Sleep-induced amaurosis fugax

Amaurosis fugax is a manifestation of retinal ischemia, commonly described in the setting of carotid atherosclerotic disease. Thromboembolic, and less frequently, hemodynamic mechanisms have been described as responsible for producing negative symptoms of transient monocular vision loss during periods of wakefulness. We report an unusual presentation in which the patient became symptomatic during sleep. Initially, photopsias-positive symptoms were experienced, which caused the patient to awaken; this was immediately followed by transient monocular vision loss. Carotid endarterectomy was curative

Predictors of clinically significant postprocedural hypotension after carotid endarterectomy and carotid angioplasty with stenting

ObjectivesSignificant hypotension after carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS) has been correlated with adverse outcomes. The objective of this study was to determine risk factors that predict hypotension after patients undergo CEA and CAS.MethodsThe review included 1474 CEA patients and 157 CAS patients who underwent procedures from 2002 to 2008. Specific patient characteristics, such as comorbid diseases, degree of carotid stenosis, presence of neurologic symptoms, and preprocedure medications, were assessed. Also reviewed were specific postprocedural clinical outcomes, including hypotension requiring pressors, myocardial infarction, stroke, death, and hospital length of stay.ResultsThe incidence of clinically significant hypotension was 12.6% in CEA patients and 35% in CAS patients (P < .001). Clinically significant hypotension was correlated with increased postprocedural myocardial infarction (2.1% vs 0.5%, P = .022), increased mortality (2.1% vs 0.1%, P < .001), and length of stay >2 days (46.3% vs 27.4%, P = .01). Hypotension was not associated with increased postprocedural strokes (0.8% vs 0.6%, P = .75) or recurrent neurologic symptoms (0.4% vs 0.3%, P = .55). Preoperative nitrate use predicted a greater incidence of postprocedural hypotension (P = .043). A history of tobacco use was correlated with postprocedure hypotension (P = .033). Preprocedural strokes, the use of calcium channel blockers, β-blockers, angiotensin-converting enzyme inhibitors, prior myocardial infarction, degree of preprocedural carotid stenosis, type of stent, previous ipsilateral and contralateral interventions, and female gender did not correlate with postprocedural hypotension (P >.05).ConclusionsPostprocedural hypotension occurs more commonly with CAS than CEA and is associated with increased postprocedural myocardial infarction and length of stay, and death. Nitrates and tobacco use predict a higher incidence of postprocedural hypotension. High-risk patients should be aggressively managed to prevent the increased morbidity and mortality due to postprocedural hypotension

Incision and abdominal wall hernias in patients with aneurysm or occlusive aortic disease

AbstractIntroductionPatients undergoing midline incision for abdominal aortic reconstruction appear to be at greater risk for postoperative incision hernia compared with patients undergoing celiotomy for general surgical procedures. Controversy exists as to whether incidence of abdominal wall hernia and increased risk for incision hernia is higher in patients with abdominal aortic aneurysm (AAA) than in patients operated on because of aortoiliac occlusive disease (AOD). We conducted a prospective multi-institutional study to assess frequency of incision hernia after aortic surgery through a midline laparotomy and of previous abdominal wall hernia.MethodsPatients with AAA (n = 177) or AOD (n = 82) from three major institutions were prospectively enrolled in the study and examined. Data collected included demographic data, cardiopulmonary risk factors, smoking status, history of previous or current abdominal wall hernia (incision, inguinal, umbilical, femoral), previous midline incision, suture type, and postoperative complications. At a minimum of 6 months after laparotomy, patients were evaluated clinically for a new incision hernia. Differences were tested with the unpaired t test, X2 test, or Fisher exact test, and multiple logistic regression was used to control for confounding variables.ResultsMean follow-up of the cohort was 32.8 ± 2.3 months. Rate of abdominal wall hernia and inguinal hernia in patients with AAA versus AOD was 38.4% versus 11% (P = .001) and 23.7% versus 6.1% (P = .003), respectively. Rate of postoperative incision hernia in patients with AAA was 28.2%, and in patients with AOD was 11.0% (P = .002). Adjusting for age, smoking, chronic obstructive pulmonary disease, body mass index, diabetes, bowel obstruction, and suture type, patients with AAA had almost a ninefold risk for postoperative incision hernia formation (odds ratio [OR], 8.8; P = .0049).ConclusionCompared with patients with AOD, patients with AAA have a higher frequency of abdominal wall hernia and inguinal hernia, and are at significant increased risk for development of incision hernia postoperatively. The higher frequency of hernia formation in patients with AAA suggests the presence of a structural defect within the fascia. Further studies are needed to delineate the molecular changes of the aorta and its relation to the abdominal wall fascia

The apparent immunological tolerance of the female rabbit to homologous seminal plasma proteins

Thesis (M.A.)--Boston UniversityPLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at [email protected]. Thank you.Investigations into the antigenicity of components of semen have been undertaken since the end of the last century. Landsteiner, Metalnikov, and Metchnikoff almost simultaneously demonstrated in 1899, antibody formation after the injections of sperm or testicular extracts of humans, bulls, guinea pigs and rabbit into various experimental animals. Since this time, many other investigators have demonstrated antibody formation using a wide variety of antigens from different animals and various routes and methods of immunization. The interest in this area of immune-reproduction is projected along two planes of interest. On the one hand is the idea that the immunization of a female could serve as another approach to the problem of contraception. The other plane of interest, and the one in which we were most interested, involves the possibility of a female being immunized against seminal plasma proteins through natural exposure to semen during sexual intercourse. Numerous investigators have shown semen and its components to be antigenic when injected intravenously, intraperitoneally, and subcutaneously into animals of another species. This present investigation involves three related experiments. First, using bovine serum albumen as the antigen, the vaginal mucosa of rabbits was investigated for its ability to absorb and subsequently form antibodies to this absorbed antigen. It was found that this route could serve as an effective route of immunization. Second, bovine seminal plasma was introduced into the vagina of rabbits in order to determine the antigenic nature of seminal plasma proteins. It was shown that this material was antigenic and that the vagina was an effective route of immunization. Third, rabbit seminal plasma was placed in the rabbit vagina. After repeated intravaginal inseminations, no detectable level of antibodies were found in the rabbits blood serum. Thus, it was shown that the vagina of rabbit is an effective route of immunization, and that while heterologous seminal plasma is antigenic, homologous seminal plasma does not cause an immunological response in the rabbit. It is suggested that the inability of the female of a species to form antibodies against its own seminal plasma proteins may have as its basis the presence of a bipotential reproductive tract in the early embryo. Thus, before a competent immunological system is developed, the embryo has native protein which are the same as those of the male ejaculate. Another possible explanation concerns the presence in the female of homologues of the male accessory sex glands, which may secrete protein identical to the male seminal plasma proteins.2031-01-0

Distal migration and deformation of the Greenfield vena cava filter

We have presented two patients in whom distal migration of the Greenfield vena cava filter has resulted in complications. In one patient there was marked deformation of the vena cava filter struts for an unknown reason resulting in perforation of the vena cava filter and the small bowel. In a second patient the distal migration resulted in poor alignment of the filter and recurrent pulmonary emboli. We feel that the Greenfield filter represents an excellent choice for caval interruption but that we would like to draw attention to the complication of distal migration. In addition, we would like to point out deformation of the struts of the Greenfield filter for which we have no explanation and which, to our knowledge, has not been reported previously. © 1986