Impact of diarrhoea and acute respiratory infection on environmental enteric dysfunction and growth of malnourished children in Pakistan: a longitudinal cohort study

Background

Diarrhoea and acute respiratory infections (ARI) are assumed to be major drivers of growth and likely contribute to environmental enteric dysfunction (EED), which is a precursor to childhood malnutrition. In the present study, we checked the correlation between diarrhoeal/ARI burden and EED using a novel duodenal histological index.

Methods

Between November 2017 and July 2019, a total of 365 infants with weight-for-height Z scores (WHZ score) of <-2 were enrolled, and 51 infants with WHZ scores of >0 and height-for-age Z scores (HAZ scores) of >-1 were selected as age-matched healthy controls. Morbidity was assessed weekly and categorised as the total number of days with diarrhoea and acute respiratory infection (ARI) from enrolment until two years of age and was further divided into four quartiles in ascending order.

Findings

The HAZ declined until two years of age regardless of morbidity burden, and WHZ and weight-for-age Z scores (WAZ scores) were at their lowest at six months. Sixty-three subjects who had a WHZ score <-2 and failed to respond to nutritional and educational interventions were further selected at 15 months to investigate their EED histological scores with endoscopy further. EED histological scores of the subjects were higher with increasing diarrhoeal frequency yet remained statistically insignificant (p = 0.810).

Interpretation

There was not a clear correlation between diarrhoea and ARI frequency with growth faltering, however, children with the highest frequency of diarrhoea had the highest EED histological scores and growth faltering.

Funding

Bill and Melinda Gates Foundation and The National Institutes of Health.

Environmental enteric dysfunction: gut and microbiota adaptation in pregnancy and infancy

Environmental enteric dysfunction (EED) is a subclinical syndrome of intestinal inflammation, malabsorption and barrier disruption that is highly prevalent in low- and middle-income countries in which poverty, food insecurity and frequent exposure to enteric pathogens impair growth, immunity and neurodevelopment in children. In this Review, we discuss advances in our understanding of EED, intestinal adaptation and the gut microbiome over the 'first 1,000 days' of life, spanning pregnancy and early childhood. Data on maternal EED are emerging, and they mirror earlier findings of increased risks for preterm birth and fetal growth restriction in mothers with either active inflammatory bowel disease or coeliac disease. The intense metabolic demands of pregnancy and lactation drive gut adaptation, including dramatic changes in the composition, function and mother-to-child transmission of the gut microbiota. We urgently need to elucidate the mechanisms by which EED undermines these critical processes so that we can improve global strategies to prevent and reverse intergenerational cycles of undernutrition.

Quantitative Morphometry and Machine Learning Model to Explore Duodenal and Rectal Mucosal Tissue of Children with Environmental Enteric Dysfunction

Environmental enteric dysfunction (EED) is a subclinical enteropathy prevalent in resource-limited settings, hypothesized to be a consequence of chronic exposure to environmental enteropathogens, resulting in malnutrition, growth failure, neurocognitive delays, and oral vaccine failure. This study explored the duodenal and colonic tissues of children with EED, celiac disease, and other enteropathies using quantitative mucosal morphometry, histopathologic scoring indices, and machine learning-based image analysis from archival and prospective cohorts of children from Pakistan and the United States. We observed villus blunting as being more prominent in celiac disease than in EED, as shorter lengths of villi were observed in patients with celiac disease from Pakistan than in those from the United States, with median (interquartile range) lengths of 81 (73, 127) µm and 209 (188, 266) µm, respectively. Additionally, per the Marsh scoring method, celiac disease histologic severity was increased in the cohorts from Pakistan. Goblet cell depletion and increased intraepithelial lymphocytes were features of EED and celiac disease. Interestingly, the rectal tissue from cases with EED showed increased mononuclear inflammatory cells and intraepithelial lymphocytes in the crypts compared with controls. Increased neutrophils in the rectal crypt epithelium were also significantly associated with increased EED histologic severity scores in duodenal tissue. We observed an overlap between diseased and healthy duodenal tissue upon leveraging machine learning image analysis. We conclude that EED comprises a spectrum of inflammation in the duodenum, as previously described, and the rectal mucosa, warranting the examination of both anatomic regions in our efforts to understand and manage EED.

Impact of enteropathogens on faltering growth in a resource-limited setting

Introduction

Environmental enteropathy is an important contributor to childhood malnutrition in the developing world. Chronic exposure to fecal pathogens leads to alteration in intestinal structure and function, resulting in impaired gut immune function, malabsorption, and growth faltering leading to environmental enteropathy.

Methods

A community-based intervention study was carried out on children till 24 months of age in Matiari district, Pakistan. Blood and fecal specimens were collected from the enrolled children aged 3-6 and 9 months. A real-time PCR-based TaqMan array card (TAC) was used to detect enteropathogens.

Results

Giardia, Campylobacter spp., enteroaggregative Escherichia coli (EAEC), Enteropathogenic Escherichia coli (EPEC), Enterotoxigenic Escherichia coli (ETEC), and Cryptosporidium spp. were the most prevailing enteropathogens in terms of overall positivity at both time points. Detection of protozoa at enrollment and 9 months was negatively correlated with rate of change in height-for-age Z (ΔHAZ) scores during the first and second years of life. A positive association was found between Giardia, fecal lipocalin (LCN), and alpha 1-Acid Glycoprotein (AGP), while Campylobacter spp. showed positive associations with neopterin (NEO) and myeloperoxidase (MPO).

Conclusion

Protozoal colonization is associated with a decline in linear growth velocity during the first 2 years of life in children living in Environmental enteric dysfunction (EED) endemic settings. Mechanistic studies exploring the role of cumulative microbial colonization, their adaptations to undernutrition, and their influence on gut homeostasis are required to understand symptomatic enteropathogen-induced growth faltering.

SARS-CoV-2 associated pathogenesis, immune dysfunction and involvement of host factors: a comprehensive review

Infectious diseases, especially viral infections, have emerged as a major concern for public health in recent years. Recently emerged COVID-19, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has been declared a pandemic by World Health Organization since March 2020. It was first identified in Wuhan, China, in December 2019 and has since claimed more than a million lives. Complicated symptoms are associated with rising incidence and fatality rates, while many of the vaccine candidates are in the final stages of clinical trials. This review encompasses a summary of existing literature on COVID-19, including the basics of the disease such as the causative agent's genome characterization, modes of transmission of the virus, pathogenesis, and clinical presentations like associated immune responses, neurological manifestations, the variety of host genetic factors influencing the disease and the vulnerability of different groups being affected by COVID-19.

