Analgesic efficacy of stellate ganglion block in head and neck cancer pain: A case series.

Patients with head and neck cancer (HNC) have ongoing pain but Stellate ganglion block which is a sympatholytic block may be a viable therapy for treating it. The data were retrospectively collected from five histopathologically confirmed HNC patients who had completed chemotherapy and radiation doses. Stellate ganglion block was given to these patients and was subsequently monitored for 3 months to assess pain alleviation and overall satisfaction. Over a 3-month period, there was a decrease in the pain levels with a better quality of life so the stellate ganglion block can be a promising modality for reducing the pain of HNC.

Psychological adjustments among lower limb amputees in North Indian population: A cross-sectional study.

Introduction: Limb amputation is an extremely stressful event for an individual, following which the amputee develops inferior body image, anxiety, and changes in self-concept and identity. For holistic rehabilitation, understanding the psychosocial status of the amputee and its' predictors is of utmost importance. Objective: The aim of the article is to assess the psychological adjustments in patients with lower limb amputation and determine its clinical and sociodemographic correlates. Material and Methods: A observational cross-sectional study was conducted from 2020 to 2022 among lower limb amputees of a tertiary care hospital in Lucknow which serves as the only rehabilitation and artificial limb center for the whole state of Uttar Pradesh. Baseline sociodemographic and clinical data were collected. The Hospital Anxiety and Depression Scale was used to determine underlying depression and anxiety, while the Trinity Amputation and Prosthesis Experience Scale was used for understanding the psychological adjustment. Results: The mean age of the amputee was 39.47 ± 16.99 years. The mean general, social adjustment, and adjustment to limitation score was 16.3 ± 3.34, 15.19 ± 3.59, and 12.76 ± 3.15, respectively. Male amputees, aged >40 years, and pensioners had significantly higher scores for general adjustment (P < 0.05). Those aged >40 years were pensioners and had no underlying depression and anxiety and had better social adjustment (P < 0.05). Those with transfemoral amputation had a significantly lesser adjustment to limitation (P = 0.003). Conclusion: Young age amputees had poor general and social adjustments and more activity restriction but high prosthesis satisfaction as compared to the elderly. Those with transfemoral amputation had a poor adjustment to limitation while those wearing above-knee prosthesis had more activity restriction.

Erector spinae plane block for post-operative analgesia in thoracolumbar spine surgery: A randomised controlled trial.

Background and Aims: Thoracolumbar spine surgery is one of the most painful surgical procedures. This study's primary objective was to evaluate the effect of erector spinae plane (ESP) block on post-operative cumulative morphine consumption at 24 h in patients undergoing thoracolumbar spine surgery. Methods: Seventy adults posted for thoracolumbar spine surgery were randomised into the control group [Number of patients (n)=35], who received general anaesthesia without any nerve block, and the intervention group (n = 35), who received bilateral ultrasound (US)-guided ESP block at the level of spine surgery with 0.25% bupivacaine 20 mL after standard general anaesthesia. Along with intravenous patient-controlled analgesia morphine, post-operative analgesia was standardised for both groups. Total morphine consumption, visual analogue scale (VAS) score to evaluate pain, overall patient satisfaction, and any side effects were compared at 24 h. The statistical analysis was done using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL). Results: Post-operative total morphine consumption at 24 h was significantly decreased in the intervention group compared to the control group [5.69 (1.549) versus 9.51 (1.634) mg; P < 0.001]. Post-operative VAS scores were also significantly decreased in the intervention group at rest (P < 0.001) and on movement (P < 0.001). Patient satisfaction scores were more favourable in the intervention group [3.8 (0.4) versus 3.2 (0.6); P < 0.001]. Post-operative nausea and vomiting were found more in the control group but were not significant (n = 14 versus 8; P = 0.127). Conclusion: US-guided ESP block significantly reduces post-operative morphine consumption and improves analgesia and patient satisfaction without adverse effects in patients undergoing thoracolumbar spine surgery.

Form, synapses and orientation topography of a new cell type in layer 6 of the cat's primary visual cortex.

Here we report the morpho-functional features of a novel type of deep-layer neuron. The neuron was selected from a large pool of intracellularly labelled cells based on the large cell body, numerous spine-free dendrites with an overall interneuron morphology. However, the axon gave off long-range axons up to 2.8 mm from the parent soma in layers 5/6 before entering the white matter. The boutons were uniformly distributed along the axon without forming distinct clusters. Dendritic length, surface area and volume values were at least 3 times larger than any known cortical neuron types with the exception of giant pyramidal cells of layer 5. Electron microscopy of the boutons revealed that they targeted dendritic spines (78%) and less frequently dendritic shafts (22%). Nearly half of the postsynaptic dendrites were immunopositive to GABA. Superimposing the axonal field on the orientation map obtained with optical imaging showed a preponderance of boutons to cross-orientations (38%) and an equal representation of iso- and oblique orientations (31%). The results suggest an integrating role for the layer 6 stellate neuron which projects to a functionally broad range of neurons in the deep cortical layers and to other cortical and/or subcortical regions.

