Postthrombotic or non-postthrombotic severe venous insufficiency: Impact of removal of superficial venous reflux with or without subcutaneous fasciotomy

BackgroundSevere chronic venous insufficiency is often associated with therapy-resistant or recurrent venous leg ulcers, either as a result of deep vein thrombosis (DVT)- (postthrombotic syndrome [PTS]) or superficial venous insufficiency (SVI). Frequently present dermatoliposclerosis affects the skin as well as the subcutaneous and subfascial structures, which may impact tissue pressures and compromise skin perfusion. This study was undertaken to measure tissue pressures in PTS and SVI limbs and to evaluate the impact of removal of superficial venous reflux with or without concomitant subcutaneous fasciotomy.MaterialIn eight patients with recurrent, therapy-resistant venous leg ulcers, due to PTS (11 limbs, 12 ulcers) and 14 patients with severe SVI (14 limbs, 14 ulcers), subcutaneous fasciotomy was performed in addition to removal of superficial reflux. They were compared with eight patients with PTS (11 limbs, 11 ulcers) and 10 patients with SVI (13 limbs, 13 ulcers) who did not have fasciotomy in addition to removal of their superficial venous reflux. Intramuscular (i.m.) and subcutaneous (s.c.) tissue pressures and transcutaneous oxygen tension (TcPO2) were measured prior to, immediately after, and 3 months following the surgical intervention. Healing of ulcer (spontaneous or by skin grafting) at 3 months was also observed.ResultsThere were no statistical differences between the groups regarding gender and age distribution or ulcer age at the time of surgery. All patients had in addition to surgery compression stockings class II (30 mm Hg). The i.m. tissue pressure was higher in patients with PTS compared with SVI patients, while s.c. tissue pressure and TcPO2 did not differ between the groups. When fasciotomy was performed, i.m. and s.c. tissue pressures decreased and TcPO2 increased significantly. Without fasciotomy, only s.c. tissue pressure decreased first at 3 months postoperatively. In the SVI-group, i.m tissue pressure was significantly decreased at 3 months in the group without fasciotomy.ConclusionsPatients with severe chronic venous insufficiency with therapy-resistant or recurrent ulcer disease due to deep and superficial insufficiency have higher i.m. tissue pressures than patients with only superficial venous reflux, even though both groups have higher i.m. and s.c. tissue pressures compared with normal values. Eradication of all superficial reflux lowers s.c. tissue pressure, while additional fasciotomy lowers both i.m. and s.c. tissue pressures and increases TcPO2, which seems to promote ulcer healing

Long-term outcome after surgical intervention and interventional procedures for the management of Takayasu’s arteritis in children

ObjectiveThere is little information available on the results of reconstructive arterial surgery for Takayasu’s arteritis in children. This study evaluates midterm to long-term outcome after surgical, as well as interventional, procedures.MethodsFrom 1984 through 2004, 10 children (5 boys and 5 girls; age, 12.7 ± 2.6 years) with Takayasu’s arteritis were referred to our center. Baseline cardiovascular assessment included contrast angiography (n = 4), magnetic resonance imaging–angiography (n = 3), and combined contrast angiography plus magnetic resonance imaging–angiography (n = 3). Two patients had disease confined to the thoracic aorta, 4 had disease confined to the abdominal aorta, and 4 had combined thoracoabdominal aortic disease. Steno-occlusive lesions were predominant in 92% of cases. Seven patients were maintained on steroid therapy throughout the follow-up period. Eight children underwent complex surgical procedures, 1 patient had balloon dilatation of the renal and mesenteric arteries, and 1 patient had combined vascular surgery with percutaneous transluminal angioplasty. Overall, 24 grafts (polytetrafluoroethylene, Dacron grafts, and cryopreserved homografts) were implanted in various locations.ResultsThere were no perioperative deaths. Arterial hypertension regressed in all patients, and cardiac function normalized in all 4 patients with dilative cardiomyopathy. Over a 20-year period, 1 patient presented with sudden death and 2 showed nonfatal disease progression, one of whom required surgical reintervention. The occlusion rate was higher in Dacron grafts.ConclusionsOur study shows that despite the extent and severity of vascular lesions, children with Takayasu’s arteritis could benefit from reconstructive surgery, with low mortality, morbidity, and satisfactory long-term results

Intra-aortic balloon counterpulsation in US and non-US centres: results of the Benchmark® Registry

