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Abstract

Background:  Regional and local anaesthetic techniques are thought to improve postoperative pain control and functional outcomes following total knee arthroplasty, potentially leading to a reduction in hospital length of stay.

Objectives:  The objective of this study was to evaluate the reporting quality and discuss the clinical findings of the available literature on these modalities that included length of stay as a study outcome.

Data sources:  The electronic databases Pubmed, Scopus, Medline, Web of Science and Cochrane library were searched using key words.

Review methods:  Eight-hundred and forty-three papers were identified in the search. Fifteen of these met the inclusion criteria. Eight further studies were identified from their reference lists to give a final total of 23 studies that were reported against the consolidated standards of reporting trials (CONSORT) 2001 statement checklist.

Results:  The mean criteria CONSORT score was 17.3/22 (79%). The majority of studies that compared femoral nerve blocks with placebo or conventional pain management modalities failed to demonstrate a significant reduction in length of stay. All studies that compared femoral nerve blocks with epidurals found no significant difference in length of stay. Only half of the studies comparing local anaesthetic techniques to placebo or conventional pain management methods found a significant reduction in length of stay.

Conclusions:  The reporting quality has specific deficiencies in the areas of sample size calculation, randomization whilst there was under-reporting of blinding. Regional and local anaesthetic techniques have not demonstrated a clear reduction in hospital length of stay. Epidurals and femoral nerve blocks have similar impacts on length of stay.

Abstract

Background:  The histological characteristics of follicular thyroid carcinomas (FTCs) are important predictors of prognosis, and lesions can be classified as either minimally invasive follicular carcinoma (MIFC) or widely invasive follicular carcinoma (WIFC) based on histopathological characteristics. There has been controversy surrounding the histological classification of FTC, which can present challenges to clinicians attempting to deliver accurate prognostic information to their patients. The aim of the present study was to examine cases of metastatic FTC for characteristics that may predict aggressive tumour behaviour.

Methods:  The Monash University Endocrine Surgery Unit database was searched for patients with FTC. The histopathology reports were collated for these patients to confirm the diagnosis of FTC, classify patients into MIFC versus WIFC, and examine for key characteristics such as the capsular and/or vascular invasion. The thyroid specimens from patients with metastatic FTC were examined by reviewing pathologists. It was hypothesized that patients with metastatic disease would likely have WIFC as their primary lesion.

Results:  There were 64 patients with FTC identified during the period of 1997–2009. Of these, 10 patients were found to have metastatic disease. On review of the histopathology, three patients were found to have WIFC,four patients had MIFC and three patients did not have definite features of FTC found in the thyroid gland.

Conclusion:  Currently accepted histological classification of FTC is inadequate and fails to accurately predict patients with distant metastatic disease and a more aggressive clinical course. It is thus the policy of our unit to recommend total thyroidectomy and radioactive iodine ablation for all patients with FTC.

The increasingly aggressive endovascular management of tibial artery occlusive disease is understandable given the fact that endovascular surgeons have routinely acquired increased technical skill and gained access to enabling endovascular hardware. However, the many options available to treat atheromatous lesions, including balloon angioplasty, cryoplasty, excisional atherectomy, rotational atherectomy, self-expanding stent placement, covered stent placement, balloon expandable stent placement, and drug-eluting stent placement, have driven the treatment of lesions faster than data has provided guidance.

This meticulous evaluation of the repeatability and reproducibility of venous duplex imaging by a distinguished group of investigators represents the first phase of the Investigating Venous Evaluation and Standardization of Testing (INVEST) study, the program initiated by the American Venous Forum to develop reporting standards for diagnostic venous studies. Given the extraordinarily widespread use of venous duplex imaging and its critical role in the diagnosis and treatment of chronic venous insufficiency, such standardization is vital for the clinical and research missions associated with this disease.