Application of the mirror technique for block-face scanning electron microscopy.

The mirror technique adapted for electron microscopy allows correlating neuronal structures across the cutting plane of adjoining light microscopic sections which, however, have a limited thickness, typically less than 100 µm (Talapka et al. in Front Neuroanat, 2021, https://doi.org/10.3389/fnana.2021.652422 ). Here, we extend the mirror technique for tissue blocks in the millimeter range and demonstrate compatibility with serial block-face electron microscopy (SBEM). An essential step of the methodological improvement regards the recognition that unbound resin must be removed from the tissue surface to gain visibility of surface structures. To this, the tissue block was placed on absorbent paper during the curing process. In this way, neuronal cell bodies could be unequivocally identified using epi-illumination and confocal microscopy. Thus, the layout of cell bodies which were cut by the sectioning plane can be correlated with the layout of their complementary part in the adjoining section processed for immunohistochemistry. The modified mirror technique obviates the spatial limit in investigating synaptology of neurochemically identified structures such as neuronal processes, dendrites and axons.

Comparison of Quality of Life and Bone Mass Density among Postmenopausal Women: A Cross-sectional Study.

BACKGROUND: Postmenopausal women are at highest risk of developing osteoporosis, since their bone mineral density is reduced due to decrease in estrogen level. Various other physiological, emotional, and psychological changes jeopardize the health of these vulnerable females in total and reduce their quality of life (QoL). AIMS AND OBJECTIVES: To compare the QoL and bone mass density (BMD) among normal BMD, osteopenic, and osteoporotic postmenopausal women. SETTING AND DESIGN: A cross-sectional observational study was conducted in the outpatient department of physical medicine and rehabilitation at a tertiary care center of northern India from August 2019 to February 2020. MATERIALS AND METHODS: Baseline sociodemographic characteristics of all postmenopausal women were collected using a quantitative tool. Assessment of QoL was done by pretested and validated QUALEFFO-41 scale. For all the women, a bone mineral densitometry test was performed on the L1-L4 lumbar spine, femoral neck, and forearm by the dual-energy X-ray absorptiometry method. STATISTICAL ANALYSIS: One-way ANOVA test was used to compare the mean BMD values across the three groups. Determination of predictive factors for QoL was performed using stepwise logistic regression analysis. RESULTS: Significant differences were noted for the mean values of the three domains, i.e., pain, physical, and social function (P < 0.01). Women with osteoporosis had significantly higher pain scores as compared to others. Among those with osteoporosis, the pain scores have significantly increased gradually as age increases. CONCLUSION: Postmenopausal women with osteopenia and osteoporosis have poor QoL as compared to those with normal BMD.

Comparison of Plaque Removal Efficacy of a Novel Flossing Agent with the Conventional Floss: A Clinical Study.

INTRODUCTION: The various methods for plaque control include mechanical plaque control methods which comprises use of toothbrushes, flosses, interdental brushes, and chemical plaque control which includes mouthwashes, dentrifices. The need for the study was to prove the efficacy of flossing in children using gumchucks. MATERIALS AND METHODS: A total sample size of 24 children age groups 6-12 years according to chronological age were selected. In 12 patients, flossing using gumchucks was done and in 12 patients flossing using unwaxed floss without handle was done. Proximal plaque index was taken at 0,2,4,6 weeks to assess the efficacy of both types of floss in removal of interproximal plaque. At the end of 6 weeks, patient's parents were asked to fill up the questionnaire. RESULTS: In the intragroup comparison for gumchucks, significant plaque reductions were found at 4 and 6 weeks. In the intragroup comparison for unwaxed floss, significant reduction for plaque marginal index were recorded from baseline to 2 and 4 weeks. In the intergroup comparison, significant reduction in plaque index was recorded at 4 and 6 weeks. CONCLUSION: Gumchucks have the high efficacy of plaque removal as well as easy in use for children routinely. Also when surveyed majority of the patents preferred gumchucks if available in the stores. HOW TO CITE THIS ARTICLE: Kiran SDP, Ghiya K, Makwani D, Bhatt R, Patel M, Srivastava M. Comparison of Plaque Removal Efficacy of a Novel Flossing Agent with the Conventional Floss: A Clinical Study. Int J Clin Pediatr Dent, 2018;11(6):474-478.

Evaluation of the Efficacy of Play Therapy among Children Undergoing Dental Procedure through Drawings Assessed by Graphological Method: A Clinical Study.

