Elevated physiological arousal is associated with larger but more variable neural responses to small acoustic change in children during a passive auditory attention task.

Little is known of how autonomic arousal relates to neural responsiveness during auditory attention. We presented N = 21 5-7-year-old children with an oddball auditory mismatch paradigm, whilst concurrently measuring heart rate fluctuations. Children with higher mean autonomic arousal, as indexed by higher heart rate (HR) and decreased high-frequency (0.15-0.8 Hz) variability in HR, showed smaller amplitude N250 responses to frequently presented (70%), 500 Hz standard tones. Follow-up analyses showed that the modal evoked response was in fact similar, but accompanied by more large and small amplitude responses and greater variability in peak latency in the high HR group, causing lower averaged responses. Similar patterns were also observed when examining heart rate fluctuations within a testing session, in an analysis that controlled for between-participant differences in mean HR. In addition, we observed larger P150/P3a amplitudes in response to small acoustic contrasts (750 Hz tones) in the high HR group. Responses to large acoustic contrasts (bursts of white noise), however, evoked strong early P3a phase in all children and did not differ by high/low HR. Our findings suggest that elevated physiological arousal may be associated with high variability in auditory ERP responses in young children, along with increased responsiveness to small acoustic changes.

Ectopic pregnancy risk factors for ART patients undergoing the GnRH antagonist protocol: a retrospective study.

BACKGROUND: In-vitro fertilization is a known risk factor for ectopic pregnancies. We sought to establish the risk factors for ectopic pregnancy in GnRH antagonist cycles examining patient and stimulation parameters with an emphasis on ovulation trigger. METHODS: We conducted a retrospective, cohort study of 343 patients undergoing 380 assisted reproductive technology (ART) cycles with the GnRH antagonist protocol and achieving a clinical pregnancy from November 2010 through December 2015. RESULTS: Significant risk factors for ectopic pregnancy in the univariate analysis included prior Cesarean section (CS), endometriosis, mechanical factor infertility, longer stimulation, elevated estradiol and progesterone levels, GnRH agonist trigger, higher number of oocytes aspirated, and insemination technique. Independent risk factors for ectopic pregnancy in the multivariate analysis included GnRH agonist trigger, higher number of oocytes aspirated, insemination technique, and prior Cesarean section. CONCLUSION: Excessive ovarian response, IVF (as opposed to ICSI), prior Cesarean section and GnRH agonist trigger were found to be independent risk factors for ectopic pregnancy. Caution should be exercised before incorporating the GnRH agonist trigger for indications other than preventing OHSS. When excessive ovarian response leads to utilization of GnRH agonist trigger, strategies for preventing ectopic pregnancy, such as a freeze all policy or blastocyst transfer, should be considered. Further studies should elucidate whether adjusting the luteal support can reduce the ectopic pregnancy risk.

Shabbes burn, a burn that occurs solely among Jewish orthodox children; due to accidental shower from overhead water heaters.

From January 1990 to January 2000, 35 children were treated in our department for Shabbes burn, a unique scald burn that occurred mainly among orthodox Jews during the Sabbath. A retrospective review was conducted to determine the extent of the problem, to understand the burn mechanism and to suggest a prevention program. A shower of hot water from the Sabbath heater is the cause of this burn. Among the Shabbes burn cases, 27 patients were female (77%) and 17 children (48%) were between 3 and 6 years old. It is suggested that this is a common burn that occurs among orthodox Jewish families and affects mainly females. Education programs using the media directed to the Jewish orthodox population have been conducted, this combined with redesigned of the heater, have reduced significantly the incidence of the burn as seen in our institute. However, even though efforts have been supported widely, there remains a need for educational and governmental regulations on a national level. This could aid orthodox Jews not only in Israel but globally, as well.

The effect of propofol anaesthesia on oocyte fertilization and early embryo quality.

