Risk Of Need Research Articles

Approach to Inguinal Hernia in High-risk Geriatric Patients: Should it be Elective or Emergent?

Elderly patients are more prone to have inguinal hernia due to weakened abdominal musculature. However, surgical repair of inguinal hernia (SRIH) may not be performed or may be delayed due to greater risk in presence of comorbidities. Present study is investigation of outcome of elective and emergency SRIH in geriatric patients. Records of total of 384 high-risk (American Society of Anesthesiology classification III-IV) patients aged >65 years who underwent SRIH between January 2010 and December 2014 were reviewed. Patients were divided into 2 groups according to procedure type: elective (Group EL) or emergency (Group EM). Demographic features and surgical and postoperative period data of 2 groups were recorded and compared. Demographic data were similar, but number of ASA IV patients was greater in Group EM. Frequency of intestinal resection was significantly greater in emergency surgery group (1% vs 21%; p<0.01). Length of hospital stay (1.3 days vs 7.9 days; p<0.01) and intensive care unit stay (0.17 days vs 4.04 days; p<0.01) were also greater in Group EM. Morbidity (1% vs 24%; p<0.01) and mortality (0.3% vs 11%; p<0.01) were also significantly higher in Group EM compared to elective SRIH group. Emergency inguinal hernia surgery is associated with significantly higher morbidity and mortality compared with elective SRIH in high-risk geriatric patients. Elective hernia repair in these patients should be considered to reduce risk of need for intestinal resection as well as length of hospital stay.

The Population-Based Risk of Need for Coronary Revascularization According to the Presence of Type 2 Diabetes Mellitus and History of Coronary Heart Disease in the Korean Population.

BackgroundWhether diabetic patients without a history of coronary heart disease (CHD) have the same risk of CHD events as non-diabetic patients with a history of CHD remains controversial. This study aimed to determine whether type 2 diabetes mellitus (T2DM) is a coronary heart disease (CHD) equivalent in the need for coronary revascularization procedures (RVs) in the Korean population.Methodology/Principal FindingsWe followed 2,168,698 subjects who had oral anti-diabetic drugs (OADs)-taking T2DM in 2008 and/or CHD in 2007–2008 (i.e., recent CHD). We used systematic datasets from the nationwide claims database of the Health Insurance Review and Assessment service of Korea, which is representative of the whole population of Korea, from January 2007 to December 2012. The primary study endpoint was the development of need for RVs (i.e., incident CHD) after January 2009 among three groups based on their status of T2DM and recent CHD, i.e., T2DM only, recent CHD only, and both T2DM and recent CHD. After adjustment for age and sex, patients with recent CHD only had 2.14 times the risk of incident CHD (95% CI, 2.11–2.18, P<0.001) compared with patients with T2DM only. Patients with both T2DM and recent CHD demonstrated approximately 2-fold increased risk of incident CHD compared with subjects with recent CHD only (95% CI, 1.75-1.82), while 4-fold increased risk compared with subjects with T2DM only (95% CI, 3.71-3.87). The risk of incident CHD also differed according to sex and age.Conclusions/SignificanceThis analysis of data from the nationwide claims database revealed that T2DM did not have a recent CHD equivalent risk in the Korean population. These results suggest that an appropriate strategy for the CHD risk stratification in diabetic patients should be adopted to manage this population.

PD47-11 PREDICTORS OF QUALITY OF LIFE IN MEN WITH LOCALIZED PROSTATE CANCER: THE ROLE OF TREATMENT DECISION MAKING SATISFACTION, NEUROTICISM, AND SEXUAL FUNCTIONING