Gut integrity and duodenal enteropathogen burden in undernourished children with environmental enteric dysfunction

Environmental enteric dysfunction (EED) is a subclinical condition of intestinal inflammation, barrier dysfunction and malabsorption associated with growth faltering in children living in poverty. This study explores association of altered duodenal permeability (lactulose, rhamnose and their ratio) with higher burden of enteropathogen in the duodenal aspirate, altered histopathological findings and higher morbidity (diarrhea) that is collectively associated with linear growth faltering in children living in EED endemic setting. In a longitudinal birth cohort, 51 controls (WHZ > 0, HAZ > −1.0) and 63 cases (WHZ< -2.0, refractory to nutritional intervention) were recruited. Anthropometry and morbidity were recorded on monthly bases up to 24 months of age. Dual sugar assay of urine collected after oral administration of lactulose and rhamnose was assessed in 96 children from both the groups. Duodenal histopathology (n = 63) and enteropathogen analysis of aspirate via Taqman array card (n = 60) was assessed in only cases. Giardia was the most frequent pathogen and was associated with raised L:R ratio (p = 0.068). Gastric microscopy was more sensitive than duodenal aspirate in H. pylori detection. Microscopically confirmed H. pylori negatively correlated with HAZ at 24 months (r = −0.313, p = 0.013). Regarding histopathological parameters, goblet cell reduction significantly correlated with decline in dual sugar excretion (p< 0.05). Between cases and controls, there were no significant differences in the median (25^th, 75^th percentile) of urinary concentrations (μg/ml) of lactulose [27.0 (11.50, 59.50) for cases vs. 38.0 (12.0, 61.0) for controls], rhamnose [66.0 (28.0, 178.0) vs. 86.5 (29.5, 190.5)] and L:R ratio [0.47 (0.24, 0.90) vs. 0.51 (0.31, 0.71)] respectively. In multivariable regression model, 31% of variability in HAZ at 24 months of age among cases and controls was explained by final model including dual sugars. In conclusion, enteropathogen burden is associated with altered histopathological features and intestinal permeability. In cases and controls living in settings of endemic enteropathy, intestinal permeability test may predict linear growth. However, for adoption as a screening tool for EED, further validation is required due to its complex intestinal pathophysiology.

EED is a subclinical condition of compromised gut integrity secondary to frequent and repeated exposure to enteropathogens in global settings with a high prevalence of undernutrition. In this study, we reported association of gut mucosal architecture with a dual sugar intestinal permeability assay (lactulose-rhamnose) in Pakistani children. In the presence of duodenal enteropathogens, features such as chronic inflammation, intra-epithelial lymphocytosis, enterocyte injury and Paneth cell reduction were consistently observed. When comparing undernourished cases and controls living in the same setting, we found urinary excretion of the sugars was similar among groups; however, variability in HAZ among children at 24 months was partially explained by a model that includes excretion values.

Three-dimensional Visualization Software Assists Learning in Students with Diverse Spatial Intelligence in Medical Education

This study evaluated effect of mental rotation (MR) training on learning outcomes and explored effectiveness of teaching via three-dimensional (3D) software among medical students with diverse spatial intelligence. Data from n = 67 student volunteers were included. A preliminary test was conducted to obtain baseline level of MR competency and was utilized to assign participants to two experimental conditions, i.e., trained group (n = 25) and untrained group (n = 42). Data on the effectiveness of training were collected to measure participants' speed and accuracy in performing various MR activities. Six weeks later, a large class format (LCF) session was conducted for all students using 3D software. The usefulness of technology-assisted learning at the LCF was evaluated via a pre- and post-test. Students' feedback regarding MR training and use of 3D software was acquired through questionnaires. MR scores of the trainees improved from 25.9±4.6 points to 28.1±4.4 (P = 0.011) while time taken to complete the tasks reduced from 20.9±3.9 to 12.2±4.4 minutes. Males scored higher than females in all components (P = 0.016). Further, higher pre- and post-test scores were observed in trained (9.0±1.9 and 12.3±1.6) versus untrained group (7.8±1.8; 10.8±1.8). Although mixed-design analysis of variance suggested significant difference in their test scores (P < 0.001), both groups reported similar trend in improvement by means of 3D software (P = 0.54). Ninety-seven percent of students reported technology-assisted learning as an effective means of instruction and found use of 3D software superior to plastic models. Software based on 3D technologies could be adopted as an effective teaching pedagogy to support learning across students with diverse levels of mental rotation abilities.

Pathobiome driven gut inflammation in Pakistani children with Environmental Enteric Dysfunction

Environmental Enteric Dysfunction (EED) is an acquired small intestinal inflammatory condition underlying high rates of stunting in children <5 years of age in low- and middle-income countries. Children with EED are known to have repeated exposures to enteropathogens and environmental toxins that leads to malabsorptive syndrome. We aimed to characterize association of linear growth faltering with enteropathogen burden and subsequent changes in EED biomarkers. In a longitudinal birth cohort (n = 272), monthly anthropometric measurements (Length for Age Z score- LAZ) of asymptomatic children were obtained up to 18 months. Biological samples were collected at 6 and 9 months for the assessment of biomarkers. A customized TaqMan array card was used to target 40 enteropathogens in fecal samples. Linear regression was applied to study the effect of specific enteropathogen infection on change in linear growth (ΔLAZ). Presence of any pathogen in fecal sample correlated with serum flagellin IgA (6 mo, r = 0.19, p = 0.002), fecal Reg 1b (6 mo, r = 0.16, p = 0.01; 9mo, r = 0.16, p = 0.008) and serum Reg 1b (6 mo, r = 0.26, p<0.0001; 9 mo, r = 0.15, p = 0.008). At 6 months, presence of Campylobacter [β (SE) 7751.2 (2608.5), p = 0.003] and ETEC LT [β (SE) 7089.2 (3015.04), p = 0.019] was associated with increase in MPO. Giardia was associated with increase in Reg1b [β (SE) 72.189 (26.394), p = 0.006] and anti-flic IgA[β (SE) 0.054 (0.021), p = 0.0091]. Multiple enteropathogen infections in early life negatively correlated with ΔLAZ, and simultaneous changes in gut inflammatory and permeability markers. A combination vaccine targeting enteropathogens in early life could help in the prevention of future stunting.

Serum anti mullerian hormone and renalase levels in predicting the risk of preeclampsia

OBJECTIVE

The aim of the study was to explore the association of serum AMH and Renalase with the risk of preeclampsia thereby assessing them as screening tools, reducing the risk of gravid consequences of preeclampsia.

MATERIALS AND METHODS

This cross-sectional study recruited n = 95 pregnant women between 14 and 32 gestational weeks. They were categorized as a) women with gestational hypertension (n = 45); b) women with pre-eclampsia (n = 20) and c) normotensive pregnant women (n = 30) according to the ACOG criteria. Anthropometrics data and blood and urine samples were collected. AMH and Renalase levels were measured by ELISA assay.

