Emergent Case Research Articles

Outcome of Pseudoaneurysm Repair: A Single Tertiary Center Experience in Pahang, Malaysia

Introduction: Symptomatic arterial pseudoaneurysm is not an uncommon emergent vascular case presenting to a tertiary hospital. These are mainly associated with infection, iatrogenic puncture or trauma. The resultant morbidity, limb loss and mortality present a challenge to the surgeons managing these cases. Materials and method: We retrospectively reviewed all case notes of all pseudoaneurysm repair done at our centre from Jan 2015 to May 2017. Results: A total of 20 cases were treated surgically, with majority 16(80%) had ligation of the affected arteries. The rest were managed with reconstruction of the arteries with synthetic graft. In 7 patients (35%), the aetiology was identified as iatrogenic intravenous drug injection. Staphylococcus aureus remained the main causative organism with Treponema Pallidum and Burkholderia pseudomallei as the other organisms identified in the cultures. Our 3 patients with graft reconstruction had long term oral antibiotics upon discharge. Conclusion: Majority of pseudoaneurysms presented to our center results in ligation of the artery. Repair of mycotic aneurysm needs careful consideration as graft infection remains a lethal complication and no consensus is available regarding the duration of post-operative antibiotic cover.

A Semi-Analytical Model for the Hydraulic Resistance Due to Macro-Roughnesses of Varying Shapes and Densities

A friction model resulting from investigations into macro-roughness elements in fishways has been compared with a broad range of studies in the literature under very different bed configurations. In the context of flood modelling or aquatic habitats, the aim of the study is to show that the formulation is applicable to both emergent or submerged obstacles with either low or high obstacle concentrations. In the emergent case, the model takes into account free surface variations at large Froude numbers. In the submerged case, a vegetation model based on the double-averaging concept is used with a specific turbulence closure model. Calculation of the flow in the roughness elements gives the total hydraulic resistance uniquely as a function of the obstacles’ drag coefficient. The results show that the model is highly robust for all the rough beds tested. The averaged accuracy of the model is about 20% for the discharge calculation. In particular, we obtain the known values for the limiting cases of low confinement, as in the case of sandy beds.

Analysis of Postoperative Venous Thromboembolism in Patients With Chronic Ulcerative Colitis: Is It the Disease or the Operation?

Patients with IBD have a higher baseline risk of venous thromboembolism, which further increases with surgery. Therefore, extended venous thromboembolism chemoprophylaxis has been suggested in certain high-risk cohorts. The purpose of this study was to determine whether the underlying diagnosis, operative procedure, or both influence the incidence of postoperative venous thromboembolism. This was a retrospective review. The American College of Surgeons-National Surgical Quality Improvement Project database was analyzed. The NSQIP database was queried for patients with chronic ulcerative colitis and non-IBD undergoing colorectal resections using surgical Current Procedural Terminology codes modeled after the 3 stages used for the surgical management of chronic ulcerative colitis from 2005 to 2013. We measured 30-day postoperative venous thromboembolism risk in patients with chronic ulcerative colitis based on operative stage and risk factors for development of venous thromboembolism. A total of 18,833 patients met inclusion criteria, with an overall rate of venous thromboembolism of 3.8. Among procedure risk groups, venous thromboembolism rates were high risk, 4.4%; intermediate risk, 1.6%; and low risk, 0.7% (across risk groups, p < 0.01). Emergent case subjects exhibited a higher rate of venous thromboembolism than their elective counterparts (6.9% vs 3.1%). Factors significantly associated with venous thromboembolism on adjusted analysis included emergent risk case (adjusted OR = 7.85), high-risk elective case (adjusted OR = 5.07), intermediate-risk elective case (adjusted OR = 2.69), steroid use (adjusted OR = 1.54), and preoperative albumin <3.5 g/dL (adjusted OR = 1.45). Because of its retrospective nature, correlation between procedures and venous thromboembolism risk can be demonstrated, but causation cannot be proven. In addition, data on inpatient and extended venous thromboembolism prophylaxis use are not available. Emergent status and operative procedure are the 2 highest risk factors for postoperative venous thromboembolism. Extended venous thromboembolism prophylaxis might be appropriate for patients undergoing these high-risk procedures or any emergent colorectal procedures. See Video Abstract at http://links.lww.com/DCR/A339.

