Infected upper extremity aneurysms: a review

Staphylococcus aureus sepsis and hemoptysis as messengers of a rather impractically located mycotic aneurysm

BACKGROUND

Mycotic aortic aneurysms (MAA) arise due to infection of a pre-existent aneurysm or aneurysmal degeneration of an infected vascular wall. MAA of the thoracic aorta are relatively rare. Treatment is mainly guided by clinical experience as there are no large randomized trials available.

CASE PRESENTATION

A 79-year-old patient was hospitalized with staphylococcus aureus sepsis and MAA originating from the ostium of the left common carotid artery (CCA). Initial treatment consisted of high-dose antibiotics and blood pressure control. After 48 hours, a CT-angiography revealed rapid growth of the MAA with imminent rupture. Various treatment options were considered: a covered stent in the left CCA, a carotid-subclavian bypass with ligation of the left CCA ostium or arch replacement, or an extra-anatomical transposition of the supra-aortic vessels combined with a thoracic endoprosthesis. The last option was selected and, combined with six weeks of antibiotics, proved successful in controlling the impending rupture and treating the MAA.

CONCLUSIONS

Endovascular techniques are used if open surgery is refused, when surgical risks are prohibitively high (as definitive or palliative treatment), or as an emergency temporary treatment until definitive surgical treatment is feasible. Our high-risk patient underwent endovascular treatment for MAA as a definitive treatment. Endovascular treatment is increasingly becoming the treatment of choice due to the high morbidity and mortality of open surgical repair. Although the main concern using endovascular treatment is absence of debridement, recent studies show that combining endovascular treatment and long-term antibiotic therapy represents a potentially durable treatment and viable alternative to open surgical repair.

State of the art review: The management of chronic vascular disorders in the hand and upper limb

This review article summarizes the basic principles of vascular anatomy, physiology, diagnostic work-up and treatment for patients with nontraumatic upper extremity vascular disorders. Vascular disorders can be considered vasospastic or occlusive. The most commonly encountered vasospastic condition is Raynaud's Phenomenon secondary to scleroderma. While historically this has been managed medically with vasodilators, more advanced cases can benefit from surgical treatment to improve blood flow and minimize tissue loss, with compelling evidence that earlier surgical intervention can modify disease process and should be considered. Occlusive disease can present as aneurysm or thrombosis and often requires surgical treatment with resection of the occluded segment with or without vascular reconstruction. In advanced atherosclerotic disease or end stage ischemia, arterialization of the venous system can be considered to avoid more proximal amputations.

True Idiopathic Brachial Artery Aneurysm Treated With a Saphenous Vein Graft

Purpose: The objective of this study is to report a case of a 65-year-old woman who presented with pallor and pain of her left arm secondary to a true arterial brachial aneurysm, which was successfully treated with saphenous vein bypass and embolization of the aneurysm sac. A review of the literature is also presented. Case report: A 65-year-old woman presented with an acute onset of pallor and pain of her left forearm, and hand. On physical examination, there was a pulsatile mass at the forearm. A doppler ultrasound showed a fusiform aneurysmal dilatation of the brachial artery of 23 mm of diameter. A dynamic contrast-enhanced MRI angiogram confirmed a fusiform dilation of the distal brachial artery. The patient was scheduled for open repair. A fusiform 20 x 60 mm aneurysm of the distal brachial artery extending to the cubital fossa was found and a brachial artery to radial and ulnar arteries bypass with interposed reverse right saphenous vein was created. Embolization of the aneurysm sac was performed using Gelita-spon ® (Gelita Medical, Eberbach, Germany). A final angiogram showed an adequate perfusion through the bypass to the hand, and no contrast in the aneurysmal sac. Postoperative course was uneventful with discharge on the fourth postoperative day. Conclusion: Revascularization with autologous saphenous vein graft and exclusion of the aneurysm with local embolization is a good treatment alternative in a patient with symptomatic brachial aneurysm with distal embolization.