RESULTS

The mean age of study cohort was 27.3 ± 6.2 year and weight was 65.1 ± 14.1 kg. Blood pressures were significantly higher in pre-eclamptic patients versus both the gestational hypertensive females and controls (p < 0.05). AMH was found to be significantly higher in controls but no difference was observed between gestational hypertensive and pre-eclamptic patients. No difference was seen for serum Renalase among the three groups (p > 0.05). AMH showed a negative weak correlation with diastolic blood pressure (r = -0.272; p = 0.008) that remained significant even after adjustment (r = -0.236; p = 0.023) whereas Renalase did not show any difference (r = -0.051; p > 0.05). Females with low levels of AMH were 1.07 times at risk of developing hypertension even after adjustment for age and BMI (p < 0.05).

CONCLUSION

Low AMH levels may lead to hypertension in pregnancy suggesting a role in detecting vascular diseases as well as its effect on ovarian aging. However, further research is required to establish a causal relationship.

Preclinical medical students' perspective on technology enhanced assessment for learning

OBJECTIVE

To explore the potentials of technology-assisted assessment for learning using Kahoot software in teaching session.

METHODS

This cross-sectional study was conducted at Aga Khan University, Karachi, to investigate the usefulness of formative assessment based on the use of Kahoot, a quiz-based learning platform, in undergraduate setting.Six lectures were offered to undergraduate medical students with integration of assessment for learning (AfL) activities. Students' perception was sought via questionnaire regarding effectiveness of quizzing on classroom dynamics, meaningful learning and assessment practice.

RESULTS

Of the 171 respondents, 155(91%) stated that technology-enriched methodologies were in line to their learning strategy while 138(81%) students rated their experience with technology-supported assessment for learning as "Excellent". The students perceived highest positive influence on the classroom dynamics [109(63.8%)], followed by assistance to learning [100(58.58%)] and assessment performance [88(51.7%)]. Overall, 133(78%) students agreed to the notion that quizzes aided in summarisation of concept and consolidation of essential content. Additionally, 113(66%) participant expressed that anonymity helped them take quizzes as earnest opportunity to learn without any fright of failure.

CONCLUSIONS

AfL leads to a paradigm shift in the classroom, transferring the ownership of learning to the students. There is a need to implement such activities as a routine across diverse educational settings such as labs, lectures or even clinical rotations.

Cross talk between serum Kisspeptin-Leptin during assisted reproduction techniques

Background & objective:

Leptin facilitates onset of puberty by impact on hypothalamic Kisspeptin, gonadotropin releasing hormone, follicle stimulating and luteinizing hormone. The link of peripheral Leptin-Kisspeptin in regulating the ovarian and endometrial tissue in relation to adiposity is unknown. Therefore, we wanted to identify Kisspeptin-Leptin association with body mass index (BMI) and success of assisted reproductive treatments (ART) in infertile females.

Methods:

A cross sectional study was carried from August 2014 till May 2016 after receiving ethical approval at Australian Concept Infertility Medical Centre, and Aga Khan University. The study group comprised of females with an age range of 25-37 year who had duration of unexplained infertility for more than two years. They were grouped as; underweight (<18 kg/m²), normal weight (18-22.9 kg/m²), overweight 23-24.99 kg/m² and obese (>25 kg/m²). Kisspeptin and Leptin levels were measured by enzyme linked immune sorbent assay before down regulation of ovaries and initiation of treatment protocol of ART. Failure of procedure was detected by beta human chorionic gonadotropin <25mIU/ml (non-pregnant) whereas females with levels >25mIU/ml and cardiac activity on trans-vaginal scan were declared pregnant.

Results:

Highest Kisspeptin and Leptin levels were seen in normal weight group (374.80 ± 185.08ng/L; 12.78 ± 6.8 pg/ml) respectively, yet the highest number of clinical pregnancy was observed in overweight group (42%).A strong correlation of Kisspeptin with Leptin (r=0.794, p=0.001) was observed in the overweight females.

Conclusion:

Leptin-Kisspeptin-fertility link is expressed by maximum number of clinical pregnancies in the female group that showed strongest relationship between serum Leptin and Kisspeptin levels, irrespective of their BMI.

Predictive accuracy of anti mullerian hormone as indicator of ovarian follicle loss in cyclophosphamide treated mice

OBJECTIVE

To evaluate the strength of anti-mullerian hormone in reflecting the stages of ovarian toxicity-induced by cyclophosphamide.

METHODS

This study was conducted in December 2014 and comprised female mice that were divided into four groups: group A served as control, group B received three weekly injections of cyclophosphamide, group C was co administered alpha-tocopherol along with cyclophosphamide, while group D solely received alpha-tocopherol. The ovaries were evaluated for follicular dynamics, and anti-mullerian hormone was assessed using mouse enzyme-linked immunosorbent assay kit. The data was analysed using SPSS 19.

RESULTS

There were 40 mice in the study. Histological analysis revealed severely reduced ovarian reserve in group B(p<0.01).In group C alpha-tocopherol conserved the ovarian reserve to near normal, thus follicle count was significantly higher than group B (p<0.05). However, this moderate reduction was still lower than the controls (p<0.01). Furthermore, the number of corpus lutea and atretic follicles were significantly higher in groups B and C (p<0.01). Regarding hormonal analyses in comparison to controls, anti-mullerian hormone levels were low in group B (p<0.01), while group C reported an insignificant fall in serum anti-mullerian hormone levels (p=0.101).

CONCLUSIONS

There was substantial evidence that anti-mullerian hormone monitoring during chemotherapy administration may fulfil the criteria of earliest diagnostic indicator of secondary infertility.

Interleukin-18 polymorphism as an inflammatory index in metabolic syndrome: A preliminary study

AIM

To assess circulatory levels of interleukin-18 (IL-18) and determine whether the presence of IL-18 promoter polymorphism influences metabolic syndrome phenotypes.

METHODS

This study recruited one hundred and eighty individuals divided into three groups with sixty subjects each as: Normal weight (18.0-22.9 kg/m²), overweight (23.0-25.9 kg/m²) and obese (> 26.0 kg/m²) according to South Asian criteria of BMI. Fasting blood glucose (FBG), Lipid profile, insulin, IL-18 and tumor necrosis factor (TNF)α were measured using ELISA kits, whereas low density lipoprotein (LDL)-cholesterol, insulin resistance (HOMA-IR) and insulin sensitivity (QUICKI) were calculated. The body fat percentage (BF) was measured through bioelectrical impedance analysis; waist and hip circumference were measured. Genotyping of IL-18 -607 C/A polymorphism was performed by using tetra-primer amplification refractory mutation system. Student t test, One-way analysis of variance, Hardy-Weinberg equilibrium, Pearson’s χ² test and Pearson’s correlation were used, where a P value < 0.05 was considered significant.