Background: An inflammatory reaction in vascular tissue is a potential factor linking restenosis after angioplasty. Although cilostazol, a selective phosphodiesterase type 3 inhibitor that is a unique antiplatelet drug and vasodilator, has been reported to be anti-inflammatory, its effect on the inflammatory action of mononuclear cells homing to endothelial cells is not clearly understood. In this study, whether cilostazol inhibits neointimal formation and improves inflammatory actions by inhibiting sialyl Lewis X (SLX) expression on mononuclear cells and E-selectin expression on endothelial cells was evaluated. Methods: The effect of cilostazol (1, 3, 10, 30 μM) on expression of E-selectin in human umbilical vein endothelial cells and SLX in rat mononuclear cells stimulated with lipopolysaccharide by immunofluorescence and real-time polymerase chain reaction (n = 3) was studied. Additionally, a double-balloon injury model was used on rat carotid arteries to evaluate vascular intimal hyperplasia. 0.1% cilostazol was administered 3 days before the first balloon injury, and the second balloon injury was performed 7 days after the first injury. Cilostazol administration was continued until rats were sacrificed 14 days after the second angioplasty. The expression of SLX on mononuclear cells and E-selectin on endothelial cells by immunofluorescence (n = 10) and real-time polymerase chain reaction (n = 5) were studied. Results: Cilostazol effectively inhibited the expression of SLX on mononuclear cells and E-selectin on endothelial cells. Cilostazol inhibited the migration of mononuclear cells in neointimal regions and neointimal hyperplasia after balloon injury. The numbers of macrophages and T-lymphocytes and the hyperplasia area in neointimal regions decreased from 71.06 ± 20.04, 1121 ± 244.4 cells per section, 206,400 ± 96,150 mm2 to 29.65 ± 16.73, 374.2 ± 124.5 cells per section, and 101,900 ± 16,150 mm2 due to the administration of cilostazol. Conclusions: These results demonstrate that the protective effect of cilostazol against neointimal hyperplasia may be mediated by its anti-inflammatory actions of mononuclear cells homing to endothelial cells by decreasing SLX and E-selectin expression. Clinical Relevance: It is reported that cilostazol inhibits neointimal hyperplasia by decreasing the expression of some cell-adhesion molecules. We evaluated the effects of cilostazol for the expression of sialyl Lewis X (SLX) on mononuclear cells and E-selectin on endothelial cells, which interaction is the first step of inflammation action. Cilostazol was thought to show the anti-inflammatory actions by decreasing SLX and E-selectin expression in addition to decreasing the expression of some cell-adhesion molecules.

A 80-year-old man was admitted to our department because of an arterial dilatation into the abdomen recorded during a routine ultrasound scan. His medical history was notable for smoking, chronic obstructive pulmonary disease, hypertension, hypercholesterolemia, and atrial fibrillation in anticoagulant therapy. The patient never underwent abdominal surgery and he was asymptomatic for abdominal pain.

“Only one who devotes himself to a cause with his whole strength and soul can be a true master. For this reason mastery demands all of a person”–Albert Einstein It is with the greatest honor that I stand before you today as president of the Eastern Vascular Society on this special 25th Anniversary of the society. This society has been very special to me since I joined 21 years ago, and I have not missed one single meeting since I joined in 1990. The Eastern Vascular Society was founded in 1987 by leaders in vascular surgery on the east coast of the United States, who have led the way in our society and played a prominent role in the leadership of our national Society for Vascular Surgery (SVS). In looking at the names of our past presidents, eight of them have served as president of the SVS/American Association for Vascular Surgery. It should also be noted that from the current officers of the Society for Vascular Surgery, the president, the vice-president, secretary, and the treasurer are current members of the Eastern Vascular Society.

You received a call advising that Mr S. H. Irk was in the emergency room having considerable wound pain following an above-knee amputation you performed 6 months ago. You discharged him from your clinic 6 weeks postoperatively to his primary care physician, still complaining of more pain than usual. Your examination, clinical lab tests, and X-rays do not reveal any serious problems, but he is writhing in pain and begging for relief. Mr Irk has been to a number of different physicians in the interlude including a chiropractor, a pain specialist, several primary care physicians, and a psychiatrist without relief. He has braced up with increasing amounts of analgesics, the latest of which was oral Dilaudid. His last source of pain meds on the street has dried up. You admit him with orders for analgesics. What should your treatment plan be?