INTRODUCTION: Behavior modification is defined as the attempt to alter human behavior and emotion in a beneficial way and accordance with the laws of learning. Play therapy is one such behavior modification technique. The study aimed to evaluate the efficacy of play therapy among children undergoing dental treatment by the graphological method. MATERIALS AND METHODS: Children were made to draw before treatment, after treatment of one class 1 lesion without application of any behavior modification technique and after treatment of the second lesion of class 1 caries with play therapy. Graphologist and scores assessed drawings were given by graphological method. RESULTS: Significant reductions in stress levels were observed in the drawings which were made after play therapy. CONCLUSION: Play therapy is an effective behavior modification technique in pediatric dentistry, which may be used in routine dental practice.How to cite this article: Kiran SDP, Vithalani A, Sharma DJ. Patel MC, Bhatt R, Srivastava M. Evaluation of the Efficacy of Play Therapy among Children Undergoing Dental Procedure through Drawings Assessed by Graphological Method: A Clinical Study. Int J Clin Pediatr Dent.,2018;11(5):412-416.

Sex determination from mesiodens of Indian children by amelogenin gene.

CONTEXT: The identification of sex is the first and the foremost step in forensic science. Teeth consist of enamel which is the hardest tissue available in the body, protector of DNA presents in pulp tissue at the time of exposure of tooth to adverse conditions. Teeth can be stated as a sealed box of mystery as it contains various human and bacterial DNA for molecular utilization. AIM AND OBJECTIVE: The aim is to determine sex from mesiodens on the basis of gene identification by the polymerase chain reaction (PCR). SETTINGS AND DESIGN: Total number of sample was 8 human-extracted mesiodens. DNA was isolated and was subjected to PCR analysis with use of predesigned primers for amelogenin (AMEL) X and AMEL Y genes. RESULTS: Isolation of genomic and mitochondrial DNA from mesiodens was successful in six samples (75%). In samples, quantity of DNA present was also calculated. CONCLUSION: Mesiodens are a good source of DNA and are a very useful tool in identification of sex using PCR analysis which was simple and effective. Hence, the procedure presented in the present study can be applied for extraction of DNA and identification of sex for forensic purpose.

Role of Anatomic variations of Uncinate Process in Frontal Sinusitis.

The osteomeatal complex plays an important role in the development of Chronic rhinosinusitis. The ethmoidal infundibulum is bordered medially by the uncinate process, and the anatomic relationship between the ethmoidal infundibulum and the frontal recess may depend upon the types of attachment of the uncinate process. The osteomeatal complex is the main area targeted in chronic rhinosinusitis and within it uncinate process is the first anatomical structure encountered. The aim of this study was to evaluate the types of attachment of the uncinate process and its implications in the development of sinus inflammation. The significance of anatomical variations of uncinate process in chronic sinusitis were evaluated. A prospective CT scan study on 64 patients of chronic sinusitis (128 uncinate processes) was done. The results were tabulated and analyzed using Statistical Package for Social Science 16.0. Type I superior attachment of uncinate process into the lamina papyracea was the most common variety in all ages and both sexes and a statistically significant association between Type 1 Uncinate process and frontal sinusitis was found. (P < 0.05). The superior attachment of uncinate process alters the frontal sinus drainage and causes the frontal sinusitis.

Comparative Evaluation of Chronic Rhinosinusitis Patients by Conventional Radiography, Computed Tomography and Diagnostic Nasal Endoscopy (DNE).

Chronic rhinosinusitis is a common condition in medical practice. It is defined as inflammation of the mucosa of nose and paranasal sinuses, the fluids within these cavities, and/or the underlying bone that has been present with or without treatment for at least 12 weeks duration. In 1997, a detailed definition of the syndrome was developed by the Rhinosinusitis Task Force of the American Academy of Otolaryngology-Head and Neck Surgery, consisting of the major and minor diagnostic criterias. To study the role of conventional radiography, nasal endoscopy and computed tomography in the early diagnosis of chronic rhinosinusitis. The study was carried out in the Department of Otorhinolaryngology, Saraswati Institute of Medical Sciences. A total of 100 patients with clinical evidence of sinonasal diseases were evaluated with conventional radiography, Nasal endoscopy and computed tomographic evaluation. Out of 100 patients; 58 were male and 42 were female. M:F ratio = 1.38:1. Majority of the patients were being in the age group of 21-30 years (30 %). The most common finding on conventional radiography was opacification of maxillary sinus (42 %) followed mucosal thickening (26 %), haziness of the maxillary sinus (19 %) followed by air-fluid level (13 %). Five basic radiological patterns of sinonasal inflammatory disease are identified among 100 patients. These were (1) Infundibular 16 %, (2) Ostiomeatal unit 32 %, (3) Sphenoethmoidal 8 %, (4) Sinonasal polyposis 28 %, (5) Unclassified 16 %. The sensitivity and specificity of plain film radiography for detecting sinus opacifications was unacceptably low for paranasal sinuses, hence conventional radiography should not be used as a single diagnostic tool in preoperative evaluation. Nasal endoscopy having sensitivity and specificity almost as good as CT scanning, and being an outpatient procedure may reduce unnecessary diagnostic CT scanning procedures. It allows an unparalleled vision with brilliant illumination of nose and paranasal sinuses. Endoscopic directed procedures have high accuracy due to vision controlled and incomparable guidance in treatment of nasal and nasopharyngeal pathologies. CT scan can be reserved as second level investigation for the subgroup of patients with negative endoscopy who remain symptomatic on follow up.

