Risk Factors for Stroke After Carotid Paraganglioma Surgery

BACKGROUND

The Carotid Paraganglioma Cooperative International Registry (CAPACITY) is an international registry composed of 1,432 patients with carotid body tumors (CBT) from 11 centers from 4 countries. The aim of this study was to identify risk factors for patients who presented stroke after carotid paraganglioma resection.

METHODS

Clinical characteristics and demographics of patients who presented transoperatively and postoperatively stroke from the CAPACITY database were retrospectively gathered. Regression analysis was performed using single logistic regression with Omnibus' test for possible factors that might contribute to present stroke.

RESULTS

Out of 1,432 patients, 8 (0.5%) female patients presented stroke. Median age was 53 years (range: 41-70 years). Six strokes occurred transoperatively, diagnosed clinically in the immediate postoperative period. Of them, none of the patients received any further treatment. Three of them died on postoperative day 2, 3, and 4. Two patients developed stroke during the first 24 postoperative hours, patients showed dysarthria, and aphasia. One of them was reintervened with thrombectomy due to thrombosis of the common carotid artery the other patient was treated conservatively. Median follow-up was 16 months (range: 2-72 months). Single logistic regression analysis revealed a history of diabetes mellitus (odds ratio (OR) 7.62), carotid artery disease (OR 17.51), and vascular lesion (OR 2.37) to have significantly increased odds of stroke during CBT surgery.

CONCLUSIONS

In the present study history of diabetes mellitus, carotid artery disease, and vascular lesion had increased odds of stroke during CBT surgery. Findings are limited by low event rate and even larger cohorts are needed to fully define preventive preoperative strategies for preventing stroke.

Clinical prediction rules in acute appendicitis: which combination of variables is more effective at predicting?

BACKGROUND

Clinical prediction rules have been designed to reduce variability and improve the diagnostic process. However, there are no unanimous criteria regarding which of them is the most efficient for the diagnosis of acute appendicitis.

AIM

The primary aim of this study was to assess the diagnostic efficacy of the most commonly used clinical prediction rules. The second aim was to identify the combination of the smallest number of clinical and analytical variables that would allow a cost-effective diagnostic approach.

METHODS

A retrospective observational study was conducted of 458 patients who were evaluated for right iliac fossa pain between January 2010 and December 2016. The scores tested were Alvarado, AIR, RIPASA, and AAS. Univariate and multiple regressions were used for validation.

RESULTS

Alvarado one was the most efficient to establish a positive diagnosis of acute appendicitis. However, the most simplified and predictive combination variables included anorexia, white blood cell count > 8275 leukocytes/mL, neutrophilia (> 75%), abdominal pain < 48 h, migrating pain, and temperature out the range of 37-39ºC.

CONCLUSIONS

A new and effective CPR (HMC score) for predicting appendicitis in patients presenting with the right iliac fossa pain has been established.

Impact of nutritional and inflammatory status in patients with critical limb-threatening ischemia

BACKGROUND

A pro-inflammatory state and a poor nutritional status have been associated with severity and prognosis of patients with peripheral arterial disease (PAD). The clinical applicability of the different pre-operative nutritional and inflammatory biomarkers in patients with critical limb-threatening ischemia (CLTI) was analyzed.

METHODS

A retrospective observational study was performed, that included all patients with CLTI revascularized from January 2016 to July 2019. The inflammatory state was calculated using neutrophil/lymphocyte (NLR), lymphocyte/monocyte (LMR) and platelet/lymphocyte ratios (PLR). For nutritional status, the Prognostic Nutritional Index (PNI) was calculated. Mortality and number of major amputations at 6 months and hospital length-of stay were studied.

RESULTS

310 patients were included. Higher levels of NLR and lower levels of PNI were associated with mortality (6.61±5.6 vs. 3.98±3.27, P=0.034; 40.33±7.89 vs. 45.73±7.48, P=0.05, respectively). Lower levels of PNI and LMR (42.57±7.82 vs. 45.44±7.65, P=0.036; 2.77±1.61 vs. 3.22±1.75, P=0.013, respectively) and higher levels of NLR (6.91±7.85 vs. 3.94±2.57, P=0.023) were associated with major amputations. The mean hospital length-of-stay was higher in patients with lower levels of PNI and LMR (P=0.000 and P=0.003) and higher levels of NLR and PLR (P=0.001 and P=0.002). A PNI<42.87 predicted short-term mortality with a 66.7% of sensitivity and a 66.8% of specificity (P=0.000).

CONCLUSIONS

Our experience suggests that these inflammatory and nutritional biomarkers are independent predictors of short-term mortality and major amputations. In addition, our results suggest that PNI could be used to predict the short-term mortality with high sensitivity and specificity.