Propofol, frequently used for i.v. induction of anaesthesia in assisted reproduction procedures, has been suspected of damaging oocytes. Concentrations of propofol have recently been shown to increase in follicular fluid during oocyte retrieval. Our study was designed to assess whether exposure to increasing concentrations of propofol has a measurable effect on in-vitro fertilization, cleavage and embryo development. A cohort of 130 women underwent i.v. anaesthesia using propofol and fentanyl. Time of anaesthesia from i. v. injection of propofol was measured, as were the doses of the two drugs. In 32 women expected to have more than 15 oocytes retrieved, first, middle and last oocytes were cultured separately. The mean time from i.v. injection to first follicle aspiration was 200 s. The mean time for the aspiration of each additional oocyte was 17.6 s. In 10 out of 11 cases where follicular fluid concentrations of propofol were measured, there was an increase from the first to the last follicle, but no difference was found in the ratio of mature to immature oocytes. Nor were any differences found in fertilization, cleavage and embryo cell number. In so far as in-vitro development reflects embryo quality, we conclude that the time elapsed between retrieval of the first and last oocyte does not affect oocyte quality.

Carotid endarterectomy in octogenarians: comparison with patient characteristics and outcomes in younger patients.

OBJECTIVES: Carotid endarterectomy has been shown to be of clear benefit to selected patients. However, recent trials of carotid endarterectomy versus best medical therapy have excluded octogenarians, and some authors have suggested that carotid endarterectomy would have an unfavorable cost-benefit relationship in octogenarians. We compared patients and results for carotid endarterectomy in octogenarians and younger patients. METHODS: We reviewed the results for 582 primary carotid endarterectomies (90 in octogenarians and 492 in younger patients) performed in 528 patients between February 1, 1985, and January 31, 1998 (all data were collected prospectively for the most recent 301 carotid endarterectomies). Conventional surgical technique was used with general anesthesia, selective shunting, and selective patching. Main outcome measures were perioperative and late ipsilateral stroke and death. RESULTS: The two groups were similar with respect to indications for carotid endarterectomy and patient characteristics, except that octogenarians were more likely to have histories of congestive heart failure or hypertension and less likely to have histories of smoking or chronic lung disease. Carotid endarterectomy was performed for asymptomatic disease in 27% of the octogenarians and 33% of the younger patients (P =.31). Stenosis was >/=80% in 90% of the octogenarians and 78% of the younger patients (P =.014). Perioperative strokes, all of which were ipsilateral, occurred in one octogenarian (1.1%) and eight younger patients (1.6%, P = 1.00). No octogenarians and two younger patients died within 30 days of surgery (P = 1.00). Length of stay and direct costs associated with carotid endarterectomy were similar for octogenarians and younger patients. Late strokes occurred in two octogenarians (one ipsilateral) and four younger patients (two ipsilateral). Life table estimates of freedom from ipsilateral stroke at 2 years were 98% and 97% for octogenarians and younger patients, respectively (log-rank P =.69), and life table estimates of patient survival at 4 years were 81% and 89% for octogenarians and younger patients, respectively (P =.11). Octogenarians represented an increasing fraction of the carotid endarterectomies performed during the study period. CONCLUSIONS: Octogenarians selected for carotid endarterectomy were similar to younger patients with respect to indications for carotid endarterectomy and comorbidities. Early mortality, early and late neurologic outcome, complications, and resource utilization were similar for the two groups, and more than 75% of octogenarians survived 4 years after undergoing carotid endarterectomy. Cost-benefit analyses for carotid endarterectomy, which are highly sensitive to expected patient survival, might not be pertinent to individual patient situations. Intellectually intact octogenarians without unusually severe comorbidities are good candidates for and should be offered the benefits of carotid endarterectomy.

Individual implantation rate: proposal for a new index for evaluation of assisted reproduction results.

OBJECTIVE: To assess whether implantation in assisted reproductive technology (ART) cycles is a random event. DESIGN: Retrospective analysis of results. SETTING: Division for Reproductive Endocrinology and ART, Department of Obstetrics and Gynecology, Haemek Medical Center, Afula, Israel. PATIENT(S): A cohort of all cycles reaching ET from July 1, 1995, through June 30, 1996, and a cohort of all pregnancies recorded from January 1, 1995, through October 31, 1996. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Rate of multifetal pregnancy in relation to overall pregnancy rate. The number of gestational sacs observed by sonography, out of transferred embryos in conception cycles, was defined as the individual implantation rate. RESULT(S): Of 367 ETs, 75 (20.4%) yielded pregnancies, of which 31 (41%) were multifetal. Considering the mean number of embryos transferred (3.67), if implantation would have been random, multifetal gestation rate should have been only 14.8%, significantly less than the observed rate. In 110 pregnancies recorded between January 1995 and October 1996, individual implantation rate was 49.4% +/- 27.1% in intracytoplasmic sperm injection cycles compared with 40.5% +/- 20.4% in IVF cycles. CONCLUSION(S): Embryo implantation is not a random event. The index of individual implantation rate may help shed light on mechanisms underlying implantation.

