptured aneurysms, early operation (within 1 h of admission) increased from 8.7% to 55.8% (P<0.0001), prevalence of intraoperative hypotension decreased (50.0% to 23.5%; P<0.001), and major venous injury decreased (18.0% to 5.2%; P<0.05). Mortality, however, did not decrease significantly (54.2% to 44.2%; P=0.32). In conclusion, there was a significant decrease in mortality and morbidity associated with non-ruptured abdominal aortic aneurysm repair over the four decades studied. In addition, older patients with smaller aneurysms and more co-morbid conditions were operated on during this period. Mortality for patients operated on for ruptured abdominal aortic aneurysm repair has not changed significantly.     

Fate of the excluded abdominal aortic aneurysm sac: long-term follow-up of 831 patients

PURPOSE: Nonresective treatment of the infrarenal abdominal aortic aneurysm by proximal and distal ligation of the aneurysm sac (exclusion) combined with aortic bypass has been previously reported. A 10-year experience with 831 patients undergoing this procedure was reviewed. METHODS: From 1984 to 1994, 831 (761 elective, 70 urgent) of 1103 patients being treated for abdominal aortic aneurysm underwent repair with the retroperitoneal exclusion technique. Perioperative morbidity and mortality, estimated blood loss, transfusion requirements, natural history of the excluded aneurysm sac, and long-term survival were all assessed. RESULTS: The operative mortality rate for patients undergoing exclusion and bypass was 3.4%. The incidence of nonfatal perioperative complications was 5.2%. Colon ischemia requiring resection occurred in 2 (0.2%) of the 831 patients. Estimated blood loss was 638 +/- 557 cc (50 to 330 cc). On follow-up 17 (2%) patients were found to have patent aneurysm sacs as detected by duplex examination. Fourteen patients required surgical intervention. No cases of graft infection or aortoenteric fistula have been noted. CONCLUSION: Retroperitoneal exclusion and bypass is a viable alternative to traditional open endoaneurysmorraphy in surgery for abdominal aortic aneurysm. Most excluded aneurysm sacs have thrombosis without any long- or short-term complications; however, in a small number of patients delayed rupture of patent aneurysm occurs, thus emphasizing the need for diligent follow-up and appropriate intervention.     

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.     

Exposure to environmental and mainstream tobacco smoke and risk of spontaneous abortion

The present nationwide, multicenter clinical study was carried out in 26 departments of surgery to define the incidence and attendant mortality of intestinal infarction following abdominal aortic surgery, and to identify patients at risk of it. The data consist of 1752 patients who underwent abdominal aortic reconstruction during 1991-1993 as recorded in the Finnish national vascular registry (FINNVASC). Among the 1752 operations, 27 patients treated at 14 different hospitals had intestinal ischemia, and the complete patient records of all 27 cases were reanalyzed. The incidence of bowel infarction was 1.2%. Among patients operated on for a ruptured aneurysm it was 3.1%, whereas 1.0% of patients with nonruptured aneurysm and 0.6% of those operated on for aortoiliac occlusive disease developed intestinal infarction. In 14 patients (67%) the lesion affected the left colon. The overall 30-day mortality rate was 13% but reached 67% among those with intestinal infarction. We conclude that acute intestinal ischemia with bowel infarction is an infrequent but serious complication of abdominal aortic surgery. It is mainly related to surgery due to aneurysmal disease, and patients with occlusive aortoiliac disease present ischemic complications in the intestines less often. Hypotensive patients being treated for ruptured aneurysm are at greatest risk of intestinal ischemia.     

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.     

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.     

Expansion pattern and risk of rupture of abdominal aortic aneurysms that were not operated on

OBJECTIVE: To analyse the outcome of selective management of patients with abdominal aortic aneurysms, the expansion patterns of the aneurysms, and the factors that influenced the rate of rupture. DESIGN: Retrospective study. SETTING: Malm? General Hospital, Lund University, Malm?, Sweden. SUBJECTS: 155 patients (96 men and 59 women) with abdominal aortic aneurysms who were not selected for operation for whatever reason were included in the study immediately after their first ultrasound scan. MAIN OUTCOME MEASURES: Mortality, expansion rate (mm/year) measured on ultrasound scan, and rate of rupture of aneurysm. RESULTS: Median aneurysmal diameter was 40 mm (range 20-80), and length (n = 106) 70 (range 28-140). The patients were followed up for a median of 3.4 years (range 0-10.2). A total of 107 patients died and in 21 the aneurysms ruptured (4 were operated on and survived). Thirteen patients were re-evaluated and operated on electively. Ultrasonography was repeated in 98 patients, the median expansion rates (mm/year) were 3.1 (diameter) and 1.9 (length). There was a significant linear relationship between initial size (diameter and length) and rate of expansion of diameter. The risk of rupture was greater in larger aneurysms that were expanding more quickly. The cumulative mortality was not affected by the 21 aneurysms that ruptured. CONCLUSION: Selective management of patients with aortic aneurysms is justified.     