Aortic Neck Anatomic Features and Predictors of Outcomes in Endovascular Repair of Abdominal Aortic Aneurysms Following vs Not Following Instructions for Use.

BACKGROUND: A significant number of patients undergo endovascular repair of abdominal aortic aneurysms (EVAR) outside the instructions for use (IFU). This study will examine various aortic neck features and their predictors of clinical outcomes. STUDY DESIGN: We performed a retrospective analysis of prospectively collected data on EVAR patients. Neck features outside IFU were analyzed. Kaplan-Meier and multivariate analyses were used to predict their effect as single features, or in combination, on outcomes. RESULTS: Fifty-two percent of 526 patients had 1 or more features outside the IFU. The overall technical success rate was 99%, and perioperative complication rates were 7% and 12% for IFU vs outside IFU use, respectively (p = 0.04). Type I early endoleak and early intervention rates were 7% and 10% for IFU vs 18% and 24% for outside IFU (p = 0.0002 and p < 0.0001). At a mean follow-up of 30 months, freedom from late type I endoleak and late reintervention at 1, 2, and 3 years for IFU were 99.5%, 99.5%, and 98.4%, and 99.4%, 98%, and 96.8%; vs 98.9%, 98.1%, and 98.1%, and 97.5%, 96.2%, and 95.2% for outside IFU (p = 0.049 and 0.799), respectively. Survival rates at 1, 2, and 3 years for IFU were 97%, 93.5%, and 89.8%; vs 93.7%, 88.8%, and 86.3% for outside IFU (p = 0.035). Multivariate analysis showed that a neck angle > 60 degrees had odds ratios for death, sac expansion, and early intervention of 6, 2.6, and 3.3, respectively; neck length < 10 mm had odds ratios of 2.8 for deaths, 3.4 for early intervention, 4.6 for late reintervention, and 4.3 for late type I endoleak. CONCLUSIONS: Patients with neck features outside IFU can be treated with EVAR; however, they have higher rates of early and late type I endoleak, early intervention, and late death.

The value and economic analysis of routine postoperative carotid duplex ultrasound surveillance after carotid endarterectomy.

BACKGROUND: Several studies have reported on the role of postoperative duplex ultrasound surveillance after carotid endarterectomy (CEA) with varying results. Most of these studies had a small sample size or did not analyze cost-effectiveness. METHODS: We analyzed 489 of 501 CEA patients with patch closure. All patients had immediate postoperative duplex ultrasound examination and were routinely followed up both clinically and with duplex ultrasound at regular intervals of 1 month, 6 months, 12 months, and every 12 months thereafter. A Kaplan-Meier analysis was used to estimate the rate of ≥50% and ≥80% post-CEA restenosis over time and the time frame of progression from normal to ≥50% or ≥80% restenosis. The cost of post-CEA duplex surveillance was also estimated. RESULTS: Overall, 489 patients with a mean age of 68.5 years were analyzed. Ten of these had residual postoperative ≥50% stenosis, and 37 did not undergo a second duplex ultrasound examination and therefore were not included in the final analysis. The mean follow-up was 20.4 months (range, 1-63 months), with a mean number of duplex ultrasound examinations of 3.6 (range, 1-7). Eleven of 397 patients (2.8%) with a normal finding on immediate postoperative duplex ultrasound vs 4 of 45 (8.9%) with mild stenosis on immediate postoperative duplex ultrasound progressed to ≥50% restenosis (P = .055). Overall, 15 patients (3.1%) had ≥50% restenosis, 9 with 50% to <80% and 4 with 80% to 99% (2 of these had carotid artery stenting reintervention), and 2 had late carotid occlusion. All of these were asymptomatic, except for one who had a transient ischemic attack. The mean time to ≥50% to <80% restenosis was 14.7 months vs 19.8 months for ≥80% restenosis after the CEA. Freedom from restenosis rates were 98%, 96%, 94%, 94%, and 94% for ≥50% restenosis and 99%, 98%, 97%, 97%, and 97% for ≥80% restenosis at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. Freedom from myocardial infarction, stroke, and deaths was not significantly different between patients with and without restenosis (100%, 93%, 83%, and 83% vs 94%, 91%, 86%, and 79% at 1 year, 2 years, 3 years, and 4 years, respectively; P = .951). The estimated charge of this surveillance was 3.6 × 489 (number of CEAs) × $800 (charge for carotid duplex ultrasound), which equals $1,408,320, to detect only four patients with ≥80% to 99% restenosis who may have been potential candidates for reintervention. CONCLUSIONS: This study shows that the value of routine postoperative duplex ultrasound surveillance after CEA with patch closure may be limited, particularly if the finding on immediate postoperative duplex ultrasound is normal or shows minimal disease.