pathology. In the present study, our objective was to determine if MetS is associated with adverse final pathology and risk of treatment failure in men undergoing radical prostatectomy (RP). METHODS: Patients undergoing RP (2004-2013) were identified using our prospectively maintained institutional database. Salvage RPs and men who received neoadjuvant therapies were excluded. MetS required any 3 of 5 components (obesity, diabetes or impaired fasting glucose, hypertension, low HDL-cholesterol, and high triglycerides). The outcomes were PC grade and stage on final RP pathology, and RP treatment failure, defined by a post-RP serum PSA 0.2, or use of salvage therapies such as radiation or androgen deprivation therapy (patients were censored if adjuvant radiation was given). Multivariable logistic regression, Kaplan-Meier analyses, and Cox-proportional Hazards models were used. RESULTS: Of final cohort of 1939 men, 439 (22.6%) had MetS. Median follow up was 36 months. On RP pathology, there were 1321 (68.1%) with Gleason 7 disease, 113 (5.8%) with Gleason 8-10 disease, and 663 (34.2%) men with extraprostatic disease ( pT3). Increasing number of MetS components was associated with a progressively increasing probability of higher grade (p-trend1⁄40.002) and higher stage (p-trend1⁄40.02) disease. In multivariable logistic regression analyses, MetS was associated with an increased risk of Gleason 8-10 disease ( 3 vs. 0 components: OR1⁄42.51, 95%CI1⁄41.33-4.71, p1⁄40.004) and extraprostatic disease ( 3 vs. 0 components: OR1⁄41.36, 95%CI1⁄41.02-1.81, p1⁄40.04). Decreased use of nerve-sparing in men with MetS was noted, suggestingmoreaggressive resection. Inunadjustedanalyses,MetSwas associated with an increased risk of need for salvage therapy (HR1⁄41.38, 95%CI1⁄41.04-1.83, p1⁄40.03). These associations were attenuated upon adjusting for stage and grade, suggesting these parameters are driving the associations. Overall probability of RP failure was similar between men with and without MetS (5-yr failure-free survival: 71.4% vs. 75.5%). CONCLUSIONS: MetS is associated with an increased risk of harbouring extraprostatic and high-grade disease on final RP pathology (with a biological gradient present), which appears to drive an increased risk of needing salvage therapy after RP. However, with more aggressive resection, similar failure-free outcomes can be achieved in wellselected patients.

Deciduous-dentition malocclusion predicts orthodontic treatment needs later: Findings from a population-based birth cohort study

Estimating orthodontic treatment need in the permanent dentition using information from the deciduous-dentition malocclusion may assist in defining the time for appropriate orthodontic intervention. Our objective was to investigate whether malocclusion in the deciduous teeth predicts orthodontic treatment need in the permanent dentition. Two oral health studies nested in a birth cohort were carried out at ages 6 (n = 359) and 12 (n = 339) years. Open bite, crossbite, and canine malocclusion were assessed in the deciduous teeth. Orthodontic treatment need was determined in the permanent dentition using the dental esthetic index. Prevalence ratios were estimated using 2 dental esthetic index cutoff points: highly desirable/mandatory orthodontic treatment and only mandatory orthodontic treatment. We tested all combinations of the deciduous malocclusion and the outcomes, controlling for confounders. Children with only open bite and those with concurrent open bite and canine malocclusion were more likely to have either highly desirable/mandatory orthodontic treatment or only mandatory orthodontic treatment needs by age 12. The combination of crossbite and open bite in the deciduous teeth was associated with the highest risk of need for mandatory orthodontic treatment. Malocclusion in the deciduous teeth is a risk factor for orthodontic treatment need in the permanent dentition. Children with malocclusion at a young age should be monitored regularly, and caregivers may be able to better prepare for possible orthodontic treatment.

Effects of inpatient geriatric interventions in a German geriatric hospital: Impact on ADL, mobility and cognitive status.

Given the demographic changes, the need for effective geriatric intervention is obvious. Geriatric care aims to maintain the highest possible level of independence and quality of life and to reduce the risk of need for care. This study investigated the benefits of geriatric care on functional performance, mobility and cognition. This study involved a retrospective analysis of clinical data from 646 patients. At hospital admission and discharge functional status was assessed using the Barthel index. Mobility was evaluated by means of the Tinetti test and cognition by the mini-mental state examination (MMSE). A follow-up was conducted on 112 patients 2-5 months after hospital discharge. Statistical analysis included t-tests including Cohen's d for effect size and multivariate regression analysis. The mean age of the study population was 81.1 ± 7.1 years including 439 women (68%) and 207 men (32%). There were significant average improvements for activities of daily living (ADL), mobility and cognition comparing discharge and admission scores. For functional and mobility status, effect sizes were medium to high. Regression analyses showed that ADL improvement was predicted by functional, mobile and cognitive status at admission. Follow-up analyses revealed a high percentage of former patients still living at home and an overall maintenance of ADL levels. Geriatric patients seem to experience long-term improvements during geriatric treatment, which appears to fulfill its aim of recovering independence. For a better understanding of relevant factors for the recreation of geriatric patients, further research is needed, e.g. with respect to the impact of the nutritional status.

