Editor's Choice - Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users.

BACKGROUND: Previous studies comparing endografts with suprarenal and infrarenal fixation for endovascular abdominal aortic aneurysm repair (EVAR) have found conflicting results and did not account for differences in patient selection. This study aims to evaluate the differences in outcomes among surgeons who routinely use either suprarenal or infrarenal fixation, as well as all surgeons in the Vascular Study Group of New England (VSGNE). METHODS: All patients undergoing EVAR in the VSGNE from 2003 to 2014 were identified. All ruptured aneurysms, repairs with concomitant procedures, and infrequently used stent grafts (<50) were excluded. Suprarenal endografts included Talent, Zenith, and Endurant; infrarenal endografts included AneuRx and Excluder. Grafts were compared among surgeons who used only one type of endograft (suprarenal or infrarenal) for >80% of cases, as well as all surgeons. Multivariate regression and Cox hazard models were utilised to account for patient demographics, comorbidities, operative differences, and procedure year. RESULTS: This study identified 2574 patients (suprarenal, 1264; infrarenal, 1310) with 888 endografts placed by routine users (suprarenal, 409; infrarenal, 479). There were no differences in baseline comorbidities, including the estimated glomerular filtration rate, between suprarenal and infrarenal fixation, or between patients with endografts placed by routine and non-routine users. Patients treated with suprarenal endografts received more contrast than all users (102 mL vs. 100 mL, p = .01) and routine users (110 mL vs. 88 mL, p < .01), but other vascular and operative details were similar. Among all users, patients treated with suprarenal grafts had higher rates of creatinine increase >.5 mg/dL (3.7% vs. 2.0%, p = .01), length of stay >2 days (27% vs. 19%, p < .01), and discharge to a skilled nursing facility (9.2% vs. 6.7%, p = .02). There were no differences in 30 day or 1 year mortality. Following adjustment, suprarenal stent grafts remained associated with an increased risk of renal deterioration (OR 2.0; 95% CI 1.2-3.4) and prolonged length of stay (OR 1.8; 95% CI 1.4-2.2). Among routine users, suprarenal fixation was also associated with higher rates of renal dysfunction (3.7% vs. 1.3%, p = .02; OR 2.9; 95% CI 1.1-7.8). CONCLUSION: Despite potential differences in patient selection, endografts with suprarenal fixation among all users and routine users were associated with higher rates of renal deterioration and longer length of hospital stay. Longer-term data are needed to determine the duration and severity of renal function decline and to identify potential benefits of decreased migration or endoleak.

Comparison of Renal Complications between Endografts with Suprarenal and Infrarenal Fixation.

OBJECTIVES: Surgeons have multiple grafts options available for the endovascular treatment of abdominal aortic aneurysm (EVAR), and some hypothesize that suprarenal fixation endografts may result in higher rates of renal complications than infrarenal endografts. This study aimed to compare the outcomes of contemporary suprarenal and infrarenal endografts. METHODS: The Targeted Vascular Module of the National Surgical Quality Improvement Project was utilised to identify patients undergoing EVAR for infrarenal aneurysm from 2011 to 2013. Pre-operative and operative variables and 30 day outcomes were compared among suprarenal (Zenith and Endurant) and infrarenal fixation devices (Excluder). Renal complications included creatinine increase > 2 mg/dL or new dialysis, as defined by NSQIP. Multivariate regression was completed to account for patient demographics, comorbidities, and operative characteristics. RESULTS: A total of 3587 patients were evaluated including 2273 (63%) with suprarenal grafts and 1314 (37%) with infrarenal grafts. Patients with suprarenal grafts were less commonly white (84% vs. 88%, p < .01) and more commonly male (83% vs. 80%, p = .03). There were no differences in age or comorbidities. Renal complications (1.1% vs. 0.1%, p < .01) and length of stay more than 2 days (34% vs. 25%, p < .01) occurred more commonly after suprarenal fixation. After adjustment, suprarenal grafts had significantly higher rates of renal complications (OR, 12.0; 95% CI, 1.6-91) and length of stay more than 2 days (OR, 1.4; 95% CI, 1.2-1.7). CONCLUSION: Overall rates of renal complications following EVAR are low. Patients selected for suprarenal stent grafts are at increased risk of renal complications and prolonged length of stay, which may be due to selection bias, deployment techniques, or the presence of a bare stent overlying the renal arteries. Further studies are necessary to evaluate the mechanism and duration of renal dysfunction and important long-term outcomes of interest.

Treatment outcome and follow-up of multidrug-resistant tuberculosis patients, West Coast/Winelands, South Africa, 1992-2002.

SETTING: Brooklyn Chest Hospital, Western Cape, South Africa. OBJECTIVE: To evaluate the treatment outcome and 2- and 5-year follow-up of patients treated for multidrug-resistant tuberculosis (MDR-TB) with individualized regimens. DESIGN: Retrospective cohort study of all MDR-TB patients starting treatment during 1992-2002. Patients were evaluated every 6 months for 2 years after treatment and at 5 years when possible. RESULTS: Over 11 years, 491 (66%) of 747 MDR-TB patients received treatment with two or more second-line drugs; 239 (49%) were cured or completed treatment, 68 (14%) died, 144 (29%) defaulted from treatment, 27 (5%) failed, 10 (2%) transferred out and 3 (<1%) remained on treatment. Only 176 (36%) were tested for human immunodeficiency virus and 15 were positive. The proportion with a successful MDR-TB treatment outcome declined over time, while the proportion who defaulted remained stable. Among 410 patients who had not transferred out or died, 281 (69%) had 2-year data available: 185 (66%) were cured or completed treatment, 32 (11%) were retreated for TB and 64 (23%) died. CONCLUSIONS: Under program conditions in the West Coast/Winelands District, default rates were high and treatment success rates low. Outreach strategies for MDR-TB treatment should only be implemented if adequate resources are committed to the program.