Effect of statins on early and late clinical outcomes of carotid endarterectomy and the rate of post-carotid endarterectomy restenosis.

BACKGROUND: This study analyzed the effect of statins on clinical outcomes after carotid endarterectomy (CEA) and the rate of restenosis. STUDY DESIGN: We performed a retrospective analysis of prospectively collected data on 500 consecutive CEAs followed at 1, 6, and 12 months and every year. RESULTS: There were 299 patients on statins vs 201 without. Combined perioperative MI/death rates were 2.7% vs 4% (p = 0.416) and MI/stroke/death rates were 4% vs 5% (p = 0.607) for statins vs no statins. At mean follow-up (27 months), MI, stroke, and death rates were: 9.7%, 2.3%, and 2.3% vs 9%, 2.5% and 4.5% (p = 0.18) for statins vs no statins, respectively. Diabetic patients not on statins had 4 times more deaths (8.5% vs 2.3%) and twice as many strokes/deaths (10.2% vs 5.3%). Patients with hypercholesterolemia who were not on statins had twice as many deaths (4.3% vs 2.2%). Rates of freedom from stroke/MI/death at 1, 2, 3, and 4 years were: 94%, 90%, 85% and 77% vs 94%, 89%, 85%, and 82% (p = 0.87) for statins vs no statins, respectively. Rates of freedom from death only for patients on statins vs no statins at 1, 2, 3, and 4 years were: 98%, 98%, 97.4% and 97.4% vs 98%, 96%, 94.8% and 94.8%, respectively (p = 0.191). For diabetic patients, rates of freedom from death at 1, 2, 3, and 4 years were 99%, 99%, 97%, and 97% for statins vs 97%, 90%, 90%, and 90% without statins, respectively (p = 0.048). Post-CEA restenosis rates ≥ 50% were not significantly different between statins vs no statins (p = 0.64). CONCLUSIONS: Statins significantly lowered death rates in patients with diabetes and tended to lower both death and stroke rates in diabetic patients and patients with hypercholesterolemia. Statins had no effect on post-CEA restenosis.

The effect of chronic renal insufficiency by use of glomerular filtration rate versus serum creatinine level on late clinical outcome of carotid endarterectomy.

BACKGROUND: Several studies have reported mixed results after carotid endarterectomy (CEA) in patients with chronic renal insufficiency (CRI), and we previously reported the perioperative outcome in patients with CRI by use of serum creatinine (Cr) level and glomerular filtration rate (GFR). However, only a few of these studies used GFR by the Modification of Diet in Renal Disease equation in their analysis of long-term outcome. METHODS: During the study period, 1000 CEAs (926 patients) were analyzed; 940 of these CEAs had Cr levels and 925 had GFR data. Patients were classified into normal (GFR ≥60 mL/min/1.73 m(2) or Cr <1.5 mg/dL), moderate CRI (GFR ≥30-59 or Cr ≥1.5-2.9), and severe CRI (GFR <30 or Cr ≥3). RESULTS: At a mean follow-up of 34.5 months and a median of 34 months (range, 1-53 months), combined stroke and death rates for Cr levels (867 patients) were 9%, 18%, and 44% for Cr <1.5, ≥1.5 to 2.9, and ≥3 (P = .0001) in contrast to 8%, 14%, and 26% for GFR (854 patients) of >60, ≥30 to 59, and <30, respectively (P = .0003). Combined stroke and death rates for asymptomatic patients were 8%, 17%, and 44% (P = .0001) for patients with Cr levels of <1.5, ≥1.5 to 2.9, and ≥3, respectively, vs 7%, 13%, and 24% for a GFR of ≥60, ≥30 to 59, and <30 (P = .0063). By Kaplan-Meier analysis, stroke-free survival rates at 1 year, 2 years, and 3 years were 97%, 94%, and 92% for Cr <1.5; 92%, 85%, and 81% for Cr ≥1.5 to 2.9; and 56%, 56%, and 56% for Cr ≥3 (P < .0001); vs 98%, 95%, and 93% for a GFR ≥60; 93%, 90%, and 86% for a GFR of ≥30 to 59; and 86%, 77%, and 73% for a GFR <30 (P < .0001). These rates for asymptomatic patients at 1 year, 2 years, and 3 years were 97%, 95%, and 93% for Cr <1.5; 94%, 87%, and 82% for Cr ≥1.5 to 2.9; and 56%, 56%, and 56% for Cr ≥3 (P < .0001); vs 98%, 95%, and 94% for a GFR ≥60; 95%, 91%, and 86% for a GFR of ≥30 to 59; and 84%, 80%, and 75% for a GFR <30 (P = .0026). A univariate regression analysis for asymptomatic patients showed that the hazard ratio (HR) of stroke and death was 6.5 (P = .0003) for a Cr ≥3 and 3.1 for a GFR <30 (P = .0089). A multivariate analysis showed that Cr ≥3 had an HR of stroke and death of 4.7 (P = .008), and GFR <30 had an HR of 2.2 (P = .097). CONCLUSIONS: Patients with severe CRI had higher rates of combined stroke/death. Therefore, CEA for these patients (particularly in asymptomatic patients) must be considered with caution.