Mycotic aneurysm of the distal radial artery after cardiac catheterisation

A mycotic aneurysm of the distal radial artery following access for cardiac catheterisation is a rare complication that has not been described in the literature. We present the case of an 84-year-old man who developed bacteraemia and cellulitis over his left first dorsal webspace 2 days after undergoing cardiac catheterisation through the distal radial artery at the anatomic snuffbox. Ultrasound scanning and CT imaging were concerning for a possible pseudoaneurysm at that location. Once we confirmed that the patient had adequate flow through his hand with angiography and an Allen's test, we explored his left hand and found a mycotic aneurysm of the distal radial artery with surrounding frank purulence. We resected the aneurysm and ligated the artery. Pathology confirmed that this was a mycotic aneurysm. The patient quickly recovered from his infection after this definitive treatment.

Axillary artery aneurysm associated with Arteriovenous malformations of the upper extremity: A case report

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Axillary artery aneurysms are an uncommon upper extremity pathology and Arteriovenous malformations (AVMs) are a rare cause.

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We present a case of congenital high-flow AVMs in the upper limb who presented with an asymptomatic axillary artery aneurysm.

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Our patient was asymptomatic, but surgery was indicated because of the size of the aneurysm.

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We used a vein graft instead of a synthetic graft because the aneurysm was located close to the shoulder joint.

Introduction and importance

Axillary artery aneurysms are an uncommon upper extremity pathology. While trauma is the most common cause, degenerative aneurysms may occur in high-flow vascular conditions, such as upper extremity arteriovenous fistulas. Arteriovenous malformations (AVMs) are a rare cause.

Case presentation and discussion

We herein describe a 41-year-old male with multiple congenital high-flow AVMs in the left upper extremity who presented with an asymptomatic axillary artery aneurysm. The aneurysm was successfully treated with open resection and revascularization using a reversed basilic vein interposition graft.

Conclusion

Clinicians should be aware of the possibility of an axillary artery aneurysm in patients with upper extremity AVMs.

Management of Brachial Artery Pseudoaneurysms in Intravenous Drug Abusers

Objective To determine the outcomes of the ligation and excision of brachial artery pseudoaneurysm in IV drug abusers without revascularization.  Methodology This retrospective observational study was conducted at the vascular surgery department Shaheed Muhtarma Benazir Bhutto trauma center Karachi from January 2019 to June 2020. All the patients with a history of intravenous drug abuse presented with pulsatile mass at or near cubital fossa, diagnosed as pseudoaneurysm, age ranging from 18-70 years, and of either gender were included in the study. Patients with pseudo-aneurysm secondary to trauma, hemodialysis, arteriovenous fistula, location other than cubital fossa, and whom primary revascularization was performed were excluded. The recorded data entered and analyzed using SPSS 20.0 (IBM Corp., Armonk, NY). Results A total of 20 intravenous drug addicts were included in the study. The mean age was of 31.10 ± 7.80 years, and the mean duration of addiction was 2.24 ± 1.16 years. The right arm is affected in almost two-thirds of patients. The most common presentation in the emergency department was ruptured pseudo-aneurysm with bleeding (65%), followed by oozing with pulsatile mass (30%), and infected pulsatile mass (5%). The outcome was Limb salvage (100%), and none of the patients had developed threatened ischemia of the arm or required amputation. Conclusion The ligation and excision of the pseudo-aneurysm, without revascularization, is a safe and effective treatment option for the management of pseudoaneurysm of the brachial artery secondary to intravenous drug addiction.

Acute right upper extremity ischemia resulting from true aneurysmof right brachial artery: A case report

We report a case of 66-year-old woman with true aneurysm of the right brachial artery. She presented with acute upper extremity ischemia. The hand was cold and parenthesized and distal pulses were absent. CT angiography (CTA) revealed a 20*25 mm true brachial artery aneurysm. The aneurysm was thrombosed without distal run-off. We excised the aneurysm and reestablished the arterial flow by a reverse saphenous interposition graft. The postoperative course was uneventful.

True brachial artery aneurysm: A case report and review of literature

Introduction

A true brachial artery aneurysm is a rare pathology with an incidence of 0.17% of all peripheral artery aneurysms. This pathology can manifest devastating complications if overlooked, however, a high index of suspicion coupled with a thorough history and physical allows easy diagnosis. We present a rare case of the oldest documented patient with a true brachial artery aneurysm with idiopathic etiology.