Culture confirmed multidrug resistant tuberculosis: diagnostic delay, clinical features, and outcome.

AIMS: To determine the delay in diagnosis of multidrug resistant (MDR) tuberculosis (TB), the correlation between drug susceptibility patterns of adult-child contact pairs, the effectiveness of treatment, and the outcome in these children. METHODS: MDR M tuberculosis culture results of children were prospectively collected during a four year period in the Western Cape Province of South Africa, an area with a TB incidence of 589/100 000 population, and a new MDR TB rate of 0.94%. Folder reviews were done to retrieve clinical information. Children not already on treatment at our MDR TB clinic or TB hospital were recalled and appropriate treatment was started. Follow up was done for as long as possible. RESULTS: Thirty nine children, median age 4.5 years at first TB diagnosis and 6.2 years on MDR culture confirmation, were seen. Delay in starting appropriate MDR treatment after TB diagnosis was a median of 2 days if MDR TB source cases were taken into account, but 246 days if the drug susceptibility pattern of the source case was not considered, and 283 days if there was no known tuberculosis source case. Correlation between the drug susceptibility results of the child's and adult source case's isolates was 68%. Seventeen children had smear positive tuberculosis, of whom 13 had cavitatory pulmonary disease. Eight children had central nervous system TB. Thirty six children were treated for MDR tuberculosis, of whom four died. CONCLUSIONS: Obtaining a detailed contact history is essential as a delay in starting appropriate MDR antituberculosis treatment has potentially serious consequences.

Impact of HIV on admissions and deaths in a tuberculosis hospital--recommendations for admission and discharge criteria.

Mortality and HIV prevalence rose concordantly at Brooklyn Chest Hospital from 1998 to 2001. Death and unconfirmed tuberculosis (TB) (15% of adult admissions in a sample from 2000) were associated with HIV seropositivity. Excluding unconfirmed TB and shortening length of stay would increase the number of patients able to benefit from hospitalisation.

Pulmonary resection as an adjunct in the treatment of multiple drug-resistant tuberculosis.

BACKGROUND: Over the past decade the incidence of pulmonary disease due to drug-resistant strains of Mycobacterium tuberculosis has increased worldwide. We reviewed our local experience to clarify the benefits and risks of pulmonary resection in the management of drug-resistant strains of Mycobacterium tuberculosis. METHODS: A retrospective review was performed of 62 patients undergoing pulmonary resection for drug-resistant strains of Mycobacterium tuberculosis between January 1990 and November 1995. RESULTS: Fifty-three percent were men and 47% women with an average age of 34 years (range, 16 to 72 years). There was one postoperative death, for a perioperative (30-day) mortality of 1.6%. Sixteen complications occurred in 14 patients for an overall morbidity of 23%. Eighteen of 24 patients (75%) who were persistently sputum positive at the time of operation immediately converted to a negative sputum smear and culture. For all patients who were sputum negative after operation 80% remain relapse-free by actuarial analysis. CONCLUSIONS: We believe that operation plays an important ancillary role in the treatment of drug-resistant strains of Mycobacterium tuberculosis. The operation can be performed with acceptable morbidity and mortality and must be combined with appropriate and well-monitored pre- and postoperative antituberculous drug therapy.

Immunochemical quantification of cytochrome P450IA and IIB subfamilies in the livers of metyrapone-treated rats. Relevance to the ability of metyrapone to prevent the loss of cytochrome P-450 in rat hepatocyte culture.

Polyclonal antibodies to the major beta-naphthoflavone (BNF)-inducible form of cytochrome P-450 (P450IA) and to the major phenobarbitone (PB)-inducible form (P450IIB) have been used to quantify the contribution of these subfamilies to the total amount of cytochrome P-450 in rat livers and rat hepatocyte cultures treated with PB, BNF and metyrapone for 24 and 72 h. The P450IA and IIB subfamilies were not detectable (less than 5 pmol/mg of microsomal protein) in the livers of control rats, but administration of BNF resulted in the P450IA subfamily comprising more than 80% of the total hepatic cytochrome P-450. Administration of PB and metyrapone to rats did not elevate the level of this subfamily but elevated the levels of the P450IIB subfamily to 60% and 30% respectively of the total. Thus metyrapone is a 'PB-like' inducer. However, in contrast with their effects in vivo, treatment with PB and metyrapone of rat hepatocytes did not elevate the proportion of the P450IIB subfamily relative to that in untreated cells but rather, like BNF, increased the P450IA subfamily. This would account for the ability of metyrapone to produce in hepatocyte culture, like BNF, a pronounced induction of ethoxyresorufin O-de-ethylase activity, but it does not account for why of all inducers studied only metyrapone can maintain the total cytochrome P-450 content of cultured hepatocytes, or the activity of ethylmorphine N-demethylase. This activity is generally considered to be associated with the P450IIB subfamily, but the lack of effect of metyrapone on this subfamily in hepatocyte culture must suggest that metyrapone is able to prevent the loss of the total amount of the cytochrome by increasing the expression of other cytochromes P-450.