Supraceliac versus infrarenal aortic cross-clamp for repair of non-ruptured infrarenal and juxtarenal abdominal aortic aneurysm.

Repair of abdominal aortic aneurysms may require aortic occlusion above the renal arteries. Despite fears of renal, hepatic and intestinal ischemia, recent publications have suggested that when repair would be difficult or impossible with infrarenal aortic clamping, supraceliac clamping may not be associated with significantly increased morbidity. Between February 1985 and January 1994, 169 patients underwent elective or urgent (symptomatic but not ruptured) repair of infra- or juxtarenal abdominal aortic aneurysm. Twenty-three patients (14%) required supraceliac clamping for juxtarenal abdominal aortic aneurysm, inflammatory abdominal aortic aneurysm, or other difficult exposure problems. Supraceliac clamping and infrarenal aortic clamping patients were indistinguishable with respect to age, gender, abdominal aortic aneurysm diameter, and other co-morbidities. There was a trend toward more frequent use of supraceliac clamping in urgent operations. Preoperative angiography was used selectively and was obtained more often in supraceliac clamping patients, reflecting suspected juxtarenal or renal involvement based on computed tomography findings, but the decision to employ supraceliac clamping was made at surgery. Mean (s.d.) supraceliac clamping clamp time was 22(5) (range 12-30) min. Similar numbers of supraceliac clamping and infrarenal aortic clamping patients required bifurcated grafts, operative times were comparable, and numbers of early complications were similar in the two groups. Transfusion requirements were slightly greater and length of stay was insignificantly shorter in supraceliac clamping patients (due to a few prolonged hospital stays in infrarenal aortic clamping patients). No supraceliac clamping patient required dialysis or suffered clinically apparent hepatic failure, coagulopathy, or intestinal ischemia. There were no operative deaths and all patients were discharged from the hospital. Supraceliac clamping was not associated with greater perioperative morbidity and may have contributed to a lack of mortality by facilitating repair of difficult abdominal aortic aneurysm. Supraceliac clamping should be considered for elective and urgent abdominal aortic aneurysm repair when there is inadequate length or quality of infrarenal aorta for anastomosis, severe associated pararenal atherosclerosis, inflammatory aneurysm, or previous aortic surgery. It is concluded that selective supraceliac clamping is safe and facilitates repair of difficult aortic problems.

Carotid endarterectomy in women versus men: patient characteristics and outcomes.

PURPOSE: To examine and compare the results of carotid endarterectomy in women and men in a single-group experience. METHODS: A review of a consecutive series of 426 carotid endarterectomy procedures performed over an 11-year period. RESULTS: Women and men who underwent carotid endarterectomy were remarkably similar in nearly all characteristics except that women were less likely to have clinically overt coronary artery disease. Women were more likely than men to undergo patch closure of the carotid artery, but details of surgery and hospital stay were otherwise similar. A trend toward higher perioperative stroke risk in women was not significant, and late ipsilateral stroke risk was comparable in women and men. Women enjoyed a better late survival rate, presumably related to their lower prevalence of coronary artery disease. CONCLUSIONS: Women enjoyed similarly low risks of perioperative and late stroke and a better long-term survival rate when compared with men who underwent carotid endarterectomy. Further experience and longer follow-up in prospective randomized trials may provide more definitive information regarding the comparative efficacy of carotid endarterectomy in women and men, but our results suggest that absolute results are similar and excellent in both women and men.

Color duplex-guided compression therapy for postcatheterization pseudoaneurysms in a community hospital.