RESULTS

In an aged matched study, obese subjects showed higher levels of FBG, cholesterol, triglycerides and LDL levels as compared to normal weight (P < 0.001). Highest levels of IL-18 and TNF levels were also seen in obese subjects (IL-18: 58.87 ± 8.59 ng/L) (TNF: 4581.93 ± 2132.05 pg/mL). The percentage of IL-18 -607 A/A polymorphism was higher in overweight and obese subjects vs normal weight subjects (P < 0.001). Moreover, subjects with AA genotype had a higher BF, insulin resistance, TNFα and IL-18 levels when compared with subjects with AC (heterozygous) or CC (wild type) genotypes. However, we did not find any difference in the lipid profile between three subgroups.

CONCLUSION

This preliminary data suggests that IL-18 polymorphism affects IL-18 levels that might cause low grade inflammation, further exacerbated by increased TNFα. All these increase the susceptibility to develop MetS. Further studies are required to validate our findings.

Students' perceptions of usefulness of Anatomy demonstrations in traditional and hybrid undergraduate medical education curricula

A cross-sectional study was carried out to study students' perceptions on the usefulness of Anatomy demonstrations (AD) in the undergraduate medical education by comparing the Conventional Medical College (CMC) and problem-based learning as hybrid curriculum (HMC). Purposive sampling technique was used and all students were included. The completed questionnaire responses were returned by 92 CMC and 87 HMC students. CMC cohort understood the structural relationship more than HMC (p=0.03). AD helped 50 students (54%) of CMC to get through the theory examination, however 73 (84%) students of HMC found them useful in preparation for theory examinations (p<0.001). The importance of AD as a major content delivery strategy cannot be overemphasized in the anatomy curriculum and useful teaching strategies from various undergraduate medical curricula, such as the use of the plastic and plastinated models and the session handouts.

Kisspeptin: A Potential Factor for Unexplained Infertility and Impaired Embryo Implantation

Background

Kisspeptin (KP) is a neuropeptide that causes the release of the gonadotropin releasing hormone, which controls hypothalamo pituitary ovarian axis and exerts a number of peripheral effects on reproductive organs. The primary objective of this study was to compare baseline KP levels in females with different types of infertility and identify possible correlations with risk of failure to conceive, preclinical abortion and pregnancy after intracytoplasmic sperm injection (ICSI).

Materials and Methods

A longitudinal cohort study was carried out from August 2014 until May 2015 by recruiting 124 female patients undergoing ICSI, after obtaining ethical approval from the Australian Concept Infertility Medical Center. Cause of infertility due to male, female and unexplained factors was at a frequency of 32 (24%), 33 (31%) and 59 (45%) among the individuals respectively. KP levels were measured by ELISA assay before the initiation of the ICSI treatment protocol. Outcome of ICSI was categorized into three groups of non-pregnant with beta-human chorionic gonadotropin (β-hCG)<5-25 mIU/ml, preclinical abortion with β-hCG>25 mIU/ml and no cardiac activity, and clinical pregnancy declared upon confirmation of cardiac activity. Results based on cause of infertility and outcome groups were analyzed by one-way ANOVA.

Results

Females with unexplained infertility had significantly lower levels of KP when compared with those with male factor infertility (176.69 ± 5.03 vs. 397.6 ± 58.2, P=0.001). Clinical pregnancy was observed in 28 (23%) females of which 17 (71%) had a female cause of infertility. In the non-pregnant group of 66 (53%) females, common cause of infertility was unexplained 56(85%). A weak positive correlation of KP levels with fertilized oocytes and endometrial thickness was observed (P=0.04 and 0.01 respectively).

Conclusion

Deficiency of KP in females with unexplained infertility was associated with reduced chances of implantation after ICSI.

Polymorphism of the renalase gene in gestational diabetes mellitus

Renalase is considered as a novel candidate gene for type 2 diabetes. In this study, we aimed to investigate the relationship of serum renalase and two single nucleotide polymorphisms with gestational diabetes mellitus. One hundred and ninety-eight normotensive pregnant females (n = 99 gestational diabetes mellitus; n = 99 euglycemic pregnant controls) were classified according to the International Association of the Diabetes and Pregnancy Study criteria. Fasting and 2-h post glucose load blood levels and anthropometric assessment was performed. Serum renalase was measured using enzyme-linked immunosorbent assay, whereas DNA samples were genotyped for renalase single nucleotide polymorphisms rs2576178 and rs10887800 using Polymerase chain reaction-Restriction fragment length polymorphism method. In an age-matched case control study, no difference was observed in the serum levels of renalase (p > 0.05). The variant rs10887800 showed an association with gestational diabetes mellitus and remained significant after multiple adjustments (p < 0.05), whereas rs2576178 showed weak association (p = 0.030) that was lost after multiple adjustments (p = 0.09). We inferred a modest association of the rs10887800 polymorphism with gestational diabetes. Although gestational diabetes mellitus is self-reversible, yet presence of this minor G allele might predispose to metabolic syndrome phenotypes in near the future.

Assessment of ovarian reserve: Anti-Mullerian hormone versus follicle stimulating hormone

Background:

This study aimed to evaluate the strength of anti-Mullerian hormone (AMH) and follicle stimulating hormone (FSH) in reflecting the antral follicle count (AFC) in infertile females.

Materials and Methods:

This cross-sectional study was conducted on 160 females, visiting infertility clinic for assisted reproduction. Serum samples collected on the 3^rd day of the cycle were assayed for FSH, luteinizing hormone, and AMH while AFC was assessed via transvaginal ultrasound. The study cohort was segregated into three groups based on AFC.

Results:

Chronological age and FSH was significantly high in females with very low AFC (P < 0.01 and 0.009, respectively), yet they failed to discriminate patients with normal and higher follicle count (P = 0.65 and 0.84). Conversely, AMH reported highly significant difference between very low AFC and with those having either normal AFC (P = 0.002) or higher AFC (P = 0.001). Moreover, a significant difference in AMH was observed between normal and higher AFC group (P = 0.04).

Conclusion:

Compared to female’s age and FSH, AMH is superior in clustering study cohort on the bases of antral follicular pool, especially in setups with nonavailability of technological expertise to assess AFC. Incorporation of AMH along with other biomarkers improves estimation of baseline ovarian reserve, required to standardize dose for optimum response; avoiding the risk of failure to retrieve oocyte or inappropriate stimulation leading to ovarian hyperstimulation syndrome. Further prospective studies are required to ascertain its role in predicting the outcomes of ART in such patients.

Anti Mullerian Hormone: Ovarian response indicator in young patients receiving Long GnRH Agonist Protocol for Ovarian Stimulation

Objective:

Anti Mullerian hormone (AMH) is gaining place as ovarian marker, chiefly in infertility assistance. We explored its correlation with oocytes retrieval after long GnRH agonist protocol for stimulation, in younger and older infertile population.