Reverse shoulder arthroplasty. Part 2: Systematic review of reoperations, revisions, problems, and complications.

Purpose:Many factors influence the reoperations, revisions, problems, and complications of reverse shoulder arthroplasty (RSA). The purpose of this study was to compare those depending on the surgical approach, type of prosthesis, and indication for surgery through a comprehensive, systematic review.Materials and Methods:A literature search was conducted (1985 to June 2012) using PubMed, CINAHL, EBSCO–SPORTDiscus, and Cochrane Central Register of Controlled Trials. Levels I–IV evidence, in-vivo human studies (written in English with minimum of 2 years of follow-up and sample size of 10 patients) reporting reoperations, revisions, problems, and complications after RSA were included. The data obtained were analyzed depending on the surgical approach, type of prosthesis (with medialized or lateralized center of rotation), or indication for surgery.Results:About 37 studies were included involving 3150 patients (mean [SD] percentage of females, age, and follow-up of 72% [13], 71.6 years [3.8], and 45 months [20], respectively). Use of deltopectoral approach and lateralized prostheses had significantly higher risk of need for revision surgery (P = 0.008) and glenoid loosening (P = 0.01), but lower risk of scapular notch (P < 0.001), compared with medialized prostheses with same approach. RSA for revision of anatomic prosthesis demonstrated higher risk of reoperation (P < 0.001), revision (P < 0.001), hematoma (P = 0.001), instability (P < 0.001), and infection (P = 0.02) compared with most of the other indications.Conclusions:Lateralized prostheses had significantly higher glenoid loosening and need for revision surgery, but a significantly lower rate of scapular notching compared to medialized prostheses. The risk of reoperations, revisions, problems, and complications after RSA was increased in revision cases compared with other indications.Level of Evidence:Level IV.

International variation in policies and practices related to informed consent in acute cardiovascular research: Results from a 44 country survey

BackgroundResearch in an emergency setting such as that with an acute cardiovascular event is challenging because the window of opportunity to treat may be short and may preclude time to obtain informed consent from the patient or their representative. Some perceive that requiring informed consent in emergency situations has limited improvements in care. Vulnerable populations including minorities or residents of low-income countries are at greatest risk of need for resuscitation. Lack of enrollment of such patients would increase uncertainties in treatment benefit or harm in those at greater risk of need for resuscitation. We sought to assess international variation in policies and procedures related to exception from informed consent (EFIC) or deferred consent for emergency research. MethodsA brief survey instrument was developed and modified by consensus among the investigators. Included were multiple choice and open-ended responses. The survey included an illustrative example of a hypothetical randomized study. Elicited information included the possibility of conducting such a study in the respondent's country, as well as approvals required to conduct the study. The population of interest was emergency physicians or other practitioners of acute cardiovascular event research. ResultsUsable responses were obtained from 44 countries (76% of surveyed). Community opposition to EFIC was noted in 6 (14%) countries. Emergency Medical Services (EMS) providers in 8 (20%) countries were judged unable or unwilling to participate. A majority of countries (36, 82%) required approval by a Research Ethics Committee or similar. Government approval was required in 25 (57%) countries. ConclusionThere is international variation in practices and polices related to consent for emergency research. There is an ongoing need to converge regulations based on the usefulness of multinational emergency research to benefit both affluent and disadvantaged populations.