Statistical techniques for predicting rupture risk in abdominal aortic aneurysms: A contribution based on bootstrap

The morphometry of abdominal aortic aneurysms (AAA) has been recognized as one of the main factors that may predispose them to rupture. The need to quantify the morphometry of AAA on a patient-specific basis constitutes a valuable tool for assisting in rupture risk prediction. Previous results of this research group have determined the correlations between hemodynamic stresses and aneurysm morphometry by means of the Pearson coefficient. The present work aims to find how the AAA morphology correlates with the hemodynamic stresses acting on the arterial wall. To do so, the potential of the bootstrap technique has been explored. Bootstrap works appropriately in applications where few data are available (13 patient-specific AAA models were simulated). The methodology developed can be considered a contribution to predicting the hemodynamic stresses from the size and shape indices. The present work explores the use of a specific statistical technique (the bootstrap technique) to predict, based on morphological correlations, the patient-specific aneurysm rupture risk, provide greater understanding of this complex phenomenon that can bring about improvements in the clinical management of aneurysmatic patients. The results obtained using the bootstrap technique have greater reliability and robustness than those obtained by regression analysis using the Pearson coefficient, thus allowing to obtain more reliable results from the characteristics of the samples used, such as their small size and high variability. Additionally, it could be an indicator that other indices, such as AAA length, deformation rate, saccular index, and asymmetry, are important.

Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease

BACKGROUND

The aim of this study was to analyze duplex ultrasound (DUS) and intraoperative angiography concordance for diagnosis of lower limb peripheral artery disease and its value for surgical planning.

MATERIALS AND METHODS

This was a prospective, observational study, including patients who underwent revascularization of the lower limbs during 2018, diagnosed by DUS only or combined with preoperative computed tomography (CT) angiography. The concordance between preoperative DUS or CT angiography and the intraoperative angiography was studied using the Cohen kappa coefficient (k). The degree of agreement between the DUS-based surgical plan and the final surgical technique was also evaluated.

RESULTS

Fifty-one patients were included, with mean age of 71.8 ± 11.96 years (46-94); 23 had chronic kidney disease (45%). In 17 patients (34%), preoperative CT angiography was also performed. DUS showed a sensitivity of 100% (95% confidence interval (CI) [83.3-100%]), 80% (95% CI [50.21-100%,]), and 100% (95% CI [96.43-100%]) at the iliac, femoral, and popliteal sector, respectively, and a specificity of 93.55% (95% CI [83.29-100%]), 95.45% (95% CI [84.48-100%]), and 90.48% (95% CI [75.54-100%]) at the iliac, femoral, and popliteal sector, respectively. The positive predictive value for DUS was 60% (95% CI [7.06-100%]), 88.9% (95% CI [62.8-100%]), and 87.5% (95% CI [68.17-100%]) for the iliac, femoral, and popliteal sectors, respectively, whereas the negative predictive value was 100% (95% CI [98.28-100%]), 91.3% (95% CI [77.61-100%]), and 100% (95% CI, [97.37-100%]). The concordance between DUS and intraoperative angiography showed a k index of 0.587 (P = 0.000) in the iliac sector, 0.799 in the femoral sector (P = 0.000), and 0.699 in the popliteal sector (P = 0.000). The concordance between CT angiography/intraoperative angiography had a k index of 0.71 in the iliac sector (P = 0.0093), 0.566 in the femoral sector (P = 0.006), and 0.5 in the popliteal sector (P = 0.028). DUS-based surgical plan was accurate in 86% of cases (n = 44).

CONCLUSIONS

Our experience suggests that DUS arterial mapping of the femoral and popliteal areas is better than CT angiography and can be considered as a unique preoperative imaging test during the surgical planning in patients undergoing a lower limb revascularization procedure.

Histological Benefits of Sealants in Tracheal Lesions in Wistar Rats

INTRODUCTION

The purpose of our study was to compare the effect, on the inflammatory response and fibrosis formation, of four commercially available sealant products applied on an injured trachea in a Wistar rat population.

MATERIALS AND METHODS

We compared four different sealants: cyanoacrylate, fibrin/thrombin, albumin/glutaraldehyde, and polyethylene glycol-based hydrogel (PEG). Rats were organized into six groups of similar size. Four of them were experimental, one was a baseline control group (BCG), and the sixth one was a reference control group (RCG). The RCG and experimental groups underwent the same surgical intervention with tracheal puncture, but no sealant was applied in the RCG. The BCG underwent the same cervical and peritracheal dissection without tracheal puncture. Rats were euthanized after eight weeks.

RESULTS

The operation was performed on 54 rats, of which 12 died, leaving a final sample of 42 rats. Macroscopic analysis revealed no superficial tracheal or vascular fistulas, nor signs of local abscess. Although the groups treated with cyanoacrylate, fibrin/thrombin, and albumin/glutaraldehyde showed some degree of fibrosis, the treated area of the PEG group showed neither inflammatory nor scar signs. Microscopic assessment of the BCG and RCG showed no remarkable findings. With the exception of the PEG group, which had a light fibrosis and poor inflammatory response as did the BCG and RCG groups, the other groups showed varying degrees of fibrosis and cicatrization.