In 2010, CPT code 36147 was created and bundles the work of establishing single catheter access with the diagnostic contrast imaging of the dialysis circuit. In 2012, the introductory wording was updated to clarify reporting concerns voiced by the insurance industry and coding groups.

Arteriovenous grafts placed predialysis have primary failure rates and cumulative survival rates that are similar to grafts placed after starting dialysis therapy. The fistula first initiative (www.fistulafirst.org) strongly encourages dialysis access via arteriovenous fistulas. Some patients, however, have anatomy more suitable for a graft. In such cases the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) suggests grafts be placed three to six weeks prior to the need for dialysis therapy. It is difficult to predict the onset of time for the need of dialysis in patients not undergoing dialysis. Some surgeons postpone graft creation until after the initiation of hemodialysis reasoning graft placement prior to dialysis therapy may result in diminished time of patent access when the patient actually needs the access. However, postponing initiation of graft placement until after beginning dialysis therapy exposes the patient to the risk of catheter related bacteremia, central vein stenosis and decreased overall survival.

Greater body mass index (BMI) is associated with peripheral arterial disease (PAD) in healthy older patients who never smoked. Novel and traditional cardiovascular disease risk factors are associated with PAD. One important cardiovascular risk factor previously not associated with PAD is BMI. Epidemiologic studies have either not demonstrated a relationship between PAD and BMI (Murabito JM. Am Heart J 2002;143:961-5, and Meijer WT et al. Arch Inter Med 2000;160:2934-8) or demonstrated an inverse association (Criqui MH. Circulation 2005;112:2703-7). Such studies have had cross sectional designs. In this study the authors hypothesize poor health and smoking status might simultaneously be associated with a lower BMI and greater PAD prevalence obscuring a positive association that might exist if adiposity itself leads to development of PAD. For this study the authors evaluated the association of BMI and PAD in adults age >65 years at baseline who are participating in The Cardiovascular Health Study (The Cardiovascular Health Study is a community based study of older adults with the goal to evaluate risk factors for development and progression of vascular disease). The authors also evaluated the association of BMI with subsequent incident clinical PAD events during follow up. They used self-reported recalled weight at age 50 to estimate mid-life BMI and evaluate its association with PAD prevalence at baseline. The analysis was repeated in a subset of participants who reported good health status and who had never smoked.

Asymptomatic > than 50% carotid stenosis is a risk factor for cognitive decline following coronary artery bypass grafting (CABG). Patients anticipate CABG will improve their quality of life (Koch CG et al. Semin Cardiothorac Vasc Anesth 2008;12:203-17). Preservation and improvement of psycho- emotional well enhances quality of life. Neuropsychological disorders are being more frequently addressed in the care of the postoperative patient. Cerebrovascular disease and coronary artery disease potentionally put patients at risk for cognitive decline. In this paper the authors correlate asymptomatic carotid stenosis with cognitive decline following coronary artery bypass grafting (CABG). They sought to detect the incidence of cognitive decline following CABG, identify risk factors associated with such cognitive decline and to investigate a possible link between cognitive performance and asymptomatic carotid stenosis.

Antiplatelet therapy and statin therapy are associated with reductions in the occurrence of venous thromboembolisim (VTE) with a dose related response of statins. Many of the same inflammatory mediators are elevated in patients with atherosclerosis and venous thrombosis (van Aken BE et al. Thromb Haemost 2000;83:536-9, and Sorensen HT. Lancet 2007;370:1773-9). Patients with a diagnosis of deep venous thrombosis and pulmonary embolism have higher risk of cardiovascular events over the next 20 years. In addition, patients with myocardial infarction or stroke have an increased risk of VTE within 3 months of diagnosis (Sorensen HT et al. J Thromb Haemost 2009;7:521-528) and patients with the metabolic syndrome and those with elevated levels of low density lipoprotein are also at increased risk of VTE (Ageno W et al. Circulation 2008;117:93-102). This emerging relationship between atherosclerosis and VTE with respect to biochemical etiologic factors led the authors to hypothesize statins and antiplatelet therapy could possibly have a role in preventing VTE in patients at high risk for atherosclerosis.