One Year Survey and Implications of an Hemophilic Computerized Alert System in an University Clinic

Hemophilia patients are confronted to several issues when being treated in urgent and non-urgent situations. Immediate factor substitution can be life or limb preserving. We installed a computerized haemophilia alert system so as to be informed when one of our patients is treated in another department. Patients admitted to the hospital with a bleeding disorder trigger an alert in the hematology department as well as in the department where the patient is actually located.We defined alerts as being false positive when an alert was triggered by the admission of a patient where interaction with the hematologist wasn’t necessary and as being false negative when a triggered alert for a patient with a bleeding problem or high bleeding risk in need for interaction with the hematologist didn’t reach the hematologist.We follow 307 patients in our hemophilia consultation. From 01.01.2011 through 31.12.2011, admission of 128 hemophilic patients to our hospital triggered an alert on 232 occasions. Forty-three percent of presenting patients suffered from von Willebrand’s disease type 1, 11.5% from thrombopathies, 9% from severe hemophilia A, 9% from mild hemophilia A, 9% were hemophilia A carrier and 8% had factor XI deficiency.Out of 232 alerts in 2011, most were identified as false positive. Eighteen alerts were not followed by a contact between the treating physician and the hematology service (8%). Sixteen alerts (7%) were followed by the establishment of a substitution protocol for an intervention that wasn’t planned before, preventing, in consequence, bleeding complications thereafter. Two alerts (1%) were triggered by 2 patients, 1 suffering from von Willebrand’s disease type 1, the other from von Willebrand’s disease type 2B, with massive bleeding, where intervention by the hematologist was potentially life- or limbsaving, even if one of the alerts was only discovered the following morning.In conclusion, follow up of 232 alerts during 1 year permitted to intervene possibly life- or limbsaving in only 2 cases. In 16 cases a protocol of substitution could be established that wouldn’t have been made without the alert system. All other cases of alerts were followed up without consequences and thus increased work charge unnecessarily. We continue to follow up our patients with the alert system described. DisclosuresNo relevant conflicts of interest to declare.

Comparison of the Effect of Surfactant Administration During Nasal Continuous Positive Airway Pressure with that of Nasal Continuous Positive Airway Pressure Alone on Complications of Respiratory Distress Syndrome: A Randomized Controlled Study

Studies on early surfactant administration during nasal continuous positive airway pressure (NCPAP) [intubate-surfactant-extubate (INSURE)] have used continuous positive airway pressure and INSURE in the first hours after birth, but in many centers patients are transported from far away hospitals, reaching the center at a later time. The aim of this study was to compare the effect of INSURE with only NCPAP in the management of respiratory distress syndrome (RDS) in an outborn hospital. This study was a controlled randomized clinical trial on 60 neonates who were transported to the neonatal intensive care unit of Boo-Ali Sina Hospital. Neonates born at 27(0)/7 to 34(6)/7 weeks of gestation, aged ≤12 hours, and diagnosed with RDS were placed on NCPAP and then randomly assigned to INSURE or NCPAP alone. The primary outcome was the need for intubation and mechanical ventilation on the basis of the criteria defined by us, and the secondary outcomes were neonatal mortality and other complications of RDS. In 13 months, 60 eligible neonates were enrolled. Our participants in INSURE group received surfactant at the mean age of 5.1 hours. The relative risk of need for mechanical ventilation was 0.55 (95% confidence interval: 0.15-1.9, p=0.53), and the rate of mortality or other complications of RDS was statistically similar between the two groups. After the first few hours of life (mean age of 5.1 hours), the rate of mortality and chronic lung disease and the need for mechanical ventilation were not statistically different between patients receiving INSURE and those in receipt of NCPAP alone.