Methods:

This retrospective analysis compiled data of 166 females, receiving ICSI treatment from June 2014 to March 2015. Serum FSH, LH, Estadiol, AMH and antral follicle count were assessed. Outcomes were measured as good (5 to 19 oocytes) and bad responders.

Results:

Higher discriminatory power of AMH (AUROC; 0.771; p < 0.05) was seen in comparison to FSH (0.692; p < 0.05) and AFC (0.690; p < 0.01). AMH reported strongest association with oocyte retrieved (odds ratio of 15.06). Subgroup analysis reported 68.6 % risk of bad response with AMH levels of less than 1.37ng/ml. This association was observed more significant in young infertile patients <35 year of age (r=0.245; p=0.012) versus older population >35 year (r=0.169; p>0.05).

Conclusion:

Our study reaffirms that serum AMH correlates well with oocytes retrieved, particularly in females younger than 35 years. We suggest incorporation of AMH in baseline assessment of infertile females, who are falsely advised to postpone interventions based on their age and normal FSH levels.

Serum anti-mullerian hormone: Correlation with the ovarian follicular dynamics in healthy mice

OBJECTIVE

To evaluate the relationship between serum anti-Mullerian hormone and follicular dynamics in mice.

METHODS

This experimental study was conducted in November, 2014 at the Dow University of Health Sciences, Karachi, and comprised laboratory-bred albino mice. They were sacrifised under anaesthesia and blood was collected via cardiac puncture to assess anti-Mullerian hormone while ovaries were collected for morphometric analyses. SPSS 19 was used for data analysis.

RESULTS

There were 20 mice with a mean weight of 25±1.89 grams, while weight of the ovaries obtained from these mice was 9.6±0.92mg. The mean serum anti-Mullerian hormone was 29.89±9.7ng/ml. On average, there were 87.8+13.54 primordial follicles, 51.85±8.36 primary, 20.35±5.57 secondary, 11.30±3.38 early antral and 3.05 ± 1.27 late antral follciles (p<0.001; p=0.06)..

CONCLUSIONS

Association of anti-Mullerian hormone with follicle dynamics reflected its role as a true ovarian reserve marker. Its assessment was of great significance in infertile women as well as young patients receiving chemotherapy.

Roles of primary care physicians in managing bipolar disorders in adults

Management of bipolar disorder (BD) is challenging due to its multiple and complex facets of presentations as well as various levels of interventions. There is also limitation of treatment accessibility especially at the primary care level. Local evidence-based clinical practice guidelines address the importance of integrated care of BD at various levels. Primary care physicians hold pertinent role in maintaining remission and preventing relapse by providing systematic monitoring of people with BD. Pharmacological treatment in particular mood stabilisers remain the most effective management with psychosocial interventions as adjunct. This paper highlights the role of primary care physicians in the management of BD.

Interstudy reproducibility of the second generation, Fourier domain optical coherence tomography in patients with coronary artery disease and comparison with intravascular ultrasound: a study applying automated contour detection

Recently, Fourier domain OCT (FD-OCT) has been introduced for clinical use. This approach allows in vivo, high resolution (15 micron) imaging with very fast data acquisition, however, it requires brief flushing of the lumen during imaging. The reproducibility of such fast data acquisition under intracoronary flush application is poorly understood. To assess the inter-study variability of FD-OCT and to compare lumen morphometry to the established invasive imaging method, IVUS. 18 consecutive patients with coronary artery disease scheduled for PCI were included. In each target vessel a FD-OCT pullback (MGH system, light source 1,310 nm, 105 fps, pullback speed 20 mm/s) was acquired during brief (3 s) injection of X-ray contrast (flow 3 ml/s) through the guiding catheter. A second pullback was repeated under the same conditions after re-introduction of the FD OCT catheter into the coronary artery. IVUS and OCT imaging was performed in random order. FD-OCT and IVUS pullback data were analyzed using a recently developed software employing semi automated lumen contour and stent strut detection algorithms. Corresponding ROI were matched based on anatomical landmarks such as side branches and/or stent edges. Inter-study variability is presented as the absolute difference between the two pullbacks. FD-OCT showed remarkably good reproducibility. Inter-study variability in native vessels (cohort A) was very low for mean and minimal luminal area (0.10 ± 0.38, 0.19 ± 0.57 mm², respectively). Likewise inter-study variability was very low in stented coronary segments (cohort B) for mean lumen, mean stent, minimal luminal and minimal stent area (0.06 ± 0.08, 0.07 ± 0.10, 0.04 ± 0.09, 0.04 ± 0.10 mm², respectively). Comparison to IVUS morphometry revealed no significant differences. The differences between both imaging methods, OCT and IVUS, were very low for mean lumen, mean stent, minimal luminal and minimal stent area (0.10 ± 0.45, 0.10 ± 0.36, 0.26 ± 0.54, 0.05 ± 0.47 mm², respectively). FD-OCT shows excellent reproducibility and very low inter-study variability in both, native and stented coronary segments. No significant differences in quantitative lumen morphometry were observed between FD-OCT and IVUS. Evaluating these results suggest that FD-OCT is a reliable imaging tool to apply in longitudinal coronary artery disease studies.

In-stent restenosis after carotid angioplasty-stenting: incidence and management

PURPOSE

Carotid angioplasty-stenting (CAS) has been advocated as an alternative to carotid endarterectomy (CEA) in patients with restenotic lesions after prior CEA, primary stenoses with significant medical comorbidities, and radiation-induced stenoses. The incidence of restenosis after CAS and its management remains ill defined. We evaluated the incidence and management of in-stent restenosis after CAS.

METHODS

Patients with asymptomatic (61%) and symptomatic (39%) carotid stenosis of > or = 80% underwent CAS between September 1996 and May 2000; there were 50 procedures and 46 patients (26 men and 20 women). All patients were followed up clinically and underwent duplex ultrasonography (DU) at 3- to 6-month intervals. In-stent restenoses > or = 80% detected with DU were further evaluated by means of angiography for confirmation of the severity of stenosis.

RESULTS

No periprocedural or late strokes occurred in the 50 CAS procedures during the 30-day follow-up period. One death (2.2%) that resulted from myocardial infarction was observed 10 days after discharge following CAS. During a mean follow-up period of 18 +/- 10 months (range, 1-44 months), in-stent restenosis was observed after four (8%) of the 50 CAS procedures. Angiography confirmed these high-grade (> or = 80%) in-stent restenoses, which were successfully treated with balloon angioplasty (3) or angioplasty and restenting (1). No periprocedural complications occurred, and these patients remained asymptomatic and without recurrent restenosis over a mean follow-up time of 10 +/- 6 months.