Presentation of case

An 83-year-old gentleman presented with left upper extremity pain, erythema, and swelling for 1 week. He denied trauma to the area. Examination revealed a pulsatile mass of the antecubital fossa and decreased distal pulses. Imaging illustrated a 9mm aneurysm of the brachial artery with stenosis of the radial artery and non-enhancement of the origin of the ulnar artery. The patient underwent a brachial aneurysm excision, radial and ulnar embolectomy, and brachial to ulnar and radial artery bypass. Postoperatively, palpable pulses were appreciated in the radial and ulnar arteries. Pathology demonstrated a true aneurysm. The patient's postoperative course was uneventful and follow-up 6 months later revealed normal perfusion.

Discussion

This case highlights the importance of maintaining a high index of suspicion coupled with a thorough history and physical examination when encountering neurovascular complaints of the upper extremities. Operative intervention even in asymptomatic patients is warranted due to a high complication rate of 33%.

Conclusion

More research into the pathophysiology of this rare pathology is needed to further understand, prevent, or mitigate its complications.

Vascular Injuries in Intravenous Drug Addicts-A Single-Center Experience

BACKGROUND

Infected false aneurysms (IFA) caused by intravenous drug abuse are uncommon but challenging lesions. The best approach for the surgical management of this condition is still unknown. The aim is to present a single-center 14-year experience in the IFA treatment in intravenous drug abusers, thus providing additional data regarding the treatment options and outcome in these patients.

METHODS

A retrospective analysis of 32 consecutive patients with vascular injuries secondary to intravenous drug abuse, during the period from January 2004 to April 2018, was performed. Data of interest were extracted from patients' medical history records, anesthesia charts, and database implemented in daily practice, or were obtained by personal contact. The diagnosis was set based on history, physical examination and/or color Doppler sonography, multidetector computed tomographic angiography, and digital subtraction angiography. The outcome included graft patency, limb amputation, and mortality.

RESULTS

During study period, 32 heroin abusers, predominantly males (81%), were surgically treated due to vascular injuries, with mean age of 35.2 years. The vast majority of patients have had an injury of the lower extremity blood vessels (84.3%) and the common femoral artery was the most common site of injury (59.4%). Three-quarters of patients underwent resection of the false aneurysm and ligation of the artery without reconstruction of the blood vessel. In 7 cases (21.9%), arterial reconstruction was performed with overall failure rate of 42.86%. The overall mortality rate was 6.25% and the rate of extremity salvage was 96.7%.

CONCLUSIONS

The best treatment option is yet to be found, but based on the results of the present study, ligation of affected artery without revascularization seems to be an efficient, safe, and optimal treatment method, with minor risk of the extremity loss.

[The Treatment of Aneurysms of the Extremities Arteries - a Systematic Overview - New Therapies for Isolated Iliac Artery Aneurysm Employing a New Classification]

Aneurysms of arteries in the extremities have a low incidence and are often manifest through complications. The most serious complications are rupture and extremity-threatening ischemia. Both usually lead to the diagnosis. Absolute indications for therapy are symptomatic aneurysms and asymptomatic aneurysms of 2 cm diameter or more. The extrailiacal gold standard is interponat or bypass with venous graft material. Endovascular methods are reserved for inoperable patients and clinical decisions on special cases. In contrast, complex endovascular techniques have been established in isolated iliac aneurysms and have significantly improved treatment options. Their implementation is bound to the existence of a suitable landing zone. This is the basis for a new classification of isolated iliac artery aneurysm. With the help of morphological subtypes, this classification permits standardised procedure planning for perfusion preservation of the internal iliac artery. The present article gives an overview of the current treatment strategy for aneurysms of extremities arteries. Similarities and regional differences in therapy are discussed.

Mycotic Aneurysm of the Ulnar Artery Secondary to Bacillus Calmette-Guérin Therapy for Bladder Cancer: A Rare Presentation of Hypothenar Hammer Syndrome

Mycotic aneurysms, especially those of the upper extremity, are rarely reported in literature. These aneurysms are caused by bacterial endocarditis and, therefore, are more commonly seen in patients who are in an immunocompromised state, including those requiring bacillus Calmette-Guérin (BCG) therapy for bladder cancer. Owing to the inevitable rupture of mycotic aneurysms, the standard treatment is surgical repair with appropriate secondary antibiotics. We present a unique case of a mycotic ulnar artery aneurysm following BCG therapy and repetitive hand trauma in a patient with bladder cancer that was successfully repaired with microsurgical techniques and secondary antibiotics.

