Late Sterile Abscess Formation in Carotid Endarterectomy Following Use of BioGlue: A Word of Caution

Introduction

BioGlue (CryoLife Inc., Kennesaw, GA) is a commonly used surgical adhesive, designed to achieve haemostasis following large vessel cardiovascular operations.

Report

An 88-year-old female presents with an enlarging right sided neck mass 9 months after carotid endarterectomy with bovine pericardial patch repair which utilised BioGlue seal the patch suture line.

Conclusion

BioGlue should be used properly and with caution. In cases of late wound complication following BioGlue use, simple drainage, debridement, and removal of BioGlue remnants may be a satisfactory approach.

Descending thoracic endovascular aneurysm repair: antegrade approach via ascending aortic conduit

Challenging access situations continue to arise in endovascular aneurysm repair, despite evolving arterial access techniques. We report a modified access approach, where an ascending aortic conduit was successfully used for antegrade delivery of a thoracic endograft to repair a descending thoracic aortic aneurysm, in a patient with previous surgical ligation of the infra-renal aorta.

The role of superficial venous surgery in the management of venous ulcers: a systematic review

BACKGROUND

The complicated natural history of venous ulcers requires the continued development and improvement of treatments to ensure the most effective management. Compression therapy or surgical correction of superficial venous incompetence (SVI) are currently the main methods employed for the treatment for venous ulceration (VU). This review compares and summates the healing and recurrence rates for each treatment modality used over the last thirty years.

METHODS

Sixty-one articles investigating compression and superficial venous surgical treatments were obtained from a systematic search of electronic databases (Medline, Embase, The Cochrane Library, and Google Scholar) and then an expanded reference list review. Patient demographics, CEAP classification, patterns of venous insufficiency, type of intervention, length of follow up, healing and recurrence rates for venous ulceration was assessed. Inadequate data in seven reports led to their exclusion. Recent randomised controlled trials (RCTs) specifically comparing superficial surgery to compression therapy were reviewed and data from non-randomised and/or 'small' clinical studies prior to 2000 underwent summation analysis.

RESULTS

Five RCTs since 2000 demonstrate a similar healing rate of VU with surgery and conservative compression treatments, but a reduction in ulcer recurrence rate with surgery. The effect of deep venous incompetence (DVI) on the ulcer healing is unclear, but sub-group analysis of long-term data from the ESCHAR trial suggests that although surgery results in a less impressive reduction in ulcer recurrence in patients with DVI, these patients appear to still benefit from surgery due to the haemodynamic and clinical benefits that result. The RCTs also highlight that a significant proportion of VU patients are unsuitable for surgical treatment. Summation of data from earlier studies (before 2000), included twenty-one studies employing conservative compression alone resulted in an overall healing rate of 65% (range 34-95%) and ulcer recurrence of 33% (range 0-100%). In thirty-one studies investigating superficial venous surgery, the overall rate of ulcer healing was 81% (range 40-100%) with a post-operative recurrence rate of 15% (range 0-55%). The duration of follow up care in the surgical studies was approximately twice as long as in the conservative studies, which would lend to more reliable recurrence data.

CONCLUSIONS

Evidence from the current literature, would suggest that superficial venous surgery is associated with similar rates of ulcer healing to compression alone, but with less recurrence. The effects of post-operative compression and DVI on the efficacy of surgery are still unclear.

Objective risk-scoring systems for repair of abdominal aortic aneurysms: applicability in endovascular repair?

OBJECTIVES

Recent studies propose the use of objective risk-scoring systems as a clinical tool for selecting patients for open or endovascular abdominal aortic aneurysm repair (EVR). The aim of this study was to evaluate four established risk-scoring systems for accuracy of prediction of early mortality and morbidity following EVR.

PATIENTS AND METHODS

266 consecutive patients undergoing elective EVR at St. George's Vascular Institute between July 2001 and January 2007 were studied using a prospective database. The Glasgow Aneurysm Score (GAS), the Vascular Physiology and Operative Severity Score for the enUmeration of Mortality and Morbidity (V-POSSUM), the modified Customised Probability Index (m-CPI) and the Customised Probability Index (CPI) were applied for prediction of 30-day mortality and morbidity. Accuracy of prediction was compared using receiver operating characteristics (ROC) curve analyses.

RESULTS

30-day mortality and morbidity rates were 4% (11/266) and 8% (22/266) respectively. For prediction of mortality, GAS, V-POSSUM, m-CPI and CPI ROC curve analyses showed areas under the curves (AUCs) of 0.68 (95% confidence interval (CI), 0.48-0.87; p=0.046), 0.66 (95% CI, 0.51-0.81; p=0.067), 0.63 (95% CI, 0.45-0.81; p=0.148) and 0.65 (95% CI, 0.49-0.80; p=0.101) respectively. Corresponding AUCs for prediction of morbidity were 0.64 (95% CI, 0.51-0.76; p=0.511), 0.62 (95% CI, 0.51-0.74; p=0.505), 0.54 (95% CI, 0.41-0.67; p=0.416) and 0.55 (95% CI, 0.42-0.68; p=0.451).

CONCLUSIONS

GAS, V-POSSUM, m-CPI and CPI were poor predictors of early mortality and morbidity following EVR in this series. Caution should be applied to the use of these scoring systems for pre-operative risk stratification and treatment selection for endovascular repair of abdominal aneurysms.