CONCLUSIONS

We recommend CAS for post-CEA restenosis, primary stenoses in patients with high-risk medical comorbidities, and radiation-induced stenoses. In-stent restenoses occurred after 8% of CAS procedures and were managed without complications with repeat angioplasty or repeat angioplasty and restenting.

Mandibular subluxation for distal internal carotid exposure: technical considerations

PURPOSE

Carotid endarterectomy (CEA) has become one of the most commonly performed vascular procedures, because of the beneficial outcome it has when compared with medical therapy alone and because of the anatomic accessibility of the artery. In cases of distal carotid occlusive disease, high cervical carotid bifurcation, and some reoperative cases, access to the distal internal carotid artery may limit surgical exposure and increase the incidence of cranial nerve palsies. Mandibular subluxation (MS) is recommended to provide additional space in a critically small operative field. We report our experience to determine and illustrate a preferred method of MS.

METHODS

Techniques for MS were selected based on the presence or absence of adequate dental stability and periodontal disease. All patients received general anesthesia with nasotracheal intubation before subluxation. Illustrations are provided to emphasize technical considerations in performing MS in 10 patients (nine men and one woman) who required MS as an adjunct to CEA (less than 1% of primary CEAs). Patients were symptomatic (n = 7) or asymptomatic (n = 3) and had high-grade stenoses demonstrated by means of preoperative arteriography.

RESULTS

Subluxation was performed and stabilization was maintained by means of: Ivy loop/circumdental wiring of mandibular and maxillary bicuspids/cuspids (n = 7); Steinmann pins with wiring (n = 1); mandibular/maxillary arch bar wiring (n = 1); and superior circumdental to circummandibular wires (n = 1). MS was not associated with mandibular dislocation in any patient. No postoperative cranial nerve palsies were observed. Three patients experienced transient temporomandibular joint discomfort, which improved spontaneously within 2 weeks.

CONCLUSION

Surgical exposure of the distal internal carotid artery is enhanced with MS and nasotracheal intubation. We recommend Ivy loop/circumdental wiring as the preferred method for MS. Alternative methods are used when poor dental health is observed.

Patency and limb salvage for polytetrafluoroethylene bypasses with vein interposition cuffs

Polytetrafluoroethelene (PTFE) is often utilized in patients with limb-threatening ischemia requiring infrainguinal revascularization in the absence of autologous saphenous vein. To increase long-term patency of PTFE grafts, vein interposition cuffs have been recommended as adjunctive procedures. The purpose of this study was to assess the efficacy of vein interposition cuffs on the long-term patency and limb salvage of patients requiring prosthetic bypass grafts for limb-threatening ischemia. Prosthetic bypass grafts with vein interposition cuffs (PTFE/VC) were performed on 56 limbs in 55 patients (32 men, 23 women; mean age of 67 years) from October 1993 to January 1998. Grafts were prospectively evaluated every 3 months for the first 12 months and biannually thereafter with duplex ultrasonography. PTFE/VC and PTFE bypasses at the popliteal level appear to have comparable patencies. However, PTFE/VC appear to offer an improved patency and limb salvage for infrapopliteal bypasses in patients with critical limb ischemia. When infrapopliteal revascularization is required in the absence of autologous saphenous vein, we recommend the use of PTFE with vein interposition cuffs.

Hemodialysis access: influence of the human immunodeficiency virus on patency and infection rates

PURPOSE

The complication rate for patients who are dialysis dependent and infected with the human immunodeficiency virus (HIV) and the role of viral indicators (CD4 counts) as predictors of these complications are poorly characterized. To determine the influence of HIV status and viral activity on graft patency and infection rates, we retrospectively reviewed our results.

METHODS

Between June 1993 and March 1997, the charts of 104 patients (HIV+, n = 42; HIV-, n = 62) who required 112 hemodialysis access grafts were reviewed. Of the 112 procedures, 55 (48%) were autologous arteriovenous fistulae (AVF) procedures (HIV+, n = 23; HIV-, n = 32) and 57 (52%) were prosthetic expanded polytetrafluoroethylene grafting procedures (HIV+, n = 27; HIV-, n = 30). Transcutaneous catheter procedures were excluded from the study. The autologous AVF procedures consisted of direct and transposed AVFs. Patency rates were determined by means of life-table analysis. Infection rates and CD4 counts were compared with the chi2 test and the Fisher exact test. Significance was accepted at a P value of.05 or less.

RESULTS

The cumulative 12-month and 24-month patency rates for prosthetic grafts in patients who were HIV+ were 49% and 21%, respectively, versus 77% and 45% for patients who were HIV-. The differences in the prosthetic graft patency rates between these two groups were significant (P </=.05). The cumulative 12-month and 24-month patency rates for autologous AVF procedures did not differ significantly. The AVF procedure patency rates were 72% and 51%, respectively, in patients who were HIV+ versus 54% and 50% for patients who were HIV-. The prosthetic graft infection rate for patients who were HIV+ and HIV- were 30% and 7%, respectively ( P =.04). However, the infection rates in autologous AVF procedures did not differ between the groups (9% vs 0%; P>.05). The mean CD4+ cell counts were 174: CD4+ counts that were less than 200 did not correlate with or predict the development of infection (P >.05).

CONCLUSION

Our data showed that prosthetic graft infection rates were increased and patency rates were decreased in patients who were HIV+ as compared with patients who were HIV- and HIV+ with autologous AVFs. There were no differences in patency rates or infection rates in patients who had undergone autologous access procedures. Long-term graft patency rates were not affected by HIV status, and CD4+ lymphocyte counts were not predictive of infection development. Because the prosthetic graft infection rates exceeded those rates of autologous access procedures, we recommend the vigorous use of autologous AVFs in all patients who are HIV+, regardless of CD4+ count.

Carotid restenosis: operative and endovascular management

PURPOSE

Surgical management of carotid restenosis (CR) after carotid endarterectomy (CEA) has been associated with a higher perioperative complication rate than that of primary CEA. We recently used carotid angioplasty-stenting (CAS) as an alternative to operative management in patients who had undergone CEA within three years, and we retrospectively compared these results with those of operative management of CR and the overall results of CEA.

METHODS

CEA was performed on 1065 adult patients (58% symptomatic, 42% asymptomatic), 62% of whom were men (n = 660) and 38% of whom were women (n = 405), from 1989 to 1997. Before our initiation of a program of CAS, 16 operative procedures (1.9% of CEAs) were performed for CR in 14 adult patients (7 women and 7 men). During the last 20 months, CAS was used in the management of 17 CRs (16 patients; 9 women and 7 men).