内頸動脈瘤・中大脳動脈瘤のみられた肝動脈瘤破裂の一救命例

内頸動脈瘤・中大脳動脈瘤のみられた肝動脈瘤破裂の一救命例

The Mentored Multigenre Project: Fostering Authentic Writing Interactions Between High School Writers and Teacher Candidates

AbstractThis article describes the Mentored Multigenre Project, a virtual writing collaboration experience between high school writers and teacher candidates. Our goal was to create an authentic opportunity for our high school students to receive writing feedback from virtual writing mentors, while also creating an opportunity for our teacher candidates to practice the craft of teaching writing. In this article, the authors outline the ways in which they prepared and supported the high school students during the project. Then, the authors highlight an emergent case from the project to demonstrate the virtual writing collaboration experience in action and evaluate the extent to which it created an authentic writing experience for one high school writer. Finally, the authors share their reflections on the experience and suggestions for others interested in using a learning management system to connect high school writers with teacher candidates.

Neurosurgical Infection Rates and Risk Factors: A National Surgical Quality Improvement Program Analysis of 132,000 Patients, 2006–2014

The existing body of literature on postoperative neurosurgical infections lacks large multicenter reports on postoperative neurosurgical infections. This is the largest study to date of postoperative neurosurgical infections rates, time to event, and risk factors. Demographics, medical history, and postoperative infections were assessed for all adult patients in the large, randomized, multicenter American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database undergoing an operation with a surgeon whose primary specialty was neurological surgery from 2006 to2014. Of 3,723,797 cases from 517 institutions in the NSQIP from 2006 to 2014, 132,063 neurosurgery cases were identified. Within these patients, the 30-day rate of postoperative infections was 5.3%. Postoperatively, 1.8% of patients developed surgical site infections (SSI), and 3.9% developed other infections including pneumonia and urinary tract infections. Superficial SSI had a cumulative incidence of 0.8% at a median of 16 (interquartile range [IQR], 11-22) days. Pneumonia had a cumulative incidence of 1.4% at a median of 5 days (IQR, 2-10 days). Systemic inflammatory response syndrome had a cumulative incidence of 1.6% at a median of 3 days (IQR, 8-16 days). Predictors of postoperative infections on multivariable analysis included female sex, older age, obesity, functionally dependent status before surgery, ventilator dependence, preoperative steroid use, bleeding disorders, hyponatremia, lymphocytosis, anemia, thrombocytosis, emergent case status, wound class II-IV, American Society of Anesthesiologists class 3-5, and longer operative times. The overall ACS-NSQIP reported rate of postoperative infections was 5.3% from 2006 to 2014. Multivariable analysis demonstrated several predictive factors for postoperative infections.

Confidence in the Patient Evaluation by Junior Residents and Physician Assistant

APGO Advisor: Lee A. Learman, MD, PhD PURPOSE: To describe and compare faculty and senior resident confidence in junior resident (JRES) and physician assistant (PA) evaluation of patients with nonemergent compared with emergent gynecologic problems. BACKGROUND: Duty hour restrictions have necessitated the increasing use of PAs at the University of Chicago Department of obstetrics and gynecology. Some faculty have expressed concern about this change. METHODS: Using information from focus groups and interviews with residents, PAs, and faculty, we created three emergent and three nonemergent patient scenarios. Each scenario was used to create two subtly different cases (12 total) involving a JRES or a PA. These were sent by email to 29 faculty and 28 residents in an anonymous, voluntary survey. Respondents indicated their perceived confidence. Survey responses were summarized with counts and proportions. We adjusted for multiple testing using the Benjamini-Hochberg method. RESULTS: The 35 surveys received included 21 which were complete and 17 from faculty. Too few senior residents surveys (4) were available for analysis. In the 3 comparable sets of emergent case scenarios, faculty respondents tended to be more confident in the JRES (76.5%, 100%, 100%) than the PA (82.4%, 76.5%, 94.1%). In the 3 comparable sets of nonemergent case scenarios, faculty respondents tended to have less confidence in the JRES (76.5%, 64.7%, 100%) than the PA (88.2%, 94.1%, 100%). DISCUSSION: No large differences were identified in faculty confidence in JRES and PA management of common gynecology patient problems. Senior resident confidence in JRES and PA management could not be assessed due a low response rate.