Factors Associated With Perineal Lacerations Requiring Suture in Vaginal Births Without Episiotomy

INTRODUCTION: With the adoption of a policy of restrictive episiotomy, the interest in studying and preventing spontaneous lacerations in childbirth has increased. The present study was conducted to determine the main risk factors for perineal lacerations requiring suture in vaginal deliveries without episiotomy. METHODS: We conducted a prospective cohort study including 400 vaginal deliveries assisted in a public hospital in Brazil. During the second stage of labor, maneuvers as such directed pushing, fundal pressure, and Valsalva maneuver were avoided. A policy of no episiotomy was followed with strategies for perineal protection that included warm compresses and intrapartum perineal massage. We calculated the relative risk and its 95% confidence interval (95% CI). Multivariate analysis was performed to determine the adjusted risk of need for suture. RESULTS: We analyzed 400 women who had vaginal deliveries with no episiotomy and 6% of instrumental deliveries. The rate of perineal lacerations in primiparous (210) was 56.7% and in multiparous (190) 30%. Suture was necessary in 23% of women (30% of primiparous and 15.3% of multiparous). In multivariate analysis, the factors that remained associated with increased risk of need for suture were primiparity (adjusted risk 1.81, 95% CI 1.25–2.89) and instrumental delivery (adjusted risk 3.78, 95% CI 1.21–18.66). CONCLUSION: There was a reduced need for suture in vaginal deliveries with the application of a protocol of perineal protection and no episiotomy. Primiparity and instrumental delivery were associated with increased risk of need for suture.

Using a ‘no drain’ policy in 342 laparoscopic hepatectomies: which factors predict failure?

ObjectivesThe aim of this study was to identify factors that predict the failure of a ‘no drain’ policy in laparoscopic hepatectomy. MethodsSurgical outcomes in 342 consecutive patients undergoing laparoscopic hepatectomy were reviewed. Drains were placed only for the following predefined criteria: (i) intraoperative bile leak; (ii) bilioenteric anastomosis, and (iii) increased risk for postoperative bleeding (‘no drain’ policy). Factors leading to need for postoperative drainage or reoperation were evaluated. ResultsDrains were placed in 44 patients (drainage group). Postoperatively, additional procedures were required in five (11.4%) patients in the drainage group and in 18 (6.0%) patients in the no-drainage group. Multivariate analysis suggested that blood loss of >400ml [odds ratio (OR) 4.50, 95% confidence interval (CI) 1.41–14.2; P = 0.010] and preoperative chemotherapy (OR = 2.24, 95% CI 0.82–6.48; P = 0.120) may increase the risk for need for postoperative procedures when intraoperative prophylactic drainage is not used. ConclusionsProphylactic drainage during liver resection should be considered not only in the presence of uncontrollable bile leak or concern for postoperative bleeding risk, but also in patients who have undergone neoadjuvant chemotherapy and those in whom intraoperative blood loss is >400ml. Otherwise, a ‘no drain’ policy is safe and would enhance the advantages of minimally invasive liver surgery.

Faecal analysis and plasma complement factor 3c levels at admission for an acute attack of ulcerative colitis are predictive of the need for colectomy

Ulcerative colitis is a chronic inflammation limited to the large bowel. Early identification of reliable predictive markers addressing the risk of need for colectomy in a severe attack of ulcerative colitis is of crucial importance. To evaluate faecal characteristics and peripheral blood tests as predictive markers for subsequent risk of colectomy in a severe attack of ulcerative colitis. This was an observational study. Samples were collected in a cohort of 18 patients with a severe attack of ulcerative colitis. A panel of selected variables was evaluated (faecal characteristics, peripheral blood samples including complement factor 3c, circulating cytokines and antisecretory factor) for ability to predict colectomy. The patients were observed for up to 58 months (median 37.5, range 0.5-58 months) and allocated to one of two groups depending on the clinical outcome on the basis of the need for colectomy. Seven patients underwent colectomy. The present study showed a positive correlation between increased bowel movements (P=0.01), faecal weight/bowel movement (P=0.03) and complement factor 3c levels (P=0.01) and a need for later colectomy. None of the other laboratory markers investigated were shown to be predictive of risk for later colectomy. Early faecal analysis and measurement of complement factor 3c may be useful as predictive markers of the need for colectomy related to a severe attack of ulcerative colitis.