Practice patterns of carotid endarterectomy as performed by different surgical specialties at a single institution and the effect on perioperative stroke and cost of preoperative imaging.

BACKGROUND: Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost. METHODS: This is a retrospective analysis of prospectively collected data of 1000 consecutive CEAs performed at our institution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CTS), and vascular surgeons (VS). RESULTS: VS did 474 CEAs, CTS did 404, and GS did 122. VS tended to operate more often on symptomatic patients than CTS and GS: 40% vs 23% and 31%, respectively (P < .0001). Preoperative workups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and computed tomography angiography in 27%, 35%, and 29%; and DUS and magnetic resonance angiography in 6%, 35%, and 52% for VS, CTS, and GS, respectively (P < .001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (P = .0001) and protamine was used in 0.2%, 19%, and 8% (P < .0001) for VS, CTS, and GS, respectively. VS more often used postoperative drains; however, no association was found between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (P < .0001) for VS, CTS, and GS, respectively. Bovine pericardial patches were used more often by CTS and ACUSEAL (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) patches were used more often by GS (P < .0001). The perioperative stroke/death rates were 1.3% for VS and 3.1% for CTS and GS combined (P = .055); and were 0.7% for VS and 3% for CTS and GS combined for asymptomatic patients (P < .034). Perioperative stroke rates for patients who had preoperative DUS only were 0.9% vs 3.3% for patients who had extra imaging (computed tomography angiography/magnetic resonance angiography; P = .009); and were 0.9% vs 3% for asymptomatic patients (P = .05). When applying hospital billing charges for preoperative imaging workups (cost of DUS only vs DUS and other imaging), the VS practice pattern would have saved $1180 per CEA over CTS and GS practice patterns; a total savings of $1,180,000 in this series. CONCLUSIONS: CEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians who perform CEAs on cost-saving measures may be appropriate.

The effect of surgeon's specialty and volume on the perioperative outcome of carotid endarterectomy.

BACKGROUND: Several studies have demonstrated better outcomes for carotid endarterectomy (CEA) at high-volume hospitals and providers. However, only a few studies have reported on the impact of surgeons' specialty and volume on the perioperative outcome of CEA. METHODS: This is a retrospective analysis of CEA during a recent 2-year period. Surgeons' specialties were classified according to their Board specialties into general surgeons (GS), cardiothoracic surgeons (CT), and vascular surgeons (VS). Surgeons' annual volume was categorized into low volume (<10 CEAs), medium volume (10 to <30 CEAs), and high volume (≥30 CEAs). The primary outcome was 30-day perioperative stroke and/or death; however, other perioperative complications were analyzed. Both univariate and multivariate analyses were done to predict the effect of specialty/volume and any other patient risk factors on stroke outcome. RESULTS: Nine hundred and fifty-three CEAs were performed by 24 surgeons: 122 by seven GS, 383 by 13 CT, and 448 by 4 VS. Patients' demographics/clinical characteristics were similar between specialties, except the incidence of coronary artery disease, which was higher for CT (P < .0001). The indications for CEA were symptomatic disease in 38% for VS, 31% for GS, and 23% for CT (P < .0001). The perioperative stroke and death rates were 4.1%, 2.9%, and 1.3% for GS, CT, and VS, respectively (P = .126). A subgroup analysis showed that the perioperative stroke rates for symptomatic patients were 5.3%, 2.3%, and 2.3% (P = .511) and for asymptomatic patients were 3.6%, 3%, and 0.72% (P = .099) for GS, CT, and VS, respectively. Perioperative stroke rates were significantly higher for nonvascular surgeons (GS and CT combined) vs VS in asymptomatic patients (3.2% vs 0.72%; P = .033). Perioperative stroke/death was also significantly lower for high-volume surgeons: 1.3% vs 4.1% and 4.3% for medium- and low-volume surgeons (P = .019) (1.3% vs 4.15% for high vs low/medium combined; P = .005). More CEAs were done for asymptomatic patients in the low/medium-volume surgeons (78%) vs high-volume surgeons (64%; P < .0001) with a stroke rate of 4.6% for low/medium-volume surgeons vs 0.51% for high-volume surgeons (P = .0005). A univariate logistic analysis showed that the odds ratio of having a perioperative stroke was 0.3 (95% confidence interval [CI], 0.13-0.73; P =.008) for high-volume surgeons vs low/medium-volume surgeons, 0.4 (95% CI, 0.16-1.07; P = .069) for VS vs CT/GS and 0.2 (95% CI, 0.06-0.45; P = .0004) when patching was used. A multivariate analysis showed that the odds ratio of having a perioperative stroke for CT VS was 2.1 (95% CI, 0.71-5.92; P = .183); for GS vs VS, 1.8 (95% CI, 0.49-6.90; P = .3709); for low-volume surgeons (vs high-volume) 3.4 (95% CI, 0.96-11.77; P = .0581); medium- vs high-volume surgeons 2.2 (95% CI, 0.75-6.42; P = .1509). CONCLUSIONS: High-volume surgeons had significantly better perioperative stroke/death rates for CEA than low/medium-volume surgeons. Perioperative stroke/death rates were also higher for nonvascular surgeons in asymptomatic patients.