Altruistic Agencies and Compassionate Consumers

What makes a multimillion-dollar, transnational intimate industry possible when most people see it as exploitative? Using the newly emergent case of commercial surrogacy in India, this article extends the literature on stratified reproduction and intimate industries by examining how surrogacy persists and thrives despite its common portrayal as the “rent-a-womb industry” and “baby factory.” Using interview data with eight infertility specialists, 20 intended parents, and 70 Indian surrogate mothers, as well as blogs and media stories, we demonstrate how market actors justify their pursuits through narrating moral frames of compassion and altruism that are not incidental but systematic to and constitutive of transnational surrogacy. We observed two predominant moral frames: (1) surrogacy liberates and empowers Indian women from patriarchal control; and (2) surrogacy furthers reproductive rights. Within these frames, the market exchange of money for babies is cast as compassion, which allows commissioning clients to sidestep accusations of racism, classism, and sexism. Yet, we reveal that the ability to navigate around these threats relies on racist, classist, and sexist tropes about Third World working-class women. Further, we find that surrogate mothers did not experience significant changes in economic status after surrogacy.

Judging Stereotypes: What the European Court of Human Rights Can Borrow from American and Canadian Equal Protection Law

The concept of stereotype is novel in the case law of the European Court of Human Rights. The ECtHR has started to refer to stereotypes in several recent judgments concerning, notably, race and gender equality. In contrast, anti-stereotyping has long been a central feature of both American and Canadian equal protection law. Offering a comparison of the legal reasoning of the ECtHR and the U.S. and Canadian Supreme Courts, this Article uncovers both the pitfalls and the potential of the stereotype concept to advance transformative equality. It is hard to develop a proper legal response to stereotyping, as not all stereotypes are bad and, moreover, laws are inevitably based on generalizations. At a minimum, this Article argues, courts should name stereotypes well and carefully examine their harm. This comparative analysis shows that, at its best, legal reasoning can expose and target the invidious cycle wherein stereotyping and discrimination perpetuate each other. Both the U.S. Supreme Court and its Canadian counterpart, however, show a tendency to equate stereotypes with unfair generalizations. This Article cautions against that. Stereotypes can indeed be inaccurate or negative, but they can also be statistically correct, or prescriptive. When stereotypes are conceived of too narrowly (as only raising issues of accuracy), the concept loses its ability to strengthen a transformative equality analysis. This Article first charts and critiques the emergent ECtHR case law on stereotypes. It then offers a fresh analysis of the strengths and weaknesses of the U.S. and Canadian Supreme Courts' treatment of stereotypes. Two deceptively simple questions will form the leitmotif throughout the comparison: (i) how do these courts conceive of stereotypes, and (ii) given that stereotyping is not necessarily always negative or problematic, how do these courts determine whether the application of a stereotype is invidious? It concludes by exploring what the ECtHR can borrow from American and Canadian equal protection analysis.

