Outcomes in idiopathic pulmonary fibrosis: a meta-analysis from placebo controlled trials.

BACKGROUND: Most data on outcomes in Idiopathic Pulmonary Fibrosis (IPF) pre-dates current guidelines. Data on rates of infection is sparse; the effect of low-dose corticosteroids and disease severity is unknown. METHODS: We identified randomised-controlled trials of IPF and analysed rates of mortality, lower respiratory tract infections (LRTIs), IPF progression and acute exacerbations from the placebo arms. We standardised event rates and compared differences using incidence rate ratios (IRRs) between subgroups according to disease severity or use of low-dose immunosuppression. RESULTS: Mortality was lower in trials that recruited patients with mild-moderate disease severities only, as compared to trials where patients with severe disease were allowed (188.6 vs 78.6 deaths per 1000 patient/years, IRR 0.30-0.59, p < 0.0001). No statistical difference was seen between trials permitting and excluding low-dose prednisolone use. LRTIs were found to be commoner in trials allowing low dose prednisolone use compared with those that did not (227.1 vs 63.4 infections per 1000 patient/years. IRR 2.56-5.13, p < 0.0001), and were less frequent in trials excluding patients with severe disease (153.9 vs 257.8 infections per 1000 patient/years, IRR 0.45-0.81, p = 0.0003). Acute exacerbations occurred less frequently in trials excluding severe disease (28.2 vs 122.9 exacerbations per 1000 patient/years, IRR 0.11-0.55, p < 0.0001). There was no difference between groups in rates of IPF progression. CONCLUSION: Mortality is heterogeneous and dependent on entry criteria. Infection rates were high, both with and without immunosuppression, and were higher in severe disease. Consideration should be given to alternative outcomes to mortality in future IPF trials if severe disease is excluded.

Comparison between the transabdominal and retroperitoneal approaches for aortic reconstruction in patients at high risk.

PURPOSE: The purpose of this study was to compare the transabdominal approach with the retroperitoneal approach for elective aortic reconstruction in the patient who is at high risk. METHODS: From January 1992 through January 1997, 148 patients underwent aortic operations: 92 of the patients were classified as American Society of Anesthesia (ASA) class IV. Forty-four operations on the patients of ASA class IV were performed with the transabdominal approach (25 for abdominal aortic aneurysms and 19 for aortoiliac occlusive disease), and 48 operations were performed with the retroperitoneal approach (27 for abdominal aortic aneurysms and 21 for aortoiliac occlusive disease). There were no significant differences between the groups for comorbid risk factors or perioperative care. RESULTS: Among the patients of ASA class IV, eight (8.7%) died after operation (retroperitoneal, 3 [6.26%]; transabdominal, 5 [11.3%]; P =.5). There was no difference between groups in the number of pulmonary complications (retroperitoneal, 23 [47.9%]; transabdominal, 19 [43.2%]; P =.7) or in the development of incisional hernias (retroperitoneal, 6 [12.5%]; transabdominal, 5 [11.3%]; P =.5). The retroperitoneal approach was associated with a significant reduction in cardiac complications (retroperitoneal, 6 [12.5%]; transabdominal, 10 [22.7%]; P =.004) and in gastrointestinal complications (retroperitoneal, 5 [8.3%]; transabdominal, 15 [34.1%]). Operative time was significantly longer in the retroperitoneal group (retroperitoneal, 3.35 hours; transabdominal, 2.98 hours; P =.006), as was blood loss (retroperitoneal, 803 mL; transabdominal, 647 mL; P =.012). The patients in the retroperitoneal group required less intravenous narcotics (retroperitoneal, 36.6 +/- 21 mg; transabdominal, 49.5 +/- 28.5 mg; P =.004) and less epidural analgesics (retroperitoneal, 39.5 +/- 6.4 mg; transabdominal, 56.6 +/- 9.5 mg; P =.004). Hospital length of stay (retroperitoneal, 7.2 +/- 1.6 days; transabdominal, 12.8 +/- 2.3 days; P =.024) and hospital charges (retroperitoneal, $35,587 +/- $980; transabdominal, $54,832 +/- $1105; P =.04) were significantly lower in the retroperitoneal group. The survival rates at the 40-month follow-up period were similar between the groups (retroperitoneal, 81.3%; transabdominal, 78.7%; P =.53). CONCLUSION: In this subset of patients who were at high risk for aortic reconstruction, the postoperative complications were common. However, the number of complications was significantly lower in the retroperitoneal group. Aortic reconstruction in patients of ASA class IV appears to be more safely and economically performed with the retroperitoneal approach.

Popliteal artery aneurysm treated with a minimally invasive endovascular approach: an initial report.

PURPOSE: To report a minimally invasive approach to popliteal artery aneurysm (PAA) treatment. METHODS AND RESULTS: A 48-year-old male with a 3-cm PAA was treated electively with an endovascular in situ saphenous vein bypass and transluminal antegrade coil embolization of the PAA prior to completion of the proximal anastomosis. Two short incisions at the anastomosis sites resulted in no wound complications, and the patient was discharged after 2 days. After 14 months of follow-up, the patient is asymptomatic with continued patency of the in situ bypass and occlusion of the PAA. CONCLUSIONS: This endovascular approach for minimally invasive femoropopliteal in situ saphenous vein bypass grafting appears feasible for treatment of PAAs. This method may reduce the rate of wound complications attending classic open in situ bypass grafts.

Diagnosis of aortocaval fistula by computed tomography.

A case of an aortocaval fistula documented by contrast-enhancement computed tomography is reported. In the presence of a large abdominal aortic aneurysm, the computed tomography (CT) triad findings of: (1) vena caval effacement, (2) loss of the fat plane between the aorta and vena cava, and (3) rapid flow of contrast from the aorta into a dilated inferior vena cava is characteristic of an aortocaval fistula.

Extraluminal endoscopic-assisted ligation of venous tributaries for infrainguinal in situ saphenous vein bypass: a preliminary report.

In an attempt to obviate the need for an incision the length of the leg during in situ saphenous vein bypass, a minimally invasive operation using 'laparoscopic techniques' was developed. At operation, standard incisions were made over the proximal femoral artery/vein and the saphenous vein at the distal popliteal artery level. An angioscopic valvulotome was used to perform valvulotomy under direct vision. After valvulotomy, a distention balloon system was used to form a 'pocket' into which a laparoscope was inserted. Trocars were then inserted under direct vision and the saphenous vein dissected and side branches individually clipped. After occlusion of the venous side branches, proximal and distal arterial anastomoses were performed in the standard fashion. This minimally invasive operation using laparoscopic techniques precludes the need for a long leg incision and saphenous vein dissection, except at the proximal and distal arterial anastomoses.

Spontaneous rupture of the stomach in an adult.

We have reported a case of spontaneous rupture of the stomach in an adult. Immediate onset of severe upper abdominal pain after overindulgence in food and drink along with radiographic evidence of pneumoperitoneum and the clinical findings of massive abdominal distention, epigastric tenderness, shock, and occasionally subcutaneous emphysema should suggest the possibility of gastric rupture. The treatment is simple, but mortality is high when surgical intervention is not rapid.