Who Should Be Operated When Presenting with a Ruptured Abdominal Aortic Aneurysm? A Monocentric Study in a Tertiary Hospital.

BACKGROUND: Mortality with ruptured abdominal aortic aneurysms (rAAAs) is 80% overall, 50% when operated, and 100% when not operated. Distinguishing in emergency patients who should be operated versus being offered palliative treatment is difficult. We sought to identify key factors to consider in this decision-making. METHODS: Between 2001 and 2014, we selected all consecutive patients with rAAA treated by open or endovascular procedures in a tertiary hospital for inclusion in this retrospective, single-center study. Symptomatic aneurysms and isolated ruptured iliac aneurysms were excluded. The primary outcome was in-hospital mortality, and secondary outcomes were institutionalization rate and long-term mortality. Associations between predictive factors and in-hospital mortality were evaluated using univariate logistic regression. The local ethics committee approved this study. RESULTS: The mean age (±standard deviation) of the 72 included patients was 73 years (±9.0) and 88% were men. Among the 65 open (90%) and 7 endovascular procedures (10%), overall in-hospital mortality was 21%, 1- and 2-year mortalities were both 26%, and the institutionalization rate was 5%. Mean follow-up was 43 months (Kaplan-Meier estimate). Univariate analysis identified age as associated with a 20% per year increased risk of in-hospital mortality (correlation, P < 0.0001). Female sex was the other main preoperative risk factor correlated with in-hospital mortality (P = 0.006). Significant perioperative risk factors were suprarenal clamping (P = 0.038), amount of fresh frozen plasma transfused (P = 0.018), and number of blood transfusions (P < 0.0001). CONCLUSIONS: The most significant preoperative mortality-related factors were age and female sex. Our study also showed that institutionalization and long-term mortality are not factors to consider in the decision-making process.

A New Approach in Applying Systems Engineering Tools and Analysis to Determine Hepatocyte Toxicogenomics Risk Levels to Human Health.

There is an increasing backlog of potentially toxic compounds that cannot be evaluated with current animal-based approaches in a cost-effective and expeditious manner, thus putting human health at risk. Extrapolation of animal-based test results for human risk assessment often leads to different physiological outcomes. This article introduces the use of quantitative tools and methods from systems engineering to evaluate the risk of toxic compounds by the analysis of the amount of stress that human hepatocytes undergo in vitro when metabolizing GW7647 1 over extended times and concentrations. Hepatocytes are exceedingly connected systems that make it challenging to understand the highly varied dimensional genomics data to determine risk of exposure. Gene expression data of peroxisome proliferator-activated receptor-α (PPARα) 2 binding was measured over multiple concentrations and varied times of GW7647 exposure and leveraging mahalanombis distance to establish toxicity threshold risk levels. The application of these novel systems engineering tools provides new insight into the intricate workings of human hepatocytes to determine risk threshold levels from exposure. This approach is beneficial to decision makers and scientists, and it can help reduce the backlog of untested chemical compounds due to the high cost and inefficiency of animal-based models.

Enabling Stakeholder Involvement in Coastal Disaster Resilience Planning.

Coastal hazards including storm surge, sea-level rise, and cyclone winds continue to have devastating effects on infrastructure systems and communities despite costly investments in risk management. Risk management has generally not been sufficiently focused on coastal resilience, with community stakeholders involved in the process of making their coastline, as a system, more resilient to coastal storms. Thus, without stakeholder earlier involvement in coastal resilience planning for their community, they are frustrated after disasters occur. The U.S. National Academies has defined resilience as "the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events"(National Research Council). This article introduces a methodology for enabling stakeholder-involved resilience discussions across physical, information, cognitive, and social domains. The methodology addresses the stages of resilience-prepare, absorb, recover, and adapt-and integrates performance assessment with scenario analysis to characterize disruptions of risk-management priorities. The methodology is illustrated through a case study at Mobile Bay, Alabama, USA.

Abdominal Aortic Aneurysm: What About Screening?

The prevalence of abdominal aortic aneurysm (AAA) in general population is 4-9% with a high mortality rate when ruptured. Therefore, screening programs were developed in many countries to detect small and large AAA in selected patients. Indeed, prevalence of AAA increases in patients over 65 years old with cigarette smoking history. This paper reviews recent literature related to AAA screening focusing on epidemiology, screening tests and evidence based medicine to highlight not only advantages but also disadvantages of screening programs among population.

Intraoperative assessment of vascular access.

PURPOSE: The intraoperative quality assessment of the arteriovenous fistula for hemodialysis is an essential process to limit early failure due to technical problems or inadequate vascular quality. This step is not clearly defined in the literature with no recommendations. METHODS: We selected published articles related to the topic of intraoperative quality control of the vascular access for hemodialysis. RESULTS: The intraoperative blood flow measurement greater than 120 ml/min in autologous fistula and less than 320 ml/min in arteriovenous graft was described as predictive factors for early failure. CONCLUSIONS: The blood flow measurement should be performed after the confection of the anastomosis. When blood flow is limited, fistulography is an essential step to assess patency.

Design of electronic medical record user interfaces: a matrix-based method for improving usability.