RESULTS

The 30-day stroke morbidity-death rate for all CEAs (n = 1065) was 1.4%; 11 strokes (1. 0%) occurred (4 major strokes with disability and 7 strokes with minor or no disability), and 4 deaths (0.4%) occurred (2 deaths caused by myocardial infarction, 1 caused by intracranial hemorrhage, and 1 caused by stroke). Operative management of CR (n = 16) included patch angioplasty in 12 cases (autologous vein patches in 10 cases and synthetic patches in 2 cases), whereas interposition grafting was used in 4 cases (saphenous vein in 3 instances and synthetic [polytetrafluoroethylene] in one case). No strokes or deaths were observed. One recurrent laryngeal nerve palsy occurred (6.2%). Among the 16 patients undergoing 17 CAS procedures, the technical procedures were accomplished in all patients. No strokes or deaths occurred. No recurrent restenoses (50% or greater) have been identified within or adjacent to the CAS procedures.

CONCLUSION

CR caused by myointimal hyperplasia can be managed by operative techniques or CAS with comparable periprocedural complications. Although long-term follow-up will be required to determine the incidence of recurrent restenosis, CAS may become the preferred procedure in these cases. A randomized clinical trial ultimately will be necessary to determine the role of CAS, as compared with that of operative management.

Patency of infrainguinal polytetrafluoroethylene bypass grafts with distal interposition vein cuffs

Polytetrafluoroethylene (PTFE) prosthetic bypasses in the lower extremity have poor patency rates, particularly in limb salvage cases. Patency and limb salvage rates of PTFE bypasses supplemented by distal interposition vein cuffs were assessed in patients requiring revascularization for critical limb ischemia, in the absence of a suitable autologous saphenous vein. Between October 1993 and April 1996, 163 patients underwent 185 infrainguinal bypasses. Forty-three limbs in 42 patients (12 women, 30 men; mean age 67 years) did not have a suitable autologous saphenous vein (24%) and had femoropopliteal (20) and infrapopliteal (23) bypasses performed. Patients were examined prospectively at 3-month intervals during the first year and at 6-month intervals thereafter to determine graft patency and limb salvage. Postoperative anticoagulation with warfarin was used in 26 patients. Indications for operation included limb salvage in 41 extremities (21 rest pain/ulceration or gangrene, 20 rest pain alone), and disabling claudication in two. Patients were followed clinically for 2-30 months (mean 10 months). Cumulative 2-year life-table patencies for all grafts, femoropopliteal and infrapopliteal bypasses were 64%, 75% and 62%, respectively. Previous primary patencies at the authors' institution for PTFE bypasses without vein cuffs were 35%, 46% and 12% for the same categories. Cumulative life-table limb salvage for all PTFE/vein cuff bypasses in the present series was 76% compared with 37% in previous PTFE bypasses without vein cuffs. Adjunctive use of distal interposition vein cuffs improves prosthetic graft patency, while producing satisfactory limb salvage. Postoperative anticoagulation did not influence graft patency. PTFE/vein cuff for lower-extremity revascularization shows good 2-year patency and is an acceptable alternate conduit in patients with critical limb ischemia when autologous saphenous vein is absent.

A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation

PURPOSE

We studied the efficacy of preoperative noninvasive assessment of the upper extremity to identify arteries and veins suitable for hemodialysis access to increase our use of autogenous fistulas (AF).

METHODS

From Sep. 1, 1994, to Apr. 1, 1997, 172 patients who required chronic hemodialysis underwent segmental upper extremity Doppler pressures and duplex ultrasound with mapping of arteries and veins. The following criteria were necessary for satisfactory arterial inflow: absence of a pressure gradient between arms, patent palmar arch, and arterial lumen diameter 2.0 mm or more. The criteria necessary for satisfactory venous outflow were venous luminal diameter greater than or equal to 2.5 mm for AF and greater than or equal to 4.0 mm for synthetic bridging grafts (BG) and continuity with distal superficial veins in the arm. Intraoperative and duplex ultrasound measurements were compared. Contemporary experience was compared with the 2-year period (1992 to 1994) before implementation of the protocol.

RESULTS

During the period from Sep. 1, 1994, to Apr. 1, 1997, 108 patients (63%) had AF, 52 (30%) had prosthetic BG, and 12 (7%) had permanent catheters (PC) placed. Early failure was seen in 8.3% of AFs. Primary cumulative patency rates were 83% for AF and 74% for BG at 1 year (p < 0.05), with a mean clinical follow-up of 15.2 months. No postoperative infections were observed with AF, whereas six infections (12%) were observed with BG and two (17%) with PC insertion. During the period from June 1, 1992, to Aug. 31, 1994, 183 procedures were performed with a distribution of 14% AF, 62% BG, and 24% PC. In this earlier period the AF early failure rate was 36%, and the patency rates were 48%, 63%, and 48% for AF, BG, and PC, respectively (mean follow-up, 13.8 months).

CONCLUSION

A protocol of noninvasive assessment increased use of AFs. The cumulative patency rate of AFs was improved, and early failure rates were reduced when compared with the preceding institutional experience. Routine noninvasive assessment is recommended to document adequacy of arterial inflow and delineate venous outflow to maximize opportunities for AF.

Vein transposition in the forearm for autogenous hemodialysis access

PURPOSE

We describe a technique of superficial venous transposition in the forearm used for the formation of an arteriovenous fistula for hemodialysis access. These modifications of the single-incision radiocephalic fistula are designed to increase options for arteriovenous fistulas by using veins and arteries that are suitable for use but are not in immediate proximity.

METHODS

Arteries and veins suitable for a primary arteriovenous fistula were identified and mapped using duplex ultrasound in 89 patients. Separate incisions were used in the majority of cases, and the selected forearm vein was mobilized, angiodilated, and transposed into a subcutaneous tunnel on the volar aspect of the forearm. Before initiation of hemodialysis, duplex ultrasound scanning was performed, and the location that was most suitable for cannulation was identified. Repeat scans were performed at 3-month intervals for analysis of patency.

RESULTS

Superficial venous transpositions were performed using a single incision in 13 instances in which the vein was in immediate proximity to the radial artery (type A). Dorsal-to-volar forearm transposition (type B) was performed in 30 veins with anastomoses to the radial (n = 26), ulnar (n = 2), or brachial (n = 2) arteries. Volar-to-volar forearm transposition (type C) was performed in the remaining 46 veins, with anastomoses to the radial (n = 42), ulnar (n = 2), or brachial arteries (n = 2). Successful hemodialysis was accomplished in 81 of 89 patients (91%). The primary cumulative patency rate was 84% at 1 year and 69% at 2 years. The mean duration of follow-up was 14.3 months.

CONCLUSIONS

The use of superficial venous transposition for the formation of autogenous hemoaccess was associated with ease of cannulation by dialysis personnel, high maturation rates, reduced early failure rates, and enhanced patency rates. We recommended the use of these technical modifications to increase the use of autogenous fistulas in the forearm.