Aims To examine differences in patient characteristics and outcomes in 19 636 patients enrolled in the USA and 3027 patients enrolled in other countries undergoing intra-aortic balloon pump (IABP) counterpulsation. Methods and results Indications for IABP use; a larger percentage of US patients were identified as ‘early support and stabilization for angiography or angioplasty' (21.1% US vs 11.8% non-US), and ‘pre-operative support for high-risk CABG' (15.9% vs 6.6%). A smaller percentage of US patients vs non-US patients were identified as ‘weaning from cardiopulmonary bypass' (14.3% vs 28.2%), and ‘refractory ventricular failure' (6.2% vs 9.8%). One out of five patients in both groups was listed as ‘cardiogenic shock' (18.9% US vs 20.2% non-US). All cause, risk-adjusted, in-hospital mortality (20.1% vs 28.7%; P<0.001), and mortality with IABP in place (10.8% vs 18.0%; P<0.001) were lower at US vs non-US sites. In both US and non-US institutions, IABP associated complication rates, such as IABP-related mortality (0.05% vs 0.07%), major limb ischaemia (0.9% vs 0.8%), and severe bleeding (0.9% vs 0.8%), were low. Conclusions IABP counterpulsation is deployed at an earlier clinical stage in US patients. Mortality rates are higher for non-US patients, particularly for patients with non-surgery cardiac interventions, even after adjusting for risk factors. Complication rates were low. Physicians should therefore not be reluctant to use IABP in high-risk patients undergoing cardiac procedure

Linking world bank development indicators and outcomes of congenital heart surgery in low-income and middle-income countries: Retrospective analysis of quality improvement data

Objective Many low-income and middle-income countries (LMICs) struggle to provide the health services investment required for life-saving congenital heart disease (CHD) surgery. We explored associations between risk-adjusted CHD surgical mortality from 17 LMICs and global development indices to identify patterns that might inform investment strategies. Design Retrospective analysis: country-specific standardised mortality ratios were graphed against global development indices reflective of wealth and healthcare investment. Spearman correlation coefficients were calculated. Setting and participants The International Quality Improvement Collaborative (IQIC) keeps a volunteer registry of outcomes of CHD surgery programmes in low-resource settings. Inclusion in the IQIC is voluntary enrolment by hospital sites. Patients in the registry underwent congenital heart surgery. Sites that actively participated in IQIC in 2013, 2014 or 2015 and passed a 10% data audit were asked for permission to share data for this study. 31 sites in 17 countries are included. Outcome measures In-hospital mortality: standardised mortality ratios were calculated. Risk adjustment for in-hospital mortality uses the Risk Adjustment for Congenital Heart Surgery method, a model including surgical risk category, age group, prematurity, presence of a major non-cardiac structural anomaly and multiple congenital heart procedures during admission. Results The IQIC registry includes 24 917 congenital heart surgeries performed in children less than 18 years of age. The overall in-hospital mortality rate was 5.0%. Country-level congenital heart surgery standardised mortality ratios were negatively correlated with gross domestic product (GDP) per capita (r=-0.34, p=0.18), and health expenditure per capita (r=-0.23, p=0.37) and positively correlated with under-five mortality (r=0.60, p=0.01) and undernourishment (r=0.39, p=0.17). Countries with lower development had wider variation in mortality. GDP per capita is a driver of the association between some other measures and mortality. Conclusions Results display a moderate relationship among wealth, healthcare investment and malnutrition, with significant variation, including superior results in many countries with low GDP per capita. These findings provide context and optimism for investment in CHD procedures in low-resource settings. © 2019 BMJ Publishing Group Limited

The Cebpd (C/EBPδ) Gene Is Induced by Luteinizing Hormones in Ovarian Theca and Interstitial Cells But Is Not Essential for Mouse Ovary Function

The CCAAT/enhancer binding protein (CEBP) family of transcription factors includes five genes. In the ovary, both Cebpa and Cebpb are essential for granulosa cell function. In this study we have explored the role of the Cebpd gene in ovarian physiology by expression and functional studies. Here we report that Cebpd (C/EBPδ) is expressed in the mouse ovary in a highly restricted temporal and spatial pattern. In response to luteinizing hormone (LH/hCG), CEBPD expression is transiently induced in interstitial cells and in theca cells of follicles from the primary to pre-ovulatory stage, and overlaps in part with expression of the alpha-smooth muscle actin protein. Efficient down-regulation of CEBPD was dependent on a functional Cebpb gene. Proliferating human theca cells in culture also express Cebpd. Cells from patients with polycystic ovarian syndrome (PCOS) exhibited higher Cebpd expression levels. However, deletion of Cebpd in mice had no overt effect on ovarian physiology and reproductive function. Very little is known at present about the molecular mechanisms underlying theca/interstitial cell functions. The expression pattern of CEBPD reported here identifies a novel functional unit of mouse theca cells of primary through tertiary follicles responding to LH/hCG together with a subset of interstitial cells. This acute stimulation of CEBPD expression may be exploited to further characterize the hormonal regulation and function of theca and interstitial cells

An updated analysis of eps'/eps in the standard model with hadronic matrix elements from the chiral quark model

We discuss the theoretical and experimental status of the CP violating ratio eps'/eps. We revise our 1997 standard-model estimate-based on hadronic matrix elements computed in the chiral quark model up to O(p^4) in the chiral expansion-by including an improved statistical analysis of the uncertainties and updated determination of the Cabibbo-Kobayashi-Maskawa elements and other short-distance parameters. Using normal distributions for the experimental input data we find Re eps'/eps = (2.2 \pm 0.8) x 10^{-3}, whereas a flat scanning gives 0.9 x 10^{-3} < Re eps'/eps < 4.8 x 10^{-3}. Both results are in agreement with the current experimental data. The key element in our estimate is, as before, the fit of the Delta I=1/2 rule, which allows us to absorb most of the theoretical uncertainties in the determination of the model-dependent parameters in the hadronic matrix elements. Our semi-phenomenological approach leads to numerical stability against variations of the renormalization scale and scheme dependence of the short- and long-distance components. The same dynamical mechanism at work in the selection rule also explains the larger value obtained for \ratio with respect to other estimates. A coherent picture of K -> pi pi decays is thus provided.Comment: 15 pages, 11 figures, RevTeX, discussion updated, refs adde