Diagnostic or therapeutic arterial catheterization may be complicated by postcatheterization pseudoaneurysm. Pseudoaneurysms have generally been treated surgically, but more recently, encouraging results with duplex-guided compression therapy (DGCT) of pseudoaneurysms have been reported from university hospitals. We reviewed our experience with DGCT to assess the applicability of DGCT in a community hospital setting. Sixty-two patients presented with 63 symptomatic postcatheterization pseudoaneurysms between January 1, 1990, and December 31, 1993. Prior to October 28, 1991, all pseudoaneurysms were treated surgically. Subsequently we initiated DGCT as primary treatment for pseudoaneurysms, reserving surgery for DGCT failures and unstable patients. DGCT patients were indistinguishable from primary surgery patients, and the number of pseudoaneurysms treated did not appear to increase during the study period. DGCT was initially successful in 27 (75%) of 36 patients. Three pseudoaneurysms recurred, yielding cumulative success in 24 (67%) of 36 patients. Three of 12 DGCT failures were due to patient intolerance. DGCT was unsuccessful in three of four intra-aortic balloon pump (IABP)-associated pseudoaneurysms. There was some variation in pseudoaneurysm volume between the successful and failed groups, and a trend toward failure with larger pseudoaneurysm was not significant (13 vs. 6 cm3, p > or = 0.25). DGCT failure appears more likely in post-IABP pseudoaneurysms and possibly with larger pseudoaneurysms. Anticoagulation, type of procedure (exclusive of IABP), obesity, and other patient characteristics examined did not appear to predict success or failure of DGCT. Treatment was reserved for symptomatic patients throughout the period of study and there was no evidence that patients were more likely to be treated for pseudoaneurysms after DGCT was initiated. We conclude that DGCT is usually successful and is appropriate primary treatment for all symptomatic postcatheterization pseudoaneurysms in stable patients.

Mesenteric artery bypass: objective patency determination.

PURPOSE: Many authors have reported extended relief of intestinal ischemia by use of a variety of reconstructive techniques, but all have relied on symptomatic follow-up. None have objectively measured patency rates. The purpose of this study was to determine the primary patency rates of bypass grafts placed for acute and chronic splanchnic atherosclerotic occlusive disease with use of objective follow-up with mesenteric duplex ultrasound scanning or arteriography. METHODS: Twenty-five consecutive patients (mean age 61, female/male ratio of 2.7:1) who underwent placement of 38 splanchnic bypass grafts (29 saphenous vein grafts, 9 polytetrafluoroethylene) (22 retrograde, 16 antegrade) for ischemic symptoms (9 acute ischemia: 16 chronic ischemia) between 1984 and 1994 were monitored with either duplex scanning (30 grafts) or arteriography. Life-table and log rank analysis were used to determine and compare graft patency. RESULTS: Three patients (12%, 2 acute ischemia and 1 chronic ischemia) died after operation. Six patients (30%) had significant morbidity (4 acute ischemia and 2 chronic ischemia). During follow-up from 1 to 136 months (mean 35 months), no patient died of bowel infarction or required revision for recurrent symptoms. Objective testing revealed three graft occlusions. Symptomatic follow-up had a sensitivity of only 33% for graft occlusion when compared with objective measurement. The life-table primary patency rate was 89% at 72 months. Life-table survival for the same patients was 75% at 36 months. Patency rates for antegrade (93% at 36 months) versus retrograde (95% at 36 months) bypass and saphenous vein grafts (95% at 36 months) versus polytetrafluoroethylene (89% at 36 months) were not significantly different (p = 0.47 and 0.43, respectively). Late patency rates of grafts placed for acute ischemia (92% at 36 months) versus chronic ischemia (89% at 36 months) were not significantly different (p = 0.77). CONCLUSION: Splanchnic bypass for mesenteric ischemia, with a primary patency rate of 89% at 72 months, is an extremely durable form of revascularization. Long-term patency of grafts placed for acute ischemia does not differ significantly from that of bypasses for chronic occlusion. Duplex scanning allows standardized objective periodic follow-up of splanchnic reconstruction. Objective assessment is critical to accurately measure visceral revascularization patency rates.

The role of extraanatomic bypass in the management of bilateral aortoiliac occlusive disease.