The EU Free Movement as Seen Through the Lens of Competition Law

This paper aims to unify the law on the EU free movement of goods, particularly access to relevant markets, and EU competition law on the conduct of economic operators, i.e. traders on such markets. It seeks to ascertain the historical origins and inspirational sources of EU free movement in the wider context of EU trade law. The paper questions the goals of free movement law, which complement the goals of competition law. A re-organisation of precedent rulings on free movement will follow in accordance with the economic policy criteria devised by competition law. Free movement law is challenged through the lens of competition law to determine the extent to which these rulings construct a unified picture of EU consumer and fair competition law. The paper argues that, despite its unpredictable evolution, the judicial review of EU free movement law undertaken by the ECJ has successfully developed a sui generis body of EU consumer and fair competition law. This judicial review pragmatically shaped the internal market law during its formative and successive stages of harmonisation. It challenged administrative measures pertaining to key areas of consumer choice, traders’ freedom of action, and the wider public policy or ‘non-competition’ considerations, i.e. the protection of the environment and culture. The perception of unconstitutionality given the ECJ’s perceived intrusiveness in the area of EU private law is crucial in determining the extent to which the Court exercises the judicial function of a Supreme Court in matters of supra-national private law. In reality, the density of precedent rulings and the lack of a coherently unified framework of analysis of the emergent case law obscured the role of the Court as an instrument to ‘disempower’ the EU citizen, since national legislation and measures taken by public administrations had to be challenged. In conclusion, rules that had adverse effects on consumers and traders have been eradicated by the ECJ, obfuscating the national autonomy governing EU private economic law.

Malignant peripheral nerve sheath tumor

Type 1 neurofibromatosis (NF1) is also known as von Recklingausen's disease. Among patients affected by NF1, fast-growing plexiform type neurofibromas have a high rate of malignant transformation and need to be distinguished from benign plexiform neurofibromas. Here, we describe an emergent case presentation with rapid transformation of neurofibromatosis into a malignant peripheral nerve sheath tumor in a male patient in his early 20's, who was admitted with a 4-day history of urinary retention, pelvic “fullness,” and lower back pain. Highlighted are computed tomography imaging characteristics of malignant peripheral nerve sheath tumor, exemplified by a large retroperitoneal/pelvic mass compressing the bladder and both ureters, resulting in bilateral hydronephrosis and urinary retention, and prompting urgent surgical resection. Associated MRI images and an intraoperative photograph are also presented. The following core competencies are addressed in this article: Patient care, Medical knowledge, Systems-based practice

Thirty years after Roemer’s General Theory

This symposium is an outgrowth of a session organized for the 2012 Allied Social Sciences Convention in recognition of the 30th anniversary of the publication of John Roemer’s landmark work, A General Theory of Exploitation and Class (Roemer, 1982, hereafter cited as GTEC). While the papers by Skillman, Veneziani and Yoshihara, and Fleurbaey explore issues raised by GTEC, Roemer’s own contribution looks beyond the questions motivating his earlier work. Those questions, as described by Roemer in the introductory chapter of GTEC, were prompted by the failure of Marxian theory to explain the political behavior and uneven economic progress of modern self-identified socialist economies, such as China, the Soviet Union, Cuba and Vietnam. He contended that this failure fundamentally compromised Marxism’s effort to provide a complete account of the ‘laws of motion’ governing modern societies and its intended role as a guiding doctrine for revolutionary practice. Roemer saw the need to construct a comprehensive theory of exploitation and class that addressed the emergent case of socialist exploitation. Although the primary motivation underlying GTEC was thus to provide grounds for a historical materialist explanation of contemporary socialist experience, most of the ‘general theory’ developed in the work has to do with defining and characterizing the phenomena of exploitation and class as manifested in abstractly defined pre-capitalist and capitalist economies. Part I of GTEC established the framework of analysis while studying these phenomena in the context of subsistence economies with simple linear (‘Leontief’) production technologies and homogeneous labor. Part II extended this analytical framework to the investigation of accumulating economies with more general production possibility sets and