The Use of an Extra-corporeal Graft to Maintain Cerebral Perfusion During Thoracic Endovascular Aneurysm Repair

Endovascular access for aneurysm repair can be challenging in patients with iliofemoral occlusive disease. The carotid artery is an alternative access site, but may increase the risk of cerebral hypoperfusion during stent delivery. We describe a novel approach, where temporary extra-corporeal bypass was used to maintain cerebral perfusion during endovascular thoracic aneurysm repair via the carotid artery, in a patient with significant aorto-iliac and arch vessel disease.

An analogue assessment of repetitive hand behaviours in girls and young women with Rett syndrome

BACKGROUND

Rett syndrome is a neurodevelopmental disorder that almost exclusively affects females. In addition to neurodevelopmental regression and loss of hand skills, apraxia, deceleration of head growth, and increasing spasticity and scoliosis, a number of behavioural features are also seen, including stereotypic hand movements, hyperventilation and breath holding. The aim of the study was to investigate the extent to which analogue environmental conditions affected the frequency of repetitive hand behaviour in eight girls and young women with Rett syndrome.

METHOD

The frequency of repetitive hand movements was observed every 10 s for four 4-min sessions under the following conditions: Continuous Adult Attention, Adult Demands, Stimulation and No Stimulation.

RESULTS

The frequency of repetitive hand movements was high -- they occurred in above 60% of all intervals in all conditions for all participants and at nearly 100% for some participants in some conditions. For one participant the frequency of repetitive hand movements was somewhat reduced in the Stimulation condition; for another it was relatively increased in the No Stimulation condition.

CONCLUSIONS

Overall, environmental manipulations had relatively limited effects on repetitive hand behaviours. Repetitive hand behaviour in Rett syndrome may be maintained by automatic reinforcement or neurochemical processes and may not be primarily influenced by contingent reinforcement.

Caecal volvulus following laparoscopy-assisted sigmoid colectomy for sigmoid volvulus

CASE PRESENTATION. We report a case of caecal volvulus in a patient who underwent laparoscopy-assisted sigmoid resection for sigmoid volvulus 1 year previously. DISCUSSION. Clinico-radiological features and the management of metachronous sigmoid and caecal volvulus are discussed.

Delayed presentation of right ventricular bullet embolus

Venous bullet embolism to the heart is a rare complication of penetrating gunshot trauma. There are little data regarding long-term follow-up of missiles retained in the right ventricle. We report a rare case of right ventricular bullet embolus following a left-sided thoracic gunshot wound. The patient presented with delayed onset of cardiac irritability symptoms 4 years after injury.

Reversed-phase liquid chromatographic determination of vitamin D in milk

Vitamin D in milk is determined by a slight modification of the method of Sliva et al. [J. AOAC Int. (1992) 75, 566-571] for infant formula and enteral nutritional products. The sample is saponified for 30 min at 60 degrees C and extracted overnight into 60 mL of hexane. The hexane layer is washed, neutralized, and taken to dryness with a rotary evaporator. The sample is reconstituted in hexane and applied to 500 mg of Florisil in a solid-phase extraction column. Vitamin D is eluted with isopropyl alcohol. The eluate is evaporated to dryness under N2, and the sample is reconstituted in 1.0 mL of acetonitrile. The extract is analyzed on a C18 liquid chromatographic column (250 x 4.6 mm, 5 microns particle size) with UV detection at 265 nm. Milk samples of various fat content (i.e., skim, low fat, and whole milk) were analyzed. Spiked recoveries gave means of 81-96%; recoveries were inversely related to fat content. Assay precision ranged from 3.2 to 8.6%. The method can measure vitamins D2 and D3 individually, and no difference in the recoveries of the 2 vitamins was observed. Thus, vitamin D2 can be used as an internal standard for quantitating vitamin D3, and vice versa. The method is satisfactory for use in screening of milk for vitamin D content.

Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma

The three-view trauma series has been the standard screening examination for patients with cervical spine trauma. We conducted a prospective study to determine if the addition of supine oblique views to the three-view series would improve detection of fractures, subluxations, dislocations, or locked facets. All patients over a two-year period with suspected cervical spine injury had a five-view series obtained (three-view series and supine oblique views), and selected high-risk patients underwent thin-section conventional tomography of the cervical spine. Films were interpreted separately by two radiologists and an emergency physician, and the tomography results were used as the gold standard for comparison. Thirty-three of 58 high-risk patients had one or more fractures, subluxation, or dislocation demonstrated on tomography. There were no fractures or dislocations detected on the five-view series that were not detected or suspected on the three-view series. In areas of the cervical spine reported to be better visualized by supine oblique views than three-view series, our results indicate that supine oblique views did not improve detection but did, in certain cases, allow more specific diagnosis of injuries. Our data do not support the routine use of supine oblique views in the initial radiographic evaluation of patients with cervical spine trauma.

Radiographic diagnosis of quadriceps tendon rupture

Traumatic rupture of the quadriceps tendon is an uncommon knee injury which occurs in the elderly, and/or the obese, and in those with underlying systemic disease. Ten patients with 13 ruptures have been seen at the Massachusetts General Hospital in the last nine years. Clinically, the patient is unable to actively extend the knee. On the lateral view of the knee there is loss of normal quadriceps outline and a soft-tissue mass with calcification representing the retracted quadriceps tendon. Most patients have a hemarthrosis. The clinical diagnosis is often overlooked, and the radiologist could be the first to suggest the diagnosis.