Preferred strategies for secondary infrainguinal bypass: lessons learned from 300 consecutive reoperations

PURPOSE: To determine the optimal surgical strategies in reoperative infrainguinal bypass, we reviewed our results in 300 consecutive secondary bypasses in 251 patients operated on between Jan. 1, 1975, and Nov. 1, 1993. METHODS: There were 168 men (67%) and 83 women (33%), with a mean age of 64.8 years and a typical distribution of risk factors including smoking (76.4%), diabetes (33.7%), and coronary artery disease (47.1%). The indications for surgery were limb-threatening ischemia in 83.5% and severe claudication in 16.5% of patients. The majority of conduits (n = 213) were autogenous vein and were composed of a single segment of greater saphenous vein in 121 bypasses (57%) and various alternative veins including composite, arm, and lesser saphenous vein in 92 bypasses (43%). Prosthetic conduits included 69 polytetrafluoroethylene, 16 umbilical vein, and two Dacron grafts. RESULTS: There was one perioperative death (0.3%) and a 25% total morbidity rate including a 1.7% myocardial infarction rate. There was a 28.6% early (< 30 days) graft failure and 10.7% early amputation rate for prosthetic bypass grafts compared with 13.6% early graft failure and 5.6% early amputation rates for vein grafts. Autogenous vein bypasses had higher 5-year secondary patency rates than had prosthetic grafts (51.5% +/- 4.6% vs 27.4% +/- 6.1%, p < 0.001). Results with autogenous vein bypass improved significantly from the 1975 to 1984 to the 1985 to 1993 interval with 5-year secondary patency rates increasing from 38.3% +/- 6.9% to 59.1% +/- 5.8% (p = 0.017) and 5-year limb-salvage rates increasing from 40.4% +/- 7.6% to 72.4% +/- 6.6% (p < 0.001). Vein grafts to the popliteal and tibial outflow levels had equivalent long-term results. Vein grafts completed for claudication demonstrated results superior to those for limb salvage, with a 5-year secondary patency rate of 75.8% +/- 8.1% versus 52.3% +/- 7.9% (p = 0.048). Secondary autogenous vein bypass grafting performed after early primary graft failure (< 3 months) did particularly poorly, with only a 27.2% +/- 7.7% 4-year secondary patency rate. Greater saphenous veins tended to perform better than alternative vein bypasses, with a 5-year secondary patency rate of 68.5% +/- 6.0% compared with 48.3% +/- 10.5% (p = 0.09) and a 5-year limb-salvage rate of 77.8% +/- 7.4% versus 54.2% +/- 11.8% (p = 0.046). CONCLUSIONS: When patients suffer a recurrence of limb-threatening ischemia at the time of infrainguinal graft failure, aggressive attempts at secondary revascularization with autogenous vein are warranted based on the low surgical morbidity and mortality rates and the improved patency and limb salvage rates that are currently attainable.     

Average intake of anti-oxidant (pro)vitamins and subsequent cancer mortality in the 16 cohorts of the Seven Countries Study

This ecologic study aimed to investigate whether differences in population mortality from lung, stomach and colorectal cancer among the 16 cohorts of the Seven Countries Study could be explained by differences in the average intake of anti-oxidant (pro)vitamins. In the 1960s, detailed dietary information was collected in small sub-samples of the cohorts by the dietary record method. In 1987, food-equivalent composites representing the average food intake of each cohort at baseline were collected locally and analyzed in a central laboratory. The vital status of all participants was verified after 25 years of follow-up. The average intake of vitamin C was strongly inversely related to the 25-year stomach-cancer mortality (r = -0.66, p = 0.01), also after adjustment for smoking and intake of salt or nitrate. The average intake of alpha-carotene, beta-carotene, and alpha-tocopherol were not independently related to mortality from lung, stomach or colorectal cancer, nor was vitamin C related to lung and colorectal cancer.     

Renopancreatic transplant. Urologic complications

OBJECTIVE: Retrospective study of urological complications in our series of reno-pancreatic transplants. MATERIAL AND METHODS: Between February 1983 and May 1994 our group has conducted 93 RPT, 80 of which, mean age 36 +/- 6 years (24-54 years), are studied in this paper: 57 male and 23 female with an average time in dialysis of 20 +/- 15 months (0-84 months) and diabetes evolution of 21 +/- 5 years (11-37 years). RESULTS: Actuarial annual survival of patient, renal graft and pancreatic graft has been 85%, 79% and 74% respectively. Haematuria: 25% incidence, with graft pancreatitis etiology in 16 cases, rejection in 8 and urinary fistula in 6. Urinary infection: 85% incidence, symptomatic in 23 patients (29%) and asymptomatic in the remaining cases. Dysuria, urethritis and urethral stenosis: 14 patients, all male, most with both conditions associated. Reconversion of pancreatic exocrine secretion by intestinal route was performed in 7 patients. Urinary fistula: secondary to surgery in 9 cases and rejection in 4. Etiology of one case remained unknown. In 4 cases it was resolved with conservative treatment, and with surgical correction in 8. One patient required pancreatic transplantectomy and one patient died of AMI. CONCLUSIONS: Urological complication in RPT account for a significant morbidity, urinary fistula being the one with greater repercussion on the patient and pancreatic graft survival.     