Effects of video-relayed social support on hemodynamic reactivity and salivary cortisol during laboratory-based behavioral challenge

An attempt was made to document trends that have occured over a 25-year period in clinical presentation, preoperative evaluation, operative management, and patient outcome in patients with an abdominal aortic aneurysm. The experience (574 aneurysmectomies) of one cardiovascular surgical group was analyzed by retrospective review of hospital and office records. Changes over time of patients' ages, aneurysm sizes and statuses, prior myocardial revascularization, operative mortality, and certain other parameters were evaluated. During the period of study, there was a significant decrease in aneurysm size, increase in patients' ages, and an increased incidence of previous coronary artery bypass. No ruptured aneurysm was < 5 cm in diameter. The incidence of rupture and the operative mortality in patients with a ruptured aneurysm did not change significantly. There was a significantly (p = 0.03) lower operative mortality of 0.4% in the latter half of the series for elective aneurysmectomy. Increased utilization of preoperative cardiologic evaluation, and myocardial revascularization, has been associated with a decreased operative mortality in patients undergoing elective aneurysmectomy even though the patients are now older and have more age-related comorbidities. Elective aneurysmectomy should be offered to most patients when an abdominal aortic aneurysm is > or =5 cm in diameter.     

Improved prognosis of thoracic aortic aneurysms: a population-based study

CONTEXT: Managing thoracic aortic aneurysms identified incidentally by increased use of computed tomography, echocardiography, and magnetic resonance imaging is problematic, especially in the elderly. OBJECTIVE: To ascertain whether the previously reported poor prognosis for individuals with thoracic aortic aneurysms has changed with better medical therapies and improved surgical techniques that can now be applied to aneurysm management. DESIGN: Population-based cohort study. SETTING AND PATIENTS: All 133 patients with the diagnosis of degenerative thoracic aortic aneurysms among Olmsted County, Minnesota, residents between 1980 and 1994 compared with a previously reported cohort of similar patients between 1951 and 1980. MAIN OUTCOME MEASURES: The primary clinical end points were incidence, cumulative rupture risk, rupture risk as a function of aneurysm size, and survival. RESULTS: In contrast to abdominal aortic aneurysms, for which men are affected predominately, 51% of thoracic aortic aneurysms were identified in women who were considerably older at recognition than men (mean age, 75.9 vs 62.8 years, respectively; P= .01). The overall incidence rate of 10.4 per 100000 person-years (95% confidence interval [CI], 8.6-12.2) between 1980 and 1994 was more than 3-fold higher than the rate from 1951 to 1980. The cumulative risk of rupture was 20% after 5 years. Seventy-nine percent of ruptures occurred in women (P= .01). The 5-year risk of rupture as a function of aneurysm size at recognition was 0% for aneurysms less than 4 cm in diameter, 16% (95% CI, 4%-28%) for those 4 to 5.9 cm, and 31% (95% CI, 5%-56%) for aneurysms 6 cm or more. Overall 5-year survival improved to 56% (95% CI, 48%-66%) between 1980 and 1994 compared with only 19% between 1951 and 1980 (P<.01). CONCLUSIONS: In this population, elderly women represent an increasing portion of all patients with clinically recognized thoracic aortic aneurysms and constitute the majority of patients whose aneurysm eventually ruptures. Overall survival for thoracic aortic aneurysms has improved significantly in the past 15 years.     

Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms

PURPOSE: Long-term survival and late vascular complications in patients who survived repair of ruptured abdominal aortic aneurysms (RAAA) is not well known. The current study compared late outcome after repair of RAAA with those observed in patients who survived elective repair of abdominal aortic aneurysms (AAA). METHODS: The records of 116 patients, 102 men and 14 women (mean age: 72.5 (8.3 years), who survived repair of RAAA (group I) between 1980 to 1989 were reviewed. Late vascular complications and survival were compared with an equal number of survivors of elective AAA repair matched for sex, age, surgeon, and date of operation (group II). Survival was also compared with the age and sex-matched white population of west-north central United States. RESULTS: Late vascular complications occurred in 17% (20/116) of patients in group I and in 8% (9/116) in group II. Paraanastomotic aneurysms occurred more frequently in group I than in group II (17 vs. 8, p = 0.004). At follow-up, 32 patients (28%) were alive in group I (median survival: 9.4 years) and 53 patients (46%) were alive in group II (median survival: 8.7 years). Cumulative survival rates after successful RAAA repair at 1, 5, and 10 years were 86%, 64%, and 33%, respectively. These were significantly lower than survival rates at the same intervals after elective repair (97%, 74%, and 43%, respectively, p = 0.02) or survival of the general population (95%, 75%, and 52%, respectively, p < 0.001). Coronary artery disease was the most frequent cause of late death in both groups. Vascular and graft-related complications caused death in 3% (3/116) in group I and 1% (1/116) in group II. Cox proportional hazards modeling identified age (p = 0.0001), cerebrovascular disease (p = 0.009), and number of days on mechanical ventilation (p = 0.01) to be independent prognostic determinants of late survival in group I. CONCLUSIONS: Late vascular complications after repair of RAAA were higher and late survival rates lower than after elective repair. These data support elective repair of AAA. As two-thirds of the patients discharged after repair of RAAA are alive at 5 years, aggressive management of RAAA remains justified.     