Axillofemoral bypass is a hemodynamically inferior reconstruction that should be performed only in high-risk patients. In view of the apparent inferior patency and hemodynamic performance when compared with aortofemoral bypass, axillofemoral bypass should not be performed for claudication except in truly disabled, low-risk patients whose contraindication to aortofemoral bypass is a "hostile abdomen." Some of these patients might be candidates for extraperitoneal iliofemoral bypass, thoracofemoral bypass, or other procedures that would probably provide hemodynamically superior results. Axillofemoral bypass produces acceptable hemodynamic results, patency, and limb salvage in high-risk patients with limb-threatening ischemia and limited life-expectancy. Despite overall inferior results, relief of initial symptoms is nearly always achieved and few patients require amputation before death. Axillofemoral bypass will remain an important option in such patients. In general, we continue to favor axillobifemoral reconstructions when symptoms are significantly bilateral. However, we do not hesitate to perform axillounifemoral bypass when symptoms and disease are unilateral and alternative unilateral inflow operations are not appropriate. Outcome of operations is clearly influenced by patient selection, and this must be considered when interpreting published results. It is likely that axillofemoral bypass will continue to be a critical tool for vascular surgeons faced with desperately ill patients at risk of limb loss due to bilateral aortoiliac inflow disease. As the operative risk of aortofemoral and iliofemoral bypass continues to decrease, the admonition that a significant number of long-term survivors should prompt the surgeon to ask whether she or he is performing axillofemoral bypass when another procedure might be more appropriate is probably more true today than when DeLaurentis et al first made the following statement: If indeed this operation is designed for poor risk cardiopulmonary patients threatened with loss of limb and a short life expectancy rate, we should not expect to see reports of patients with long term survival rates.

High origin of the ulnar and radial arteries in humans.

High division of the brachial artery was found in 4 human cadavers. In all cases the brachial artery divided into main branches within the medial bicipital sulcus. Both the ulnar and radial arteries descended within the sulcus to the elbow. In one case the musculocutaneous nerve was fused with the median nerve, giving off branches to the anterior group of arm muscles.

Pre- vs postoperative pharmacologic inhibition of platelets: effect on intimal hyperplasia in canine autogenous vein grafts.

Several clinical studies have shown that pharmacologic inhibition of platelets can increase the patency of vascular grafts, but only if platelet-inhibition is initiated before surgery. This study was performed to compare the efficacy of pre- vs postoperative platelet-inhibition on the development of intimal hyperplasia in canine autogenous vein grafts. Reversed femoral veins were used to bypass the ligated femoral arteries in 15 dogs. End-to-side anastomoses were constructed. Eleven dogs were treated with aspirin (325 mg QD) and dipyridamole (25 mg BID). In six dogs treatment was begun 48 hours preoperatively and continued for 3 months. In five other dogs treatment was begun 48 hours after surgery and was continued for 3 months. In 4 control dogs no antiplatelet treatment was given. Excision of the vein grafts 3 months after surgery disclosed reduced intimal hyperplasia (p < 0.05) in the grafts excised from all of the treated animals as compared with those obtained from the control animals. However, there was no difference in intimal hyperplasia observed in the dogs treated both pre- and postoperatively (11 grafts) as compared with those treated only postoperatively (9 grafts). These data demonstrate that it is not necessary to begin antiplatelet therapy preoperatively in order to inhibit intimal hyperplasia. They also suggest that preoperative antiplatelet therapy may improve early graft patency by directly preventing thrombosis, not by inhibiting the development of intimal hyperplasia.

Pulmonary arteries dimensions and their dependences on the age, the height and body weight.

The studies were carried out on 100 right and 100 left lungs taken from human corpses of both sexes whose age varied from 1 month to 80 years. The material was divided into 3 age groups. The pulmonary arteries were injected 65% duracryl and then digested in sulfuric acid. The specimens obtained were examined to measurement the length and the diameter of the interlobar portion of the pulmonary arteries and their correlation indexes to the age, the length and the body weight. It was certain, that the pulmonary arteries dimensions still grows during man's extrafetal life; the diameter of the right pulmonary artery is usual greater than the left artery. The length of the interlobar portion of the right pulmonary artery varied in both sexes from 5 to 43 mm, and from 6 to 43 mm on the left pulmonary artery. The diameter of the some part of pulmonary arteries varied from 3 to 21 mm on the right side, and from 4.5 to 20 mm on the left side.

Electrical burn injury of the scalp--bone regrowth following application of latissimus dorsi free flap to the area.

A large defect of the scalp was observed soon after debridement of a high-tension electrical burn of the scalp. Bone scan revealed no uptake of radioactive material to the parietal bone below the necrotic tissue of the scalp. Consecutive bone scans after latissimus dorsi free flap transfer revealed progressive regrowth of the bone.