Carotid arterial trauma: assessment with the Glasgow Coma Scale (GCS) as a guide to surgical management

Management of carotid arterial injuries associated with focal neurological deficit or altered state of consciousness (SCON) remains unresolved. Experience with these injuries in one particular hospital was reviewed and the Glasgow Coma Scale (GCS) utilized to assist with clinical stratification of these patients. A literature review was also conducted to better define indications for repair or ligation of carotid injuries. From 1978 to 1990, 34 patients with carotid arterial injuries were reviewed with reference to the GCS, focal deficit, hypotension, anatomic site and mechanism of injury. The literature from 1952 to 1993 was surveyed for carotid artery injuries (1316 patients). Outcome of treatment with or without repair was compared with pre-operative neurologic status. Thirty-four patients with injuries of the common (24) or internal (10) carotid arteries were managed with repair (68%), ligation (24%) or observation (9%). The SCON was normal in 18 patients; 16 patients (88%) underwent repair and all remained normal. All patients with GCS 9-14 regained a normal SCON after surgical repair, while 10 patients with GCS < 8 had repair (5), ligation (3), and non-operative management (2); five returned to normal, four died and one remained comatose. However, outcomes correlated poorly with management. Of 1316 patients cited in the surgical literature, patients with no deficit and patients with pre-operative deficits did significantly better after repair as compared with ligation (P<0.001). In comatose patients, management did not affect outcome. It is concluded that carotid arterial injuries should be repaired in patients with normal neurologic evaluation, focal pre-operative neurologic deficits and in patients with GCS > 9. Comatose patients with GCS < 8 do poorly regardless of management. The GCS provides an objective for stratification of patients with altered SCON who benefit from repair of carotid arterial injuries.

Outcome of complex venous reconstructions in patients with trauma

PURPOSE

The role of complex venous reconstructions (CVRs) in patients with major trauma remains a controversial topic. This study evaluates the patency and clinical outcome of CVRs in a major urban trauma center.

METHODS

Between 1979 and 1994 the records of 92 patients with 100 injuries to the iliac, femoral, and popliteal venous system were reviewed. The incidence of edema, pulmonary embolism, and limb loss was documented in 75 men and 17 women (mean age of 27 years, range 14 to 59 years). The 30-day patencies were assessed in all patients with either impedance plethysmography (n = 16), venography (n = 40), or duplex scan (n = 36). Long-term patencies were assessed in 14 patients monitored for 0.5 to 9 years (mean 3.2 years).

RESULTS

Mechanisms of injury consisted of 58 gunshot wounds, 23 stab wounds, 6 shotgun wounds, and 5 blunt injuries. There were 112 associated injuries, 41 of which were concomitant arterial injuries. Forty-five of the 100 venous injuries were repaired with CVRs and included 6 (13%) spiral vein grafts, 8 (18%) panel vein grafts, 8 (18%) reversed saphenous vein interposition grafts, 8 (18%) end-to-end repairs, and 15 (33%) vein patch repairs. Thirty-day patency rates for these repairs were 50%, 50%, 75%, 88%, and 87%, respectively, and an overall patency rate of 73% was observed. The remaining 55 injuries were treated with ligation (n = 27) or lateral venorrhaphy (n = 28). The cumulative 30-day patency rate for all venous repairs was 81% (59 of 73). Fourteen patients, nine of whom had CVRs, were available for long-term follow-up. In this group CVRs demonstrated a 100% patency. One patient with a spiral vein graft repair of the common femoral vein had severe reflux causing intermittent edema and mild lipodermatosclerosis. No pulmonary emboli, limb loss, or deaths were identified in patients undergoing CVRs.

CONCLUSION

Patients with CVRs had a 30-day patency rate of 73%. Of this group panel and spiral vein grafts were less successful, exhibiting only a 50% 30-day patency rate, whereas end-to-end and vein patch repairs were successful in 88% and 87% of cases, respectively. Our overall evaluation suggests that use of CVRs results in successful venous repair; however, the postoperative patency of interposition panel and spiral grafts suggests selective use of these techniques.

A program of operative angioplasty: endovascular intervention and the vascular surgeon

PURPOSE

Vascular surgeons are ideally suited to select and perform endovascular interventions either as primary therapy or as an adjunct to bypass surgery. Attaining proficiency in endovascular techniques is an important goal in the training of vascular surgeons. We report our initial experience with a program of endovascular intervention performed in the operating room by vascular surgeons.

METHODS

During the previous three years, we performed 109 angioplasty procedures, 60 aortoiliac (55%), 32 femoropopliteal (29%), and 17 popliteal/tibial (16%), using guidewires and angioplasty balloons directed by intraoperative digital subtraction C-arm arteriography with road-mapping capabilities. Indications for angioplasty included disabling claudication in 59 patients (54%), rest pain in 18 (17%), and tissue loss in 32 (29%). Angioplasty was accompanied by stent placement in 39 of 60 aortoiliac procedures (65%) and in two of 32 femoral procedures (6%). In 16 cases (15%), the endovascular procedure was performed in conjunction with a bypass procedure. In selected cases (15, 14%), duplex scanning was the sole diagnostic method used before surgery to identify the lesion, eliminating the need for preoperative arteriographic scans. Segmental pressure measurements, duplex ultrasound scans, and treadmill exercise testing as indicated were performed before and after surgery. The efficacy of the endovascular intervention was assessed at 3-month intervals during the first year and at 6-month intervals thereafter.

RESULTS

A successful results was defined using criteria recommended by the Ad Hoc Subcommittee on Reporting Standards for Endovascular Procedures from the Society for Vascular Surgery/International Society for Cardiovascular Surgery. This included the combination of symptomatic improvement, obtaining an anatomically successful result with < 30% residual lumen stenosis, and elimination of the translesion gradient with an improvement in high thigh-brachial index or ankle-brachial index greater than 0.15. Initial success was achieved in 55 of 60 aortoiliac (92%), 28 of 32 femoropopliteal (88%), and 16 of 17 popliteal/tibial (94%) angioplasty procedures. Clinical follow-up has been achieved in all cases, with continued clinical success rates of 80%, 75%, and 82% for aortoiliac, femoropopliteal, and popliteal/tibial angioplasty procedures, respectively, with a mean follow-up of 15.7 months.

CONCLUSION

These results confirm the value of a program in which C-arm technology was used by vascular surgeons in the performance of angioplasty and stenting procedures in the operating room. This experience in therapeutic endovascular intervention will facilitate the credentialing process for future vascular surgeons.

The significance of calf muscle pump function in venous ulceration

PURPOSE

Patients with clinically evident chronic venous insufficiency were evaluated to relate the degree of insufficiency and calf muscle pump dysfunction to venous ulceration.