CONCLUSION

Our study showed that the group treated with PEG had a mild inflammatory and fibrotic response, which is useful in tracheal or tracheobronchial surgical procedures. However, groups treated with cyanoacrylate, fibrin/thrombin, and albumin/glutaraldehyde showed fibrosis and cicatrization.

Prognostic significance of an elevated neutrophil-lymphocyte ratio in the amputation-free survival of patients with chronic critical limb ischemia

BACKGROUND

The aim of this study was to investigate the utility of admission neutrophil-lymphocyte ratio (NLR) in predicting the amputation-free survival (AFS) of patients with critical limb ischemia (CLI) who underwent an elective infrainguinal therapeutic intervention.

METHODS

All patients with CLI undergoing elective infrainguinal vascular surgery (open or endovascular) at a single university teaching hospital between January 2005 and December 2009 were retrospectively identified from a prospectively maintained database. The primary end point was AFS. The cut-off of NLR >5 was used to categorize patients into low- and high-NLR groups. Kaplan-Meier analysis and long-rank test were used to compare survival between both groups. Cox regression analysis was conducted to determine independent factors affecting the AFS.

RESULTS

During a median follow-up of 31 months, 561 patients with chronic CLI underwent infrainguinal revascularization. Five-year mortality was lower in the NLR <5 group (33%) than in the NLR >5 group (49%) (P ≤ 0.001), and the AFS was significantly higher in the NLR <5 group (50%) than in the NLR >5 group (26%) (P ≤ 0.001). In a multivariate analysis, preoperative NLR >5 was independently associated with 5-year AFS (hazard ratio 2.325, 95% CI 1.732-3.121).

CONCLUSIONS

Elevated NLR predicts a worse AFS in patients undergoing infrainguinal vascular revascularization with chronic CLI, suggesting that the NLR conveys powerful prognostic information that is independent of other conventional clinical risk factors.

Asymptomatic carotid stenosis in patients with intermittent claudication: epidemiological study

AIM

The aim of this paper was to determine the prevalence of extracraneal carotid artery disease in patients with intermittent claudication, to describe classic cardiovascular risk factors in those with hemodynamically significant stenosis and to try to define subgroups at high risk, improving therefore the performance of non invasive testing.

METHODS

A prospective descriptive study was conducted, with 146 patients reporting an intermittent claudication of the lower limbs and without a previous cerebrovascular event or carotid surgery. An ultrasonography examination was done. Risk factors were registed (smoking, dislipemia, arterial hypertension, diabetes mellitus), also ischemic cardiopathy and myocardial revascularization procedures. Univariate and multivariate analysis was made to define the variables associated with hemodynamically significant stenosis.

RESULTS

Prevalence of hemodynamically significant stenosis was 23.2%. Smoking, dislipemia, arterial hypertension and diabetes mellitus were not significantly associated with carotid stenosis; 24.2% of patients affected of ischemic cardiopathy present a severe stenosis, and myocardial revascularization was a risk factor for carotid stenosis.

CONCLUSION

Patients with claudication and ischemic miocardiopathy, especially when myocardial revascularization is needed, must be explored with carotid ultrasonography. In this patients, probably of hemodynamically significant carotid stenosis that requires treatment is more frequent.

[Methicillin resistant Staphylococcus aureus infection postoperatory complications and prognosis of patients with lower extremity amputations]

BACKGROUND AND OBJECTIVE

Methicillin-resistant Staphylococcus aureus (MRSA) is associated with an increasing morbimortality when compared with other microorganisms. The aim of this study was to examine the complications and prognosis of the presence of MRSA in vascular patients with amputation of lower limbs.

PATIENTS AND METHOD

We included patients who had lower extremity amputation in our department in 2004 and displayed positive surgical wounds cultures. We compared patients with MRSA positive cultures with other microrganisms. We evaluated general characteristics, operative indications, surgical wounds microbiology, reamputations, morbimortality and mean time of stay in hospital.

RESULTS

117 patients (median age 73, 68% male) underwent lower extremity amputation. 82 of them had positive cultures and MRSA were isolated in 30% cases. Two two groups were comparable and no statistical differences were found in relation to reamputation rate, morbimortality and mean time of stay in hospital.

CONCLUSION

Presence of MRSA does not represent an additional risk of reamputation or an increase of postoperative complications. Careful wound surveillance, through wound debridement and optimal administration of antibiotics must be applied to all patients, regardless of the bacterial flora.

Effect of vagotomy on the conjugated bile acids in the dog

The effects of truncal vagotomy and selective gastric vagotomy on the conjugated bile acids and rations T/G and Tri/Di have been studied in twenty dogs. The results show that truncal vagotomy has no effect on the conjugated bile acid values determined in the 4th and 16th week. The ratio T/G increased while the Tri/Di decreased in the 16th week. The selective gastric vagotomy only shows a change of the taurocholic acid levels which are lower than the control levels in the 4th week.