Evaluation of the Increased Use of Partial Resection of Large Vestibular Schwanommas

To determine whether partial tumor removal in large vestibular schwannoma improves facial nerve outcomes while maintaining a low risk of tumor regrowth/recurrence. Retrospective chart review and prospective database. Tertiary neurotologic referral center. Four hundred patients with a vestibular schwannoma of 2.5 cm or greater in maximum diameter undergoing translabyrinthine microsurgical resection from 2001 to 2011. There were 325 gross total resections (GTR), 44 near total resections (NTR), and 31 subtotal resections (STR), with an overall mean tumor size of 3.2 cm (standard deviation, 0.7). Translabyrinthine surgical tumor resection. House-Brackmann (H-B) facial nerve grade postoperatively and at 1 year, tumor regrowth/recurrence (≥2 mm), additional treatment, and complications. Higher rates of H-B facial nerve Grades I and II were achieved at both the postoperative and 1-year follow-ups in the NTR (78%, 97%) and STR (71%, 96%) groups compared with GTR (53%, 77%) (p ≤ 0.001). Eye treatment, medical or surgical, was required more often in GTR (28.0%) than NTR and STR (8% and 21%, respectively, p ≤ 0.04), with no other differences in complications. The NTR and STR groups had a significantly higher rate of regrowth than GTR resection (21% and 22% versus 3%) (p ≤ 0.001) at average follow-up times of 3.7, 3.7, and 5.1 years, respectively, and need for further treatment occurred at a higher rate, although infrequently, in NTR and STR (2% and 10% versus 0%) (p ≤ 0.001). Near total and subtotal removal in large tumors are viable treatment options to maintain facial nerve function. During the follow-up period examined in this study, there was a low risk of need for further treatment. Longer-term follow-up is needed to better assess the need for retreatment in patients treated with NTR and STR.

Added value of umbilical vein flow as a predictor of perinatal outcome in term small‐for‐gestational‐age fetuses

To compare umbilical vein (UV) flow with standard Doppler parameters in prediction of adverse perinatal outcome in late-onset small-for-gestational age (SGA) fetuses. Umbilical, uterine and middle cerebral arteries, and UV blood flow were evaluated by Doppler before delivery in a cohort of 193 term SGA fetuses. The value of the Doppler parameters to predict risk of emergency delivery for non-reassuring fetal status and neonatal metabolic acidosis was analyzed. Fifty-three (27%) fetuses had non-reassuring fetal status requiring emergency delivery, whereas 21 (11%) newborns developed neonatal metabolic acidosis. Multivariable analysis showed that significant contributions to prediction of emergency delivery for non-reassuring fetal status and neonatal metabolic acidosis were provided by middle cerebral artery (MCA) pulsatility index (PI) and UV blood flow normalized by fetal weight. Decision tree analysis defined three groups with increasing risk of need for emergency delivery for non-reassuring fetal status: MCA-PI > 1.46 (risk 15.6%); MCA-PI ≤ 1.46 and UV blood flow > 68 mL/min/kg (risk 25%); and MCA-PI ≤ 1.46 and UV flow ≤ 68 mL/min/kg (risk 53.1%); and two groups with different risks of neonatal metabolic acidosis: UV flow > 68 mL/min/kg or UV flow ≤ 68 mL/min/kg and MCA-PI > 1.23 (risk ≤ 10%); and UV flow ≤ 68 mL/min/kg and MCA-PI ≤ 1.23 (risk 39.1%). The evaluation of UV blood flow with spectral brain Doppler allows better identification of SGA fetuses with late-onset intrauterine growth restriction at risk of adverse perinatal outcome.

Incessant slow bundle branch reentrant ventricular tachycardia in a young patient with left ventricular noncompaction

A 15-year-old girl was admitted to the cardiology outpatient clinic due to mild palpitations and documented incessant slow ventricular tachycardia (VT) with left bundle branch block (LBBB) pattern. The baseline electrocardiogram revealed first-degree atrioventricular block and intraventricular conduction defect. Transthoracic echocardiography showed prominent trabeculae and intertrabecular recesses suggesting left ventricular noncompaction (LVNC), which was confirmed by cardiac magnetic resonance imaging. During electrophysiological study, a sustained bundle branch reentrant VT with LBBB pattern and cycle length of 480 ms, similar to the clinical tachycardia, was easily and reproducibly inducible. As there was considerable risk of need for chronic ventricular pacing following right bundle ablation, no ablation was attempted and a cardioverter-defibrillator was implanted. To the best of our knowledge, no case reports of BBR-VT as the first manifestation of LVNC have been published. Furthermore, this is an extremely rare presentation of BBR-VT, which is usually a highly malignant arrhythmia.