Outcomes and risk factors of cardiac arrest after vascular surgery procedures

Despite increased awareness of the value of discussing patients' goals of care, advance directives, and code status as part of the surgical informed consent process, the actual outcomes and risks of cardiopulmonary resuscitation (CPR) remain poorly defined among some subsets of surgical patients. Thus, in an effort to generate an evidence base for communication about shared decision making and informed consent for vascular surgery patients and their surrogates, we defined the incidence, risks, and outcomes of postoperative cardiac arrest after primary vascular surgery procedures. The 2007 to 2010 National Surgical Quality Improvement Program data were queried to develop a multi-institutional database of patients undergoing vascular surgery (N = 123,581). Univariate analyses and multivariate logistic regression were used to identify crude and adjusted risk factors for postoperative cardiac arrest requiring CPR and to assess outcomes. Postoperative cardiac arrest requiring CPR was seen in 1234 of 123,581 patients (1.0%) after vascular surgery at a mean of 7.2 ± 2 days. The 30-day mortality was 73.4% compared with 2.7% among patients who did not arrest (P < .001). Of CPR survivors, 102 (12.1%) were still hospitalized at 30 days. Patient variables that were most predictive of postoperative cardiac arrest included dependent functional status (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.3-3.6; P < .001), dialysis dependence (OR, 2.7; 95% CI, 2.3-3.2; P < .001), emergent case (OR, 2.2; 95% CI, 1.9-2.5; P < .001), and preoperative ventilator dependence (OR, 2.0; 95% CI, 1.5-2.7; P < .001). Procedures associated with the highest risk included thoracic aortic surgery (OR, 6.9; 95% CI, 4.8-9.9; P < .001), open abdominal procedures (OR, 3.7; 95% CI, 3.1-4.4; P < .001), axillary-femoral bypass (OR, 2.1; 95% CI, 1.3-3.2; P = .001), and peripheral embolectomy (OR, 1.5; 95% CI, 1.2-1.9; P = .002). At least one major complication preceded cardiac arrest in 47.7% of patients including sepsis (23.5%), renal failure (14.5%), and myocardial infarction (12.1%). Patients with do not resuscitate orders were significantly less likely to undergo CPR (OR, 0.59; 95% CI, 0.39-0.93; P = .021). Patients undergoing vascular surgery who suffer a postoperative cardiac arrest frequently die in spite of receiving CPR; for those who survive, there is likely to be prolonged hospitalization and significant morbidity. These data provide an evidence base for discussing goals of care, advance directives, and code status with vascular surgery patients and their surrogates. Further research into how to best communicate risk, to elicit patient preferences, and to engage in shared decision making is needed.

An integrated change propagation scheduling approach for product design

Due to the complicated dependencies among design tasks, design changes in a design task can cause changes to many other tasks, which may cost a lot of time and resources to completely resolve them. Therefore, optimal scheduling of design change propagations is required to reduce the total process time. This article presents an integrated approach for scheduling design changes in the complex product development process by combining simulation of change propagations with optimization algorithms. The process model is built using “And/or” graphs, which can take the logic relationships among design tasks into the process model. Genetic algorithm is applied to the change process model to find the optimal propagation likelihood for each optional propagation path in order to obtain the shortest process run time. The approach is incorporated into the process-oriented computer-aided product design system, and two design changes occurring in the motorcycle engine design process, namely an initiated and an emergent design changes, are used to test the approach. The initiated design change case shows the integrated approach can find the optimal solution more efficiently than the Monte Carlo simulation method, while the emergent change case demonstrates the approach can timely find the optimal solution to the change especially when designers are pressed for delivery of their achievements.

