Is elevated creatinine level a contraindication to endovascular aneurysm repair?

AbstractPurposeIt is widely believed that chronic renal insufficiency (CRI) greatly increases the risk associated with endovascular abdominal aortic aneurysm repair (EVAR) and is a relative contraindication to the procedure and to the use of intra-arterial contrast agents (IACA). We reviewed a 5-year EVAR experience to determine whether the procedure and use of IACA have an important deleterious effect on renal function in patients with and without pre-existing CRI.MethodsEndovascular aneurysm repair (EVAR) was performed in 200 patients with a variety of endografts, with intra-arterial contrast agents. The patients were retrospectively assigned to three groups on the basis of preoperative serum creatinine concentration (Cr): group 1 (n = 108), Cr less than 1.5 mg/dL (normal range); group 2 (n = 65), Cr 1.5 to 2.0 mg/dL; group 3 (n = 27), Cr 2.1 to 3.5 mg/dL. No patients had undergone hemodialysis. In groups 2 and 3, patients received hydration perioperatively, and received mannitol intraoperatively; no nephrotoxic drugs were administered during the procedure, other than nonionic contrast agent (Omnipaque 350).ResultsThe incidence of postoperative complications between the three study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in three patients (2.7%), two of whom (1.9%) required temporary hemodialysis and one (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in two patients (3.1%); both patients (3.1%) required temporary hemodialysis, and one patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in two patients (7.4%); one patient (3.7%) required temporary hemodialysis, and one patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (P < .05), and larger contrast volume was associated with an increase in serum Cr (P < .05) during the postoperative period.ConclusionsEVAR with intra-arterial contrast agents can be accomplished in patients with chronic renal insufficiency who do not require dialysis, with limited and acceptable morbidity and mortality, similar to that observed with open aneurysm repair. Contrary to other reports in which perioperative precautions were not used, our study shows that with EVAR the risk for worsening renal failure, dialysis, and death is only slightly, and not significantly, greater in patients with preoperative chronic renal insufficiency compared with patients with normal renal function. Perioperative hypotension and increased contrast volume are significant risk factors for postoperative increase in serum Cr and death. With appropriate precautions such as averting perioperative hypotension and limiting the volume of nonionic contrast agents, elevated Cr need not be a contraindication to EVAR with intra-arterial contrast agents

Identification of road user related risk factors, deliverable 4.1 of the H2020 project SafetyCube.

Safety CaUsation, Benefits and Efficiency (SafetyCube) is a European Commission supported Horizon 2020 project with the objective of developing an innovative road safety Decision Support System (DSS). The DSS will enable policy-makers and stakeholders to select and implement the most appropriate strategies, measures, and cost-effective approaches to reduce casualties of all road user types and all severities. This document is the first deliverable (4.1) of work package 4 which is dedicated to identifying and assessing human related risk factors and corresponding countermeasures as well as their effect on road safety. The focus of deliverable 4.1 is on identification and assessment of risk factors and describes the corresponding operational procedure and corresponding outcomes. The following steps have been carried out: Identification of human related risk factors – creation of a taxonomy Consultation of relevant stakeholders and policy papers for identification of topic with high priority (‘hot topics’) Systematic literature search and selection of relevant studies on identified risk factors •Coding of studies •Analysis of risk factors on basis of coded studies •Synopses of risk factors, including accident scenarios The core output of this task are synopses of risk factors which will be available through the DSS. Within the synopses, each risk factor was analysed systematically on basis of scientific studies and is further assigned to one of four levels of risk (marked with a colour code). Essential information of the more than 180 included studies were coded and will also be available in the database of the DSS. Furthermore, the synopses contain theoretical background on the risk factor and are prepared in different sections with different levels of detail for an academic as well as a non-academic audience. These sections are readable independently. It is important to note that the relationship between road safety and road user related risk factors is a difficult task. For some risk factors the available studies focused more on conditions of the behaviour (in which situations the behaviour is shown or which groups are more likely to show this behaviour) rather than the risk factor itself. Therefore, it cannot be concluded that those risk factors that have not often been studied or have to rely more indirect and arguably weaker methodologies, e.g. self-reports , do not increase the chance of a crash occurring. The following analysed risk factors were assessed as ‘risky’, ‘probably risky’ or ‘unclear’. No risk factors were identified as ‘probably not risky’. Risky Probably risky Unclear • Influenced driving – alcohol • Influenced Driving – drugs (legal & illegal) • Speeding and inappropriate speed • Traffic rule violations – red light running • Distraction – cell phone use (hand held) • Distraction – cell phone use (hands free) • Distraction – cell phone use (texting) • Fatigue – sleep disorders – sleep apnea • Risk taking – overtaking • Risk taking – close following behaviour • Insufficient knowledge and skills • Functional impairment – cognitive impairment • Functional impairment – vision loss • Diseases and disorders – diabetes • Personal factors – sensation seeking • Personal factors – ADHD • Emotions – anger, aggression • Fatigue – Not enough sleep/driving while tired • Distraction – conversation with passengers • Distraction – outside of vehicle • Distraction – cognitive overload and inattention • Functional impairment – hearing loss (few studies) • Observation errors (few studies) • Distraction – music – entertainment systems (many studies, mixed results) • Distraction – operating devices (many studies, mixed results) The next step in SafetyCube’s WP4 is to identify and assess the effectiveness of measures and to establish a link to the identified risk factors. The work of this first task indicates a set of risk factors that should be centre of attention when identifying corresponding road safety measures (category ‘risky’)

Composition and origin of summertime air pollutants at Deep Creek Lake, Maryland

A 1 month intensive summertime field study conducted in rural western Maryland resulted in a comprehensive set of fine particle, gaseous and meteorological data. Sulfur in the assumed form of ammonium sulfate accounted for 67% of the average fine particle mass and had a very high correlation with fine particle mass (r=0.99). Other measured species, includiqg carbon and nitrate, made only minor contributions to the fine mass. Peak sulfate concentrations, averaged over 6-h intervals, exceeded 50 [mu]g m-3. Nitric acid concentrations showed strong daytime maxima and on a 24 h basis were about four times those of fine particle nitrate. Sulfur in the gas phase (SO2) constituted more than half of the total sulfur, indicating that the sampling site was being influenced by local sources. Fine particle selenium was well correlated with fine particle sulfur (r=0.70). The ratio of fine particle sulfur to selenium was 2800, characteristic of a rural site downwind of coal-burning areas. Mixed-layer back trajectories were used to identify possible source regions for the measured parameters. Wind frequency-normalized concentrations of parameters associated with coal-burning (S, Se, SO2 and mass) were highest for back trajectories arriving at Deep Creek Lake from the west-northwest. Use of Rahn and Lowenthal regional signatures showed an overwhelming dominance by the Lower Midwest region, and a surprisingly weak impact by the Upper Midwest region, at the site.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/28246/1/0000699.pd