Incessant slow bundle branch reentrant ventricular tachycardia in a young patient with left ventricular noncompaction

A 15-year-old girl was admitted to the cardiology outpatient clinic due to mild palpitations and documented incessant slow ventricular tachycardia (VT) with left bundle branch block (LBBB) pattern. The baseline electrocardiogram revealed first-degree atrioventricular block and intraventricular conduction defect. Transthoracic echocardiography showed prominent trabeculae and intertrabecular recesses suggesting left ventricular noncompaction (LVNC), which was confirmed by cardiac magnetic resonance imaging. During electrophysiological study, a sustained bundle branch reentrant VT with LBBB pattern and cycle length of 480 ms, similar to the clinical tachycardia, was easily and reproducibly inducible. As there was considerable risk of need for chronic ventricular pacing following right bundle ablation, no ablation was attempted and a cardioverter-defibrillator was implanted. To the best of our knowledge, no case reports of BBR-VT as the first manifestation of LVNC have been published. Furthermore, this is an extremely rare presentation of BBR-VT, which is usually a highly malignant arrhythmia.

Long term outcomes of lymphatic sparing laparoscopic varicocelectomy

ObjectiveTo assess the long-term occurrence of hydroceles and varicocele recurrence in patients receiving lymphatic sparing laparoscopic varicocelectomy (LSLV) compared to those receiving plain laparoscopic varicocelectomy (PLV), and also to assess the growth of testicular volume postoperatively. MethodsWe employed a standard three-trocar configuration. The spermatic vessels were identified in the retroperitoneum above the internal inguinal ring. Lymphatics were dissected free from the spermatic artery and veins based on laparoscopic appearance. The spermatic artery and veins were divided between plastic locking clips. We performed a retrospective chart review of all pediatric patients who underwent laparoscopic varicocelectomy between June 2003 and January 2009. ResultsOf a total of 97 patients, 67 underwent LSLV with mean follow-up of 45.8 ± 20.7 months and 30 underwent PLV with mean follow-up of 40.8 ± 25.3 months (p = 15). There was a 4.5% hydrocele rate in the LSLV group compared to 43.3% in the PLV group. Of the patients who underwent a PLV and subsequently developed a hydrocele, 31% (n = 4) required a hydrocelectomy, vs none of those who developed a hydrocele after LSLV. Varicocele rate was 6% in the LSLV group vs 3.3% in the PLV group. However, when the artery was not preserved, the probability of recurrence in the LSLV group was 1.3%. Time to hydrocele formation was 16 months in the LSLV group vs 37 months in the PLV group. There was catch-up testicular growth in both groups. ConclusionsThere appears to be increased risk of need for a hydrocelectomy after a PLV as compared to LSLV. Performing a lymphatic sparing, non-artery preserving, laparoscopic varicocelectomy has success and complication rates comparable with those of subinguinal microsurgical varicocelectomy. There appears to be excellent catch-up testicular growth with either laparoscopic varicocelectomy technique.

Influence of Age on Outcome in Treatment of Pulmonary Arterial Hypertension

Background: The advent of specific oral therapies for pulmonary arterial hypertension has allowed for meaningful improvement in the outcome of this condition. There is limited long term follow up data with regard to the influence of age on outcome. Aims: We sought to review the long term outcome of treatment with specific PAH therapies (endothelin receptor antagonists and phosphodiesterase inhibitors) in a cohort of patients followed at a tertiary centre with particular focus on the influence of age on long term clinical outcome. Methods: We reviewed the clinical outcome data in a cohort of patients treated with PAH specific therapies at the John Hunter Hospital since 2004. We evaluated the influence of age on outcome in terms of serial change in 6min walk test distance (6MWT) and the need for hospitalisation, death and transplantation. Results: A total of 119 patients (88% female; mean age 65± 12 years) with a baseline 6min walk test distance of 304m have been treated since 2004 with 52% having PAH complicating connective tissue disease. Age was independently associated with a greater risk of need for hospitalisation, transplant or death. Furthermore, agewas associated with a greater rate of decline in 6MWT over time. Conclusions: In a large cohort of patients treated with PAH specific therapies, age independently predicted a greater rate of deterioration in 6MWT distance and a greater need for hospitalisation and transplantation as well as an increased risk of death. This likely reflects concomitant co-morbidity limiting response to treatment.