Impact of chronic renal insufficiency using serum creatinine vs glomerular filtration rate on perioperative clinical outcomes of carotid endarterectomy.

BACKGROUND: Several studies have reported conflicting results after carotid endarterectomy in patients with chronic renal insufficiency (CRI). However, only a few used glomerular filtration rate (GFR) (Modification of Diet in Renal Disease) in their analysis. STUDY DESIGN: Nine hundred and forty carotid endarterectomies that had serum creatinine and GFR were analyzed. Patients were classified as normal (creatinine <1.5 mg/dL or GFR ≥60 mL/min/1.73 m(2)); moderate CRI (creatinine ≥1.5 to 2.9 mg/dL or GFR ≥30 to 59 mL/min/1.73 m(2)), and severe CRI (creatinine ≥3 mg/dL or GFR <30 mL/min/1.73 m(2)). RESULTS: Using creatinine, perioperative stroke and major adverse event rates for normal, moderate CRI, and severe CRI were 2%, 3.5%, and 11.1% (p = 0.091) and 2.4%, 4.4%, and 11.1% (p = 0.089) vs 1.1%, 3.7%, and 5.4% (p = 0.018) and 1.8%, 4%, and 5.4% (p = 0.086) using GFR. Univariate logistic regression analysis showed that creatinine ≥1.5 mg/dL had an odds ratio of 2.1 for having early stroke/death vs an odds ratio of 3.5 (p = 0.009) for GFR <60 mL/min/1.73 m(2). A multivariate analysis showed that GFR <60 mL/min/1.73 m(2) had an odds ratio for early stroke/death of 3.7 (p = 0.013). Using creatinine, perioperative stroke rates for symptomatic patients were 2.8%, 2.6%, and 0% and 1.6%, 4.1%, and 11.1% (p = 0.045) for asymptomatic patients with normal, moderate CRI, and severe CRI vs 1.6%, 4.7%, and 9.1% for symptomatic patients (p = 0.09) and 1%, 3.2%, and 3.9% for asymptomatic patients (p = 0.074) using GFR. Perioperative major adverse event rates for symptomatic patients using creatinine were 3.2%, 2.6%, and 0%, and for asymptomatic patients 2.1%, 5.4%, and 11.1% (p = 0.048) vs 2.1%, 4.7%, and 9.1% for symptomatic patients and 1.7%, 3.7%, and 7.7% (p = 0.193) for asymptomatic patients using GFR. Moderate/severe CRI also had more cardiac (5.7% vs 2.4%; p = 0.072) and respiratory complications (2.5% vs 0.2%; p = 0.018). CONCLUSIONS: Glomerular filtration rate (Modification of Diet in Renal Disease) was more sensitive in detecting perioperative stroke/death after carotid endarterectomy in patients with CRI. Patients with moderate/severe CRI had more major adverse events than normal patients.

Perioperative and late clinical outcomes of percutaneous transluminal stentings of the celiac and superior mesenteric arteries over the past decade.