Mycotic Aneurysm of Brachial Artery Secondary to Infective Endocarditis

Introduction

This case describes a brachial artery mycotic aneurysm (BAMA) secondary to infective endocarditis caused by Enterococcus faecalis. BAMAs are rare and potentially limb or life threatening. A literature review revealed 61 cases since 1950, primarily caused by intravenous drug use, with Staphylococcus aureus being the most common causative bacteria.

Report

A 71 year old man with known infective endocarditis presented with pulsatile swelling in his right antecubital fossa. A BAMA was confirmed on duplex scan. The patient underwent prompt extra-anatomic bypass with an ipsilateral cephalic vein graft.

Discussion

Bacterial endocarditis should be acknowledged as a cause of BAMA. Prompt diagnosis and intervention are essential.

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Brachial artery mycotic aneurysm (BAMA) secondary to infective endocarditis.

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Only case reported to be caused by haematogenous spread of Enterococcus faecalis.

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BAMAs are rare and can be potentially limb or life threatening.

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One must acknowledge bacterial endocarditis as a cause of BAMA.

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Prompt diagnosis and intervention are essential for good outcomes.

Aneurysms of the hand: Imaging and surgical technique

Hand aneurysms are a rare entity only described as case reports in the literature. The aim of our study was to describe a series of four cases and the surgical technique using an arterial bypass. We also wanted to define an algorithm for the imaging of this pathology. We have operated on four patients with hand aneurysms in the past decade or so. One patient had an aneurysm in the thumb proper palmar digital artery, one in the superficial palmar arch and the two others in the ulnar artery. All patients had an excision surgery with direct arterial bypass; no patient had a venous graft. All patients were seen a few years after the surgery and underwent an ultrasonography to check the anastomosis permeability. All anastomoses were permeable 2 to 8 years after surgery. Through a review of the literature we discuss the best algorithm for imaging a hand aneurysm. Direct arterial suture by proximal and distal mobilization allows for long-term permeability. If a graft is necessary, a graft of arterial origin should be preferred. The additional first-line examination is ultrasonography, followed by arteriography if acute ischemia is present; otherwise, CT angiography or MR angiography is performed.

Percutaneous Coil Embolization for the Treatment of a Giant Brachial Artery Pseudoaneurym in a Child

Brachial artery pseudoaneurysm is a rare phenomenon. When a diagnosis of brachial artery pseudoaneurysm is established, early and appropriate treatment should be performed as soon as possible to prevent possible complications, such as hemorrhage, rupture, and upper limb and finger losses. Open surgical repair is usually the cornerstone of treatment; however, we here report a case of giant brachial pseudoaneurysm in a 2-year-old girl, which was successfully treated with percutaneous coil embolization.

Surgical Repair of Axillary Artery Aneurysm in a 2-Year-Old Child: A Case Report

Peripheral aneurysm and pseudoaneurysm of an artery is a well-recognized but rare phenomenon in children. We report a case of an axillary artery aneurysm in a 2-year-old boy with methicillin-resistant Staphylococcus aureus septic shock, acute respiratory distress syndrome, and multiorgan dysfunction syndrome. Definitive surgical treatment with left axillary artery aneurysm exclusion and bypass with greater saphenous vein graft were performed. To our knowledge, this is the only axillary artery aneurysm ever reported in a child.

Hybrid Treatment of Large Brachial Artery Pseudoaneurysms

BACKGROUND

Conventional surgical treatment of brachial artery pseudoaneurysms (BAPs) includes aneurysm excision/opening and subsequent arterial reconstruction with different options depending on the extent of the arterial deficit. Endovascular repair of BAPs with stent grafting has also been reported but published experience remains limited. In this report, we present our experience with a novel hybrid approach consisting of primary endovascular aneurysm exclusion with a stent graft and subsequent open surgical evacuation of pseudoaneurysm content for decompression of adjacent structures.

METHODS

This study included all patients who underwent hybrid repair of a BAP within the period 2005-2014 in our institution. Data were collected retrospectively.

RESULTS

During the study period a total of 5 patients with iatrogenic BAPs were treated. Mean BAP diameter was 58 ± 4.9 mm. Technical success was 100%. Thirty-day mortality was null. No major perioperative complications were noted. Hand ischemia and neurological symptoms were reversed in all patients after the procedure. During follow-up (median 24 months, range 6-60 months) all stent grafts remained patent and no aneurysm relapse was noticed. No signs of stent-graft infection were noticed in any of the patients and no reintervention was needed.

CONCLUSIONS

Primary endovascular exclusion of BAPs with a stent graft followed by surgical evacuation of pseudoaneurysm sac content is associated with good early and mid-term results in this limited experience. Larger patient cohorts are required for further evaluation of this technique.

[Endovascular treatment of intra-thoracic left subclavian artery aneurysm]

Aneurysms of the subclavian artery are rare, and remain asymptomatic until complications. We report one case of atherosclerotic aneurysm of the proximal portion of the left subclavian artery fortuitously discovered and successfully treated by endovascular stent graft. This case report aims to illustrate endovascular procedures in the management of difficult access lesions or in high-risk surgical patients.

Donor Artery Aneurysm Formation following the Ligation of Haemodialysis Arteriovenous Fistula: A Systematic Review and Case Reports

Purpose

The purpose of this study is to investigate the pathogenesis, presentation and diagnosis of donor artery aneurysm formation following arteriovenous fistula (AVF) ligation and reach a consensus on their management.

Methods

A systematic review of literature in Ovid, MedLine, Embase, Scopus and CINHAL in the English language from 1951 to 2014 was performed. This was accompanied by two case reports. A total of 12 articles with 23 case reports were identified. Variables including patient's demographics, signs, symptoms, fistula type, duration of fistula use, time to aneurysm formation, renal transplantation, diagnostic modality, aneurysm type and size, type of surgery and outcome were reviewed.

Results

The data demonstrate a male predominance (5:1) and a median age of 47 years (range, 27-75 years). The median duration of access was 54 months (range, 6-300 months). The median time from ligation to aneurysm was 120 months (range, 6-280 months). The commonest aneurysm was of the brachial artery (BA, n = 21, 84%). The commonest type of AVF was radiocephalic (n = 15, 60%) followed by brachiocephalic AVF (n = 9, 36%). The management of choice was aneurysmectomy followed by interposition vein grafting (n = 12, 50%) with a median reported patency of 12 months (range, 1-38 months). This was followed by polytetrafluoroethylene (PTFE) grafting (n = 6, 25%) with a median reported patency of 6 months (range, 1-48 months).

Conclusions

The pathogenesis of donor artery aneurysms remains contentious. This review suggests that duplex is the investigative modality of choice and aneurysmectomy with interposition grafting is preferred over bypass.

Posttraumatic versus Mycotic Dorsalis Pedis Pseudoaneurysm

Reports of dorsalis pedis aneurysms are rare, and there are currently no reports of mycotic dorsalis pedis aneurysms in the literature. Most dorsalis pedis pseudoaneurysms are diagnosed by physical exam and color flow duplex. Surgical treatment includes aneurysm resection with or without reconstruction of the dorsalis pedis artery. We report a dorsalis pedis pseudoaneurysm diagnosed clinically and via duplex ultrasound, treated by excision and ligation of the aneurysm.

Symptomatic peripheral mycotic aneurysms due to infective endocarditis: a contemporary profile

Peripheral mycotic aneurysms (PMAs) are a relatively rare but serious complication of infective endocarditis (IE). We conducted the current study to describe and compare the current epidemiologic, microbiologic, clinical, diagnostic, therapeutic, and prognostic characteristics of patients with symptomatic PMAs (SPMAs). A descriptive, comparative, retrospective observational study was performed in 3 tertiary hospitals, which are reference centers for cardiac surgery. From 922 definite IE episodes collected from 1996 to 2011, 18 patients (1.9%) had SPMAs. Because all SPMAs developed in left-sided IE, we performed a comparative study between 719 episodes of left-sided IE without SPMAs and 18 episodes with SPMAs. We found a higher frequency of intravenous drug abuse, native valve IE, intracranial bleeding, septic emboli, multiple embolisms, and IE diagnostic delay >30 days in patients with SPMAs than in patients without SPMAs. The causal microorganisms were gram-positive cocci (n =10), gram-negative bacilli (n = 2), gram-positive bacilli (n = 3), Bartonella henselae (n = 1), Candida albicans (n = 1), and negative culture (n = 1). The median IE diagnosis delay was 15 days (interquartile range [IQR], 13-33 d) in the case of high-virulence microorganisms versus 45 days (IQR, 30-240 d) in the case of low- to medium-virulence microorganisms. Twelve SPMAs were intracranial and 6 were extracranial. In 10 cases (8 intracranial and 2 extracranial), SPMAs were the initial presentation of IE; the remaining cases developed symptoms during or after finishing parenteral antibiotic treatment. The initial diagnosis of intracranial SPMAs was made by computed tomography (CT) or magnetic resonance imaging in 6 unruptured aneurysms and by angiography in 6 ruptured aneurysms. The initial test in extracranial SPMAs was Doppler ultrasonography in limbs, CT in liver, and coronary angiography in heart. Four (3 intracranial, 1 extracranial) of 7 (6 intracranial, 1 extracranial) patients treated only with antibiotics died. Surgical resection was performed in 7 (3 intracranial, 4 extracranial) and endovascular repair in 4 (3 intracranial, 1 extracranial) patients; all of them survived. In conclusion, we found that SPMAs were a rare complication of IE that developed only in left-sided IE, and especially in native valves. Intracranial hemorrhage, embolism, multiple embolisms, and diagnostic delay of IE were more common in patients with SPMAs. The microbiologic profile was diverse, but microorganisms of low-medium virulence were predominant, and had a greater delayed diagnosis of IE than those caused by microorganisms of high virulence. SPMAs were often the initial presentation of IE. The most common location of SPMAs was intracranial. Noninvasive radiologic imaging techniques were the initial imaging test in intracranial unruptured SPMAs and in most extracranial SPMAs. Surgical and endovascular treatments were safe and effective. Endovascular treatment could be the first line of treatment in selected cases. Mortality was high in those cases treated only with antibiotics.

Forearm and hand arteries’ aneurysms – a case report of bilateral true ulnar artery aneurysm in the hypothenar eminence and systematic review of the literature

Arterial aneurysms in the forearm, wrist and hand are relatively uncommon. Penetrating injuries, arterial traumas, infections and repetitive microtraumas represent the most frequent cause of these secondary aneurysms or pseudo-aneurysms, while true nontraumaticor infective peripheral aneurysms of the upper extremities are very rarely encountered. Over the last 20 years these have been reported only sporadically, both in adults and children. We describe a case of bilateral true idiopathic saccular artery aneurysms in the hypothenar eminence, treated with excision and arterial continuity restoration by primary end-to-end anastomosis on the left side and conservatively on the right. To our knowledge, no other similar case has been documented to date. Starting from this original case we conducted a systematic review of the literature via PubMed search on peripheral aneurysms of the forearm and hand arteries from 1933 to the present, including specifically true distal ulnar and radial artery aneurysms. Etiology, clinical characteristics and management of these rare pathological entities are extensively discussed.

Swelling in the upper arm: the presentation and management of an isolated brachial artery aneurysm

True aneurysms of the brachial artery are uncommon. We describe the presentation and surgical management of an isolated, brachial artery aneurysm in a 64-year-old woman. Excision of the aneurysm and long saphenous venous interposition grafting was performed with no postoperative complications and histology demonstrated true aneurysmal degeneration.

Symptomatic axillary hematoma after ultrasound-guided infraclavicular block in a patient with undiagnosed upper extremity mycotic aneurysms

We present a case of axillary hematoma complicating an ultrasound-guided infraclavicular block in a patient with undiagnosed mycotic aneurysms of the peripheral arteries. Mycotic aneurysm is a rare medical condition with well-identified risk factors. When performing regional anesthesia in patients with these risk factors, clinicians should have a high degree of suspicion about the possible existence of vascular anomalies. A preprocedure Doppler study of the block area and real-time guidance of the needle using ultrasound may be useful.

Diagnosis and management of mycotic aneurysms

We reviewed all papers most recently reported in the literature related to infected arterial aneurysms (IAAs) affecting the aorta and vascular beds other than the aorta. In this article, we report on vascular beds other than the aorta. As is the case for aortic IAAs, infected non-aortic aneurysms are rarely encountered. The majority of recent studies are limited to case reports and small series of unusual infected aneurysms. A comprehensive review of this entity was performed based on the available literature from January through December 2008 in all languages. Available reports were analyzed with respect to demographic features, type of presentation, methods of diagnosis and therapy, follow-up, and outcome (morbidity and mortality).