This study examines a new approach of using the Design Structure Matrix (DSM) modeling technique to improve the design of Electronic Medical Record (EMR) user interfaces. The usability of an EMR medication dosage calculator used for placing orders in an academic hospital setting was investigated. The proposed method captures and analyzes the interactions between user interface elements of the EMR system and groups elements based on information exchange, spatial adjacency, and similarity to improve screen density and time-on-task. Medication dose adjustment task time was recorded for the existing and new designs using a cognitive simulation model that predicts user performance. We estimate that the design improvement could reduce time-on-task by saving an average of 21 hours of hospital physicians' time over the course of a month. The study suggests that the application of DSM can improve the usability of an EMR user interface.

[Popliteal artery aneurysms: management in 2013]. / Anévrismes de l'artère poplitée: quelle prise en charge en 2013?

Although rare, popliteal artery aneurysms are the most common peripheral aneurysms and are frequently associated with abdominal aorta aneurysms. They are often bilateral. One third of patients are asymptomatic at diagnosis, with an insidious evolution. Symptomatic patients may present with symptoms of either acute ischemia or chronic ischemia, or rarely compression or rupture. Surgical exclusion of aneurysm followed by venous bypass remains the treatment of choice. Endovascular treatment is an attractive alternative currently reserved for patients at high risk, with good anatomical criteria. Elective treatment before symptoms onset is preferable given the best results in terms of patency and complications. A conservative approach is allowed for small aneurysms without major embolic risk provided careful monitoring by ultrasound.

Appendectomy during the third trimester of pregnancy in a 27-year old patient: case report of a "near miss" complication.

The management of acute appendicitis during pregnancy is not fully established, especially regarding the choice between open and laparoscopic surgery during the third trimester. We report herein the case of a major uterine variecele hemorrhage during a laparoscopic appendectomy in a 27-year old pregnant patient at 33 weeks of amenorrhea. After conversion to a Pfannenstiel incision, the baby was delivered, the bleeding stopped and the appendectomy completed. While both mother and child fully recovered, this «near miss¼ complication underlines the challenges linked to the management of acute appendicitis during pregnancy. Based on a literature review, we propose an algorithm favoring the laparoscopic approach during the first and second trimesters, and the open approach during the third trimester (especially after the 26th week of amenorrhea). In case of unclear pre-operative diagnosis, a laparoscopy should be conducted even during the third trimester with a Mc Burney conversion when the diagnosis of appendicitis is confirmed.

Phlegmonous colitis: another source of sepsis in cirrhotic patients?

BACKGROUND: The clinical relevance of phlegmonous colitis (PC), a rare autopsy finding in cirrhotic patients, is poorly documented. We postulated that PC might be a source of sepsis in patients with portal hypertensive colopathy (PHC). CASE PRESENTATION: We report three cirrhotic patients who were admitted with abdominal sepsis and who illustrate, to various degrees, the clinico-pathological sequence of colonic alterations associated with portal hypertension. Two cirrhotic patients with PHC developed gram-negative bacteraemia and quickly responded to intravenous antibiotics. Another cirrhotic patient underwent emergency colectomy for PC, and subsequently died from multiple organ failure. Histological alterations in the operative specimen included: a) mucosal ulcerations; b) disseminated micro-abscesses in the submucosa; and c) a severe vasculopathy leading to complete obliteration of submucosal blood vessels. CONCLUSIONS: These data suggest that cirrhotic patients with PHC may progress towards PC, which, in turn, may be the cause for life-threatening sepsis.

Causes of ground failure in alluvium during the Northridge, California, earthquake of January 17, 1994

Ground failure, consisting of cracking and distributed deformation, was common in gently sloping alluvial areas during the January 17, 1994, Northridge, California, earthquake. The mechanism of ground failure was ambiguous in many locations because it was not accompanied by venting of liquefied material. To resolve this ambiguity, we conducted detailed geotechnical investigations at four sites. The investigations indicate that three of the sites are underlain by liquefiable materials that should have liquefied at the observed levels of ground shaking. At the fourth site where no liquefiable material is present, we infer that dynamic shear failure of a weak clay layer caused ground failure. The experience with ground failure during the Northridge earthquake suggests that geologically based regional mapping of areas of high liquefaction susceptibility in alluvial fan environments may be more challenging than in fluvial environments.(AU)

Observed and predicted ground deformation - Miller farm lateral spread, Watsonville, California

Following the 1989 Loma Prieta, California, earthquake, ground deformation and subsurface conditions were carefully mapped and documented at the east end of a 1.7-km-long lateral spread south of the Pajaro River near Watsonville, California. The lateral spread occurred in natural floodplain deposits that fill a former river channel. Penetration data from geotechnical soundings and correlations of median grain size of sand boils with potential source beds at the east end of the spread indicated that a 6.1-m-thick layer, 4.6 m below the land surface, liquefied. Horizontal extension across ground cracks in the study area ranged from 117 to 160 mm. Settlements ranged from 50 to 240 mm. Empirical predictions of vertical displacemnets underpredict observed settlements. We conclude that the lateral spread was a deformation failure, which resulted from transient inertial forces, as contrasted with a flow failure. We also devise a test to establish the maximum displacement by a deformation failure mechanism.(AU)

Ground motion characteristics and their relation to soil liquefaction at the wildlife liquefaction array, Imperial Valley, California

We use the earthquake shaking severity parameter Arias intensity, Ih, to assess the site specific characteristics of ground motion, and investigate the relation of those characteristics to soil liquefaction occurrence at the Wildlife liquefaction array, in response to the Elmore Ranch and Superstition Hills earthquakes of November 23 and 24, 1987.(AU)