Repair of ruptured sinus of valsalva aneurysm: determinants of long-term survival

BACKGROUND: Ruptured sinus of Valsalva aneurysm is a rare cardiac anomaly and long-term survival after surgical treatment is not well established. This study was designed to investigate the determinants of long-term survival after repair of ruptured sinus of Valsalva aneurysm. METHODS: From April 1978 to April 1996, 53 patients underwent operation for ruptured sinus of Valsalva aneurysm. The incidence among our cardiac surgical population was 0.56%. Long-term survival was investigated in 46 patients (13 to 65 years) who survived the operation, with 96.2% follow-up completeness (mean+/-standard deviation, 6.5+/-4.9 years; maximum, 17.2 years), by univariate and multivariate analyses. RESULTS: There was no early operative death and no recurrence after the initial repair. Actuarial survival was 83.8%+/-8.4% at 15 years. Reoperation, aneurysm draining into the left ventricle, aortic prosthetic dehiscence, bacterial endocarditis, and aortic cross-clamp time (<70 minutes) were significant factors in long-term survival (p < 0.05). Multivariate analysis revealed that only aortic prosthesis dehiscence was the significant factor influencing late survival (p = 0.0001). CONCLUSIONS: Surgical treatment for ruptured sinus of Valsalva aneurysm is safe and has satisfactory results. Aortic prosthesis dehiscence is the independent determinant for long-term survival. Other factors including bacterial endocarditis, concomitant ventricular septal defect repair, and aortic valve replacement did not independently influence long-term survival.     

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.     

The role of gammadelta T cells in induction of bacterial antigen-specific protective CD8+ cytotoxic T cells in immune response against the intracellular bacteria Listeria monocytogenes

PURPOSE: To study the relation between abdominal aortic aneurysms and chronical obstructive pulmonary disease (COPD), in particular the suggested common elastin degradation caused by elastase and smoking. METHODS: A cross-sectional population study and a prospective cohort study of small abdominal aortic aneurysms was performed in a community setting. All previous diagnoses recorded in a hospital computer database were received for 4404 men 65 to 73 years of age who had been invited to a population screening for abdominal aortic aneurysm. One hundred forty-one men had AAA (4.2%). They were asked to participate in an interview, a clinical examination, and collection of blood sample. Men with an abdominal aortic aneurysm 3 to 5 cm in diameter were offered annual ultrasound scans to check for expansion. RESULTS: Among patients with COPD 7.7% had abdominal aortic aneurysms (crude odds ratio=2.05). The adjusted odds ratio, however, was only 1.59 after adjustment for coexisting diseases associated with abdominal aortic aneurysm (P=.13). The mean annual expansion was 2.74 mm per year among patients with COPD, 2.72 among patients without COPD, and 4.7 mm among patients who used oral steroids compared with 2.6 among patients who did not use steroids (P < .05). Concentration of serum elastin peptide and plasma elastase-alpha1-antitrypsin complexes correlated negatively with forced expiratory volume in the first second (FEV1) among patients with COPD. However, multivariate regression analysis showed that concentration of serum elastin peptide, therapy with beta-agonists, and FEV1 correlated positively with degree of expansion but that concentration of plasma elastase-alpha1-antitrypsin complexes and serum alpha1-antitrypsin did not influence expansion, suggesting that elastase plays an important role in the pathogenesis of COPD but not of abdominal aortic aneurysm. CONCLUSION: The high prevalence of abdominal aortic aneurysm among patients with COPD is more likely to be caused by medication and coexisting diseases rather than a common pathway of pathogenesis.     

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.     