Preoperative duplex imaging prior to varicose vein surgery reduces recurrence and need for reoperation over 7 years of post operative follow-up. Inadequate surgery secondary to in adequate preoperative investigation may contribute to recurrence following surgery for primary varicose veins (Blomgren L et al. Br J Surg 2005;92:688-94). The authors previously reported recurrence and reoperation 2 years after varicose vein surgery were lower with preoperative duplex examination (Blomgrin L et al. Br J Surg 2005;92:688-94). It has also been suggested groin surgery associated with saphenous vein open surgery induces recurrence through neovascularization. The aim of the current study was to evaluate the impact of preoperative duplex imaging after seven years with respect to recurrence of varicose veins, performance of reoperation and neovascularization as a source of recurrence.

Szilagyi III infections are safely and effectively treated both short and long term with negative pressure wound therapy (NPWT). Wound infections with prosthetic graft or arterial involvement (Szilagyi grade III infections) can be associated with high morbidity and mortality (Kikta MJ et al. J Vasc Surg 1987;5:566-71). Traditional treatment for Szilagyi III infections is graft excision, radical debridement and secondary vascular reconstruction. NPWT was introduced in 1997 by Argenta and Morykwas (Morykwas MJ et al. Ann Plast Surg 1997;33:553-62). There have been small series of patients with vascular graft infections treated by NPWT without graft excision with apparently good short term results (Dosluoglu HH et al. J Vasc Surg 2010;51:1160-6).

There are mortality disparities associated with race and insurance status in patients with penetrating lower extremity vascular injury. Outcome disparities for Medicaid patients, people of color and the uninsured may be partially attributable to differences in baseline healthcare characteristics and/or hospital performance (Osborne NH et al. J Vasc Surg 2009;50:709-13). The author's considered that in trauma patients heterogeneity of injury, difficulties in injury measurement and a lack of standardized care may contribute to potential disparities in trauma outcomes, including vascular injury. Their hypothesis was that mortality rate disparities by socioeconomic status and race could be explained by injury heterogeneity. They therefore limited analysis of vascular injury to a group with homogenous injuries; those with lower extremity vascular injuries. They postulated disparities in outcome would be diminished or eliminated by such stratification. They used the National Trauma Data Bank version 7.0 of the American College of Surgeons to identify patients with lower extremity vascular injury. Univariate and multivariate analyses were performed using Stata software (version 11; StataCorp, LP, College Station, Tex). There were 4928 patients with lower extremity vascular injury identified. There were 2452 blunt injuries and 2452 penetrating injuries, with 24 cases where mechanism was unknown. Mortality was 7.6 % overall and did not differ by mechanism. Regression analysis, using mechanism as a covariate, revealed worse mortality for people of color (OR, 1.45; 95%CI, 1.03-2.02; P = .03) and worse mortality for the uninsured (OR, 1.62; 95%CI, 1.15-2.23; P = .006). When a separate analysis was performed stratified by mechanism there was no significant mortality disparity for blunt trauma; for people of color (OR, 1.28; 95%CI, 0.85-1.96; P = .23) or for the uninsured (OR, 1.33; 95% CI, 0.78-2.22; P = .29). There were however disparities for penetrating trauma, in people of color (OR, 1.18; 95%CI, 0.93-3.57; P = .08) and the uninsured (OR, 1.85; 95%CI, 1.19-2.94; P = .009).

Preoperative natriuretic peptide levels are independent predictors of cardiovascular events in the first 30 days following vascular surgery and improve predictive performance of the revised cardiac risk index.

A policy of intra-operative transcranial Doppler (TCD) and completion angioscopy was previously associated with virtual abolition of intra-operative stroke (apparent upon recovery from anaesthesia) following carotid endarterectomy (CEA). The aims of this study were to determine whether the prevalence of technical error has diminished with experience and whether our monitoring/quality control policy was still associated with low rates of intra-operative stroke 20 years after its introduction.