Inhibition of Apoptosis Signal-regulating Kinase 1 (ASK1) Attenuates Uremic Toxins’ Detrimental Effects on Cardiac and Renal Cells: Therapeutic Potential of ASK1 Inhibitors in Cardiorenal Syndrome

Background: The advent of specific oral therapies for pulmonary arterial hypertension has allowed for meaningful improvement in the outcome of this condition. There is limited long term follow up data with regard to the influence of age on outcome. Aims: We sought to review the long term outcome of treatment with specific PAH therapies (endothelin receptor antagonists and phosphodiesterase inhibitors) in a cohort of patients followed at a tertiary centre with particular focus on the influence of age on long term clinical outcome. Methods: We reviewed the clinical outcome data in a cohort of patients treated with PAH specific therapies at the John Hunter Hospital since 2004. We evaluated the influence of age on outcome in terms of serial change in 6min walk test distance (6MWT) and the need for hospitalisation, death and transplantation. Results: A total of 119 patients (88% female; mean age 65± 12 years) with a baseline 6min walk test distance of 304m have been treated since 2004 with 52% having PAH complicating connective tissue disease. Age was independently associated with a greater risk of need for hospitalisation, transplant or death. Furthermore, agewas associated with a greater rate of decline in 6MWT over time. Conclusions: In a large cohort of patients treated with PAH specific therapies, age independently predicted a greater rate of deterioration in 6MWT distance and a greater need for hospitalisation and transplantation as well as an increased risk of death. This likely reflects concomitant co-morbidity limiting response to treatment.

Strictureplasty in Selected Crohn’s Disease Patients Results in Acceptable Long-term Outcome

Strictureplasty is an alternative to resection in patients with Crohn's disease. The objective of this study was to evaluate the long-term results of patients who have undergone strictureplasty. This is a retrospective cohort study. This study was conducted at a tertiary referral center, Mount Sinai Hospital, Toronto, Ontario, Canada. All patients who had a strictureplasty of the small bowel between 1985 and 2010 were identified from a prospective database. The main outcomes were short-term complications, need for further surgery, and surgery-free survival. Multivariate analysis was performed to determine factors affecting the need for further surgery. Quality of life was measured by use of the short version of the Inflammatory Bowel Disease Questionnaire. Ninety-four patients (42 women; age at first strictureplasty, 33.4 ± 9.7 years) underwent 119 operations (range per patient, 1-4). The number of strictureplasties was 278 (range, 1-11), including 9 in the duodenum and 269 in the jejunum-ileum. The most common type of procedure was the Heineke-Mickulicz (258, 92.8%). Median follow-up of the patients was 94 months (interquartile range, 27-165 months). The surgery-free survival at 5 and 10 years was 70.7% (95% CI 59.8, 81.7) and 26.6% (95% CI 13.6, 39.6). In multivariate analysis, only age at the time of first strictureplasty was associated with the need for further surgery. Fifty-seven (64.8%) patients returned the questionnaire. The average score was 5.2 ± 1.2 (range, 2.2-7.0) with no significant differences between patients with or without previous surgery (p = 0.22), with or without simultaneous resection (p = 0.71) or with or without further surgery (p = 0.11). This study was limited by its sample size and retrospective design. Strictureplasty is a safe procedure with acceptable long-term outcomes. The risk of needing further surgery is high, which reflects the complexity of this disease. Younger age is associated with a higher risk of need for further surgery. However, most patients have a satisfactory quality of life.