Ultrastructural, stereological evaluation of satellite cells derived from musculus soleus in rats kept in hypokinesia conditions

OBJECTIVES: Selection for surgery of patients with abdominal aortic aneurysm (AAA) depends on an assessment of risk from operation compared with risk from aneurysm rupture. A study was performed to assess the levels of co-morbidity and to see whether co-morbidity was different in people with a normal aorta after ultrasonographic examination than in those with an aneurysmal aorta. SETTING AND METHODS: Over a two year period 5392 people (2341 men, 3051 women) aged 65-80 were screened using B-mode linear ultrasound, with maximum measurements taken of transverse, anteroposterior diameters, or both. All subjects were given a questionnaire seeking a history of angina, stroke, claudication, myocardial infarct, respiratory problems, and diabetes. RESULTS: 218 men and women were found to have an AAA of 3 cm or greater. The results of the questionnaire were analysed using logistic regression whereby all the co-morbid conditions were adjusted for each other and for smoking, sex, and age. The only conditions which were significantly associated with AAA in both sexes were myocardial infarction with an odds ratio (OR) of 1.66 (95% confidence interval (CI) 1.06 to 2.60) and claudication with an OR of 1.68 (95% CI 1.17 to 2.42). The association between angina and AAA was of borderline significance (OR = 1.52, 95% CI 1.00 to 2.30). Stroke was significantly associated only in women, with an OR of 3.71 (95% CI 1.42 to 9.69). Rates of diabetes and respiratory disease were not significantly different between people with AAA and normal aortas. CONCLUSIONS: These findings show there is significantly higher co-morbidity in people with ultrasound detected AAA, which might influence outcome from surgery and long term survival.     

Identification of 1,4-dihydropyridine binding domains within the primary structure of the alpha 1 subunit of the skeletal muscle L-type calcium channel

Damage to the spinal cord in course of the treatment of diseases of the infrarenal aorta is a rare but calamitous complication. The reported incidence is about 0.2%. The neurological loss is usually complete flaccid paraplegia with high mortality and rare full or partial recovery. Between 1980 and 1991, 1070 reconstructive procedures of the infrarenal aorta were performed: 821 due to aneurysm (316 elective procedures [mortality 1.6%] and 505 emergency procedures [mortality 24.5%]) and 249 due to aorto-iliac occlusive disease. Damage to the spinal cord occurred in 2 patients (2/1070, 0.19%). One patient had incomplete paraparesis following repair of an unruptured abdominal aortic aneurysm with gradual return of all neurological symptoms to normal. The second patient developed complete paraplegia following repair of a ruptured infrarenal aneurysm. There war no recovery of the symptoms. The patient died from septicaemia 4 months later.     

Results after surgical treatment of abdominal aortic aneurysm

During the period 1983-1993 altogether 403 patients were operated on for abdominal aortic aneurysm. The median age was 69.5 years. 246 were operated on electively whereas 58 had symptoms without rupture and 99 had ruptured aneurysm. The 30 day mortality in the three groups was 4.1, 12.0 and 28.3% respectively. The mortality in hospital was 4.5, 12.0 and 31.3% in the three groups respectively. Coronary artery disease dominated as cause of death in the group as a whole, whereas irreversible shock and complications secondary to haemorrhage were common in the group with ruptured aneurysm. There were no graft infections in this series, and only one superficial infection which healed without complications. Investigation and treatment of coronary artery disease might perhaps decrease the mortality rate in the elective group. These results form a basis against which the results of endovascular treatment should be compared.     

Molecular cloning, expression, and functional characterization of novel mouse sulfotransferases

STUDY OBJECTIVE: The present study was performed to determine the influence of a perioperative myocardial infarction on long-term mortality in patients who have undergone elective vascular surgery. STUDY DESIGN: This was a 4-year follow-up of patients who had undergone elective vascular procedures at a Veterans Affairs Medical Center. Between January 1989 and December 1990, 115 consecutive patients underwent surgery for either an expanding abdominal aortic aneurysm (AAA) (38%) or for pain in the lower extremities (62%). RESULTS: Vital status at 4 years postsurgery was determined for all patients. Thirty-day postoperative mortality was 3%, while estimates at 1, 2, 3, and 4 years were 19%, 26%, 35%, and 39%, respectively. Of the 45 patients who died within 4 years following surgery, the major causes of death were cardiac (40%), cancer (18%), cerebrovascular (13%), and peripheral vascular disease (11%). Univariate predictors of 1-year mortality on preoperative evaluation were an abnormal ECG, moderate or greater sized exercise thallium defect and left ventricular ejection fraction < or =40%, and a perioperative myocardial infarction. Univariate predictors of 4-year mortality were non-AAA surgery and diabetes mellitus. Perioperative myocardial infarction was a marginally significant independent predictor of 1-year mortality (p=0.06), while the need for non-AAA surgery was a strong independent predictor at 4 years. CONCLUSIONS: Cardiac mortality is the major cause of late death among patients undergoing elective vascular surgery. Although preoperative indicators of symptomatic coronary artery disease and nonfatal perioperative myocardial infarction identified those individuals at increased mortality in the first postoperative year, the extent of vascular disease at presentation may be a more important determinant of long-term survival. A randomized trial in such patients is needed to assess the best strategy for treating patients with coexistent coronary artery and vascular diseases.