Measuring perceived mutuality in close relationships: Validation of the Mutual Psychological Development Questionnaire.

In an initial validation study of the Mutual Psychological Development Questionnaire (MPDQ), a measure of perceived mutuality in close relationships, 345 respondents completed the scale for spouse or partner and friend relationships. Results indicated high interitem reliability. Construct and concurrent validity were demonstrated. MPDQ ratings were correlated with adequacy of social support, relationship satisfaction, and cohesion. Ratings correlated negatively with depression. Low spouse or partner mutuality was predictive of significant depressive symptoms in women but not in men. In a 2nd study, 81 respondents completed the scale at 2 time points. Test–retest reliability was satisfactory, and high interitem consistency was replicated. The substantive meaning of these findings, gender differences, and possible future research applications of the MPDQ are disscussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hilar cholangiocarcinoma: thin-section spiral CT findings with cholangiographic correlation

Hilar cholangiocarcinoma, a highly lethal tumor, is difficult to diagnose with conventional computed tomography (CT) because of its small size. Spiral CT allows more effective evaluation of these small lesions and better demonstrates the status of the hepatic arterial or portal venous circulation. Among 27 patients with hilar cholangiocarcinoma (infiltrative in 21, exophytic in two, polypoid in one, diffuse in three), thin-section spiral CT allowed identification of each tumor as an area of focal wall thickening that obliterated the lumen. Seventeen of the infiltrative tumors (81%) showed high attenuation. Identification of the level of biliary obstruction was possible in 63% of the patients (17 of 27). The level of obstruction was underestimated in six patients and overestimated in four. Spiral CT is a valuable method for diagnosis of hilar cholangiocarcinoma; however, spiral CT is less accurate in evaluation of intraductal tumor extent because of the limited z-axis resolution.     

31P NMR identification of metabolites and pH determination in the cyanobacterium Synechocystis sp. PCC 6308

The identity of a number of phosphorus-containing metabolites present in Synechocystis sp. PCC 6308 has been confirmed by 31P NMR spectroscopy. The presence of D-ribulose 1,5-bisphosphate (RuBP); DL-glyceraldehyde 3-phosphate (GlyP); D(-)3-phosphoglyceric acid (3PGA); D-ribulose 5-phosphate (Ru5P);6-phosphogluconic acid (6PGA); phosphoenolpyruvate (PEP); inorganic phosphate (Pi); uridine diphosphoglucose (UDPG); ADP and ATP were demonstrated by the pH dependence of their 31P NMR chemical shifts in spectra of perchloric acid cell extracts. Intracellular pH of cells was determined to be 7.5-7.7.     

ATV-related central nervous system injuries in Louisiana

All terrain vehicles (ATVs) have been associated with death and serious injury since their introduction into the marketplace. Fifteen cases of ATV-related brain and spinal cord injury reported to the Louisiana Central Nervous System Registry during 1995 were evaluated for severity, etiology, and outcome. Eleven (73%) of these injuries were sustained by persons under 18 years of age. Despite US Consumer Product Safety Commission and ATV manufacturer recommendations for age restrictions, ATVs continue to be popular recreational devices for children.     

Recovery from work shifts: How long does it take?

Although regulations on work hours usually include a minimum weekly rest period, there is little empirical evidence concerning recovery from work. Shift-working nurses (N?=?61) used a handheld computer for 28 days to complete self-ratings, cognitive-performance tasks, and a sleep diary. Many measures were worse on rest days that followed a night shift rather than a day shift and tended to be worse on 1st rest days compared with subsequent rest days. Alertness was lowest on the 1st rest day following a night shift. Social satisfaction was better on workdays that were preceded by 2 rather than 1 rest day. Reaction time (RT) decreased over consecutive night shifts and tended to increase over rest days following night shifts. The results are interpreted as being consistent with the combined adaptive costs of fatigue and adjustment to and from a nocturnal routine. The practical implications for scheduling rest days are considered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)