BACKGROUND: Several authorities have proposed stenting of the superior mesenteric artery (SMA)/celiac artery (CA) as the primary treatment for patients with chronic mesenteric ischemia. However, most of these reports had small samples and short follow-up periods. METHODS: Eighty-three patients were treated over a 10-year period. Clinical follow-up and duplex ultrasound exams were done to evaluate long-term patency. We used our newly validated duplex criteria to detect ≥70% in-stent stenosis of the SMA and CA. A Kaplan-Meier life-table analysis was used to estimate freedom from in-stent stenosis and late symptom and survival rates. RESULTS: Fifty-four SMA and 51 CA stents were analyzed. The initial technical and clinical success rates were 97% and 96%, respectively, with 2% procedure morbidity and 2% mortality. The primary late clinical success rate was 59%, and the late ≥70% in-stent stenosis rate was 51% at a mean follow-up of 31 months (range, 1-124). Freedom from late recurrent symptoms at 1, 2, 3, 4, and 5 years was 83, 77, 70, 70, and 65%, respectively. Survival rates at the same intervals were 88%, 82%, 70%, 64%, and 51%. Primary patency rates for the whole series were 69%, 48%, 39%, 28%, and 19% at 1, 2, 3, 4, and 5 years, respectively. Assisted primary patency rates for the whole series were 80%, 61%, 54%, 43%, and 34% at 1, 2, 3, 4, and 5 years, respectively. Primary patency rates for the SMA at 1, 2, 3, 4, and 5 years were 71%, 47%, 37%, 28%, and 18%, respectively; and assisted primary rates were 82%, 64%, 57%, 45%, and 32%, respectively. Primary patency rates for the CA were 68%, 50%, 40%, 29%, and 21%; and assisted primary rates were 79%, 58%, 52%, 42%, and 36% for 1, 2, 3, 4, and 5 years, respectively. There were no significant differences in either primary or assisted primary patency between the SMA and CA (P = .7729 and .8169). A secondary intervention was carried out in 30% of the series. Freedom from ≥70% in-stent stenosis for the SMA was 82%, 65%, 56%, 42%, and 34%, and that for the CA was 73%, 59%, 48%, 34%, and 25%, at 1, 2, 3, 4, and 5 years, respectively. CONCLUSIONS: Stenting of SMA/CA stenosis has high technical/early clinical success rates with a satisfactory late clinical outcome; however, it is associated with high rates of late in-stent stenosis and intervention.

Critical analysis of renal duplex ultrasound parameters in detecting significant renal artery stenosis.

BACKGROUND: Several published studies have reported differing results of renal duplex ultrasound (RDU) imaging in detecting significant renal artery stenosis (RAS) using different Doppler parameters. This study is the largest to date to compare RDU imaging vs angiography and assess various published Doppler criteria. METHODS: RDU imaging and angiography were both done in 313 patients (606 renal arteries). RAS was classified as normal, <60%, ≥ 60% to 99%, and occlusion. Main outcome measurements included renal peak systolic velocity (PSV), systolic renal-to-aortic ratio (RAR), end-diastolic velocity (EDV), and kidney lengths. RESULTS: The mean PSVs and RARs for normal, <60%, and ≥ 60% stenosis were 173, 236, and 324 cm/s (P < .0001), and 2.2, 2.9, and 4.5, respectively (P < .0001). The PSV cutoff value that provided the best overall accuracy for ≥ 60% stenosis was 285 cm/s, with a sensitivity, specificity, and overall accuracy of 67%, 90%, and 81%, respectively. The RAR cutoff value with the best overall accuracy for ≥ 60% stenosis was 3.7, with a sensitivity, specificity, and overall accuracy of 69%, 91%, and 82%, respectively. A PSV of ≥ 180 cm/s and RAR of ≥ 3.5 had a sensitivity, specificity, and overall accuracy of 72%, 81%, and 78% in detecting ≥ 60% stenosis. A PSV of ≥ 200 cm/s with an RAR of ≥ 3.5 had a sensitivity, specificity, and overall accuracy of 72%, 83%, and 78% in detecting ≥ 60% stenosis. A receiver operator characteristic (ROC) curve analysis showed that the PSV and RAR were better than the EDV in detecting ≥ 60% stenosis: PSV area under the curve (AUC) was 0.85 (95% confidence interval [CI], 0.81-0.88), EDV AUC was 0.71, and RAR AUC was 0.82 (PSV vs EDV, P < .0001; PSV vs RAR, P = .075; EDV vs RAR, P < .0001). A PSV of 285 cm/s or RAR of 3.7 alone were better than any combination of PSVs, EDVs, or RARs in detecting ≥ 60% stenosis. The mean kidney length was 10.4 cm in patients with ≥ 60% stenosis vs 11.0 cm in patients with <60% stenosis (P < .0001). Twelve percent of patients with ≥ 60% stenosis had a kidney length of ≤ 8.5 cm vs 4% in patients with <60% stenosis (P = .0003), and 5.6% (34 of 606) had accessory renal arteries on angiography, with six detected on RDU imaging. The presence of accessory renal arteries, solitary kidneys, or renal fibromuscular dysplasia had no influence on overall accuracy of using PSV values for detecting ≥ 60% stenosis. CONCLUSIONS: A PSV of 285 cm/s or an RAR of 3.7 alone can be used in detecting ≥ 60% RAS. Previously published data must be validated in individual vascular laboratories.