Early results of coronary artery bypass grafting with coronary endarterectomy for severe coronary artery disease

<p>Abstract</p> <p>Background</p> <p>Despite the existence of controversial debates on the efficiency of coronary endarterectomy (CE), it is still used as an adjunct to coronary artery bypass grafting (CABG). This is particularly true in patients with endstage coronary artery disease. Given the improvements in cardiac surgery and postoperative care, as well as the rising number of elderly patient with numerous co-morbidities, re-evaluating the pros and cons of this technique is needed.</p> <p>Methods</p> <p>Patient demographic information, operative details and outcome data of 104 patients with diffuse calcified coronary artery disease were retrospectively analyzed with respect to functional capacity (NYHA), angina pectoris (CCS) and mortality. Actuarial survival was reported using a Kaplan-Meyer analysis.</p> <p>Results</p> <p>Between August 2001 and March 2005, 104 patients underwent coronary artery bypass grafting (CABG) with adjunctive coronary endarterectomy (CE) in the Department of Thoracic-, Cardiac- and Vascular Surgery, University of Goettingen. Four patients were lost during follow-up. Data were gained from 88 male and 12 female patients; mean age was 65.5 ± 9 years. A total of 396 vessels were bypassed (4 ± 0.9 vessels per patient). In 98% left internal thoracic artery (LITA) was used as arterial bypass graft and a total of 114 vessels were endarterectomized. CE was performed on right coronary artery (RCA) (n = 55), on left anterior descending artery (LAD) (n = 52) and circumflex artery (RCX) (n = 7). Ninety-five patients suffered from 3-vessel-disease, 3 from 2-vessel- and 2 from 1-vessel-disease. Closed technique was used in 18%, open technique in 79% and in 3% a combination of both. The most frequent endarterectomized localization was right coronary artery (RCA = 55%). Despite the severity of endstage atherosclerosis, hospital mortality was only 5% (n = 5). During follow-up (24.5 ± 13.4 months), which is 96% complete (4 patients were lost caused by unknown address) 8 patients died (cardiac failure: 3; stroke: 1; cancer: 1; unknown reasons: 3). NYHA-classification significantly improved after CABG with CE from 2.2 ± 0.9 preoperative to 1.7 ± 0.9 postoperative. CCS also changed from 2.4 ± 1.0 to 1.5 ± 0.8</p> <p>Conclusion</p> <p>Early results of coronary endarterectomy are acceptable with respect to mortality, NYHA & CCS. This technique offers a valuable surgical option for patients with endstage coronary artery disease in whom complete revascularization otherwise can not be obtained. Careful patient selection will be necessary to assure the long-term benefit of this procedure.</p

Estimating epsilon'/epsilon. A Review

The real part of epsilon'/epsilon measures direct CP violation in the decays of the neutral kaons in two pions. It is a fundamental quantity which has justly attracted a great deal of theoretical as well as experimental work. Its determination may answer the question of whether CP violation is present only in the mass matrix of neutral kaons (the superweak scenario) or also at work directly in the decays. After a brief historical summary, we discuss the present and expected experimental sensitivities. In the light of these, we come to the problem of estimating epsilon'/epsilon in the standard model. We review the present (circa 1998) status of the theoretical predictions of epsilon'/epsilon. The short-distance part of the computation is now known to the next-to-leading order in QCD and QED and therefore well under control. On the other hand, the evaluation of the hadronic matrix element of the relevant operators is where most of the theoretical uncertainty still resides. We analyze the results of the currently most developed calculations. The values of the B_i parameters in the various approaches are discussed, together with the allowed range of the relevant combination of the Cabibbo-Kobayashi-Maskawa entries Im V_{td}V^*_{ts}. We conclude by summarizing and comparing all up-to-date predictions of epsilon'/epsilon. Because of the intrinsic uncertainties of the long-distance computations, values ranging from 10^{-4} to a few times 10^{-3} can be accounted for in the standard model. Since this range covers most of the present experimental uncertainty, it is unlikely that new physics effects can be disentangled from the standard model prediction. For updates on the review and additional material see http://www.he.sissa.it/review/.Comment: 42 pages, 13 figures. To appear in Reviews of Modern Physic

The relationship between increased body mass index and primary venous disease severity and concomitant deep primary venous reflux

The role of overweight in chronic venous disease is still controversial. The aim of this study was to evaluate the impact of overweight and obesity in chronic primary venous disease in relation to disease severity, using the CEAP and the Venous Clinical Severity Score (VCSS) as well as well as body weight on the presence of concomitant primary deep venous reflux