Mortality after Inpatient Open Ventral Hernia Repair

BACKGROUND: 350,000 ventral hernia repairs (VHR) are performed yearly in the US, with open repairs comprising the majority of cases.1 The medical complexity of the hernia patient imparts higher risk for serious complications, poor quality of life, and higher costs. Mortality is a distinct reality, and while prior studies have identified risk factors for mortality, they have been limited to small series lacking generalizability.2 Furthermore, no study has stratified patients based upon risk. The purpose of this study is to utilize a widely-generalizable dataset (ACS-NSQIP) to develop a risk-stratification model for mortality based solely upon preoperative factors, with the hopes of improving decision-making, patient guidance, and minimizing perioperative mortality. METHODS: Patients undergoing inpatient open VHR were identified from the 2005-2012 ACS-NSQIP databases.3 Patient comorbidities and preoperative variables were analyzed to determine statistical correlation with mortality risk. A step-wise multivariate logistic regression of all factors with p value< 0.1 was conducted and resulting significant factors were entered into a bootstrap technique. Adjusted multivariate beta-coefficients were utilized to generate weighted risk scores for each factor. Subsequently, each patient was assigned an aggregate mortality risk score, yielding the risk-assessment tool for preoperative decision-making. RESULTS: 55,760 patients underwent inpatient open VHR with an overall mortality rate of 1.26% (n=704). Independent patient factors predictive of mortality included: partial/total dependent functional status (OR=2.32), cardiovascular (OR=1.23), pulmonary (OR=1.99), renal (OR=1.81), or liver disease (OR=3.19), anemia (OR=1.32), malnutrition (OR=1.83), age>65 years (OR=2.29), ASA 4 or higher (OR=3.83), metastatic cancer (OR=2.14), and systemic inflammation (OR=1.82)(Table 1).Table 1: F.S. – functional status, CV – cardiovascular, ASA – American Society of Anesthesiology, OR – Odds Ratio, CI – Confidence interval. *CV Disease not assigned a risk score because p value > 0.05.Operative factors included emergent case (OR=1.55), wound contamination (OR=1.71), and concurrent intra-abdominal procedure (OR=1.36). Patients were stratified into 4 groups according to mortality risk: low-risk (mortality=0.37%), moderate-risk (mortality=2.24%), high-risk (mortality=10.93%), and extreme-risk (mortality=32.65%) (Figure 1).Figure 1: Additionally, length of stay, unplanned reoperations, and medical complications all increased across the 4 patient groups. The bootstrap model demonstrated high sensitivity and specificity for discriminating mortality risk with a C-statistic=0.87.CONCLUSIONS: This study is the first to provide an accurate model to predict mortality risk based upon preoperative risk factors in patients undergoing open VHR. The strongest predictors were ASA 4 or higher, liver disease, functional status, and older age. This tool allows surgeons to better counsel patients preoperatively and improve clinical decision-making to reduce complication rates and optimize outcomes, patient satisfaction, and cost-efficacy.

Innovation education programs: toward a conceptual framework

Purpose – Innovation education has been identified as a key contributor to enhancing the innovative behavior of individuals, organizations and economies; yet very little literature exists on the development and assessment of innovation education programs (IEPs). This is particularly so in the higher education and vocational education domains. The purpose of this paper is to bridge the gap in the literature, by proposing a conceptual framework of a multi-dimensional IEP. Design/methodology/approach – The paper employs a transparent and reproducible procedure and critical appraisal of the literature; coupled with emergent inquiry and case study implementation of a leading international IEP. Findings – The study provides a framework by which innovation education facilitators may develop and evaluate their IEPs. The proposed framework provides a thematic appreciation of the multi-dimensional relationships between components. Research limitations/implications – Limited within the context of this case study, geographical context and scant literature on IEPs and reproducible procedure. Originality/value – The study provides a conceptual innovation education framework, based upon a successful international innovation management program.

Outcomes of Diabetic and Nondiabetic Patients Undergoing General and Vascular Surgery

Aims. Preoperative diabetic and glycemic screening may or may not be cost effective. Although hyperglycemia is known to compromise surgical outcomes, the effect of a diabetic diagnosis on outcomes is poorly known. We examine the effect of diabetes on outcomes for general and vascular surgery patients. Methods. Data were collected from the Michigan Surgical Quality Collaborative for general or vascular surgery patients who had diabetes. Primary and secondary outcomes were 30-day mortality and 30-day overall morbidity, respectively. Binary logistic regression analysis was used to identify risk factors. Results. We identified 177,430 (89.9%) general surgery and 34,006 (16.1%) vascular surgery patients. Insulin and noninsulin diabetics accounted for 7.1% and 9.8%, respectively. Insulin and noninsulin dependent diabetics were not at increased risk for mortality. Diabetics are at a slight increased odds than non-diabetics for overall morbidity, and insulin dependent diabetics more so than non-insulin dependent. Ventilator dependence, 10% weight loss, emergent case, and ASA class were most predictive. Conclusions. Diabetics were not at increased risk for postoperative mortality. Insulin-dependent diabetics undergoing general or vascular surgery were at increased risk of overall 30-day morbidity. These data provide insight towards mitigating poor surgical outcomes in diabetic patients and the cost effectiveness of preoperative diabetic screening.

Safety brake performance evaluation and optimization of hydraulic lifting systems in case of overspeed dropping

Safety is the most important issue for mobile and industrial machinery, and overspeed dropping of lifting actuators is extremely hazardous to the equipment, environment and operators. In this paper, to evaluate and improve the safety brake performance of hydraulic lifting systems in this emergent case, a multi-objective optimization model was proposed. Considering the load impacts in the braking process, a novel indicator named remaining vibration energy was defined to simply quantify the cushion performance. A mathematical and simulation model was established, and then the simulation model was verified by experimental tests. Minimization of the remaining vibration energy, the brake distance and the pressure loss of the hydraulic fuse on normal working conditions were considered as optimization objectives after analysis of the system dynamic behavior. The optimization model using a genetic algorithm was applied to a heavy hydraulic elevator system. The results indicated that the pressure impact was reduced, and the plunger stopped more smoothly in the optimized system. Also the brake distance and the pressure loss of the fuse are limited by the design criterion. Therefore, this paper presents an optimization method of hydraulic fuses to design safer hydraulic lifting systems.

Management of emergent hypertension in Herat Regional Hospital, Afghanistan

Background Hypertensive emergency is an emergent case which all prompt consideration should be taken. Due to control of hypertension less cases of emergent hypertension is seen nowadays; so the data from April 2012 to Dec 2012 in internal ward of the regional hospital shows 305 cases (113 males and 192 females) recorded aged between 16 90 years with the average of 49 years. Number of admitting days in hospital was between 2 to 6 days. The mean rate days of hospitalization were 3 days. Although blood pressure is usually strikingly elevated (diastole pressure > 130 mmHg) emergency include hypertensive encephalopathy, hypertensive nephropathy, intra cranial hemorrhage, aortic dissention, preeclampsia, eclampsia, pulmonary edema, unstable angina or MI.

Selective cerebral perfusion with mild hypothermic lower body circulatory arrest is safe for aortic arch surgery

The antegrade selective cerebral perfusion (SCP) technique, which extends the safe time limit for arch surgery, has now gained acceptance. However, neither the optimal hypothermic temperature nor the optimal SCP flow rate has been clearly determined. From January 2008 to February 2012, a total of 105 patients underwent total arch replacement under a single surgeon (A.T.) at Shiga Medical University Hospital. The patients were 85 males and 20 females with a mean age of 73 years (range 41-88). The cause of the aneurysm was atherosclerosis in 90 patients and dissection in 15. Eighty-one patients with chronic lesion underwent elective surgery and 24 underwent emergent surgery. Univariate analysis of postoperative neurological dysfunction and early mortality was performed. The mean operation time, cardiopulmonary bypass (CPB) time, coronary ischaemic time, lower body circulatory arrest (CA) time and SCP time were 277 ± 83 min, 164 ± 40 min, 92 ± 33 min, 58 ± 22 min and 95 ± 28 min, respectively. Thirty-day mortality occurred in 1 ruptured emergent case (1%). Hospital mortality (>30 days) occurred in 3 cases (3%), 2 due to multisystem organ failure following emergent rupture and the other to cerebrovascular accident in an elective surgery case. Permanent neurological dysfunction (PND) occurred in 3 patients (3%) and temporary neurological dysfunction (TND) also in 3 patients (3%). SCP under mild hypothermia can be safely applied to aortic arch surgery and is associated with a low rate of hospital mortality and morbidity. However, prolonged SCP time is associated with incidences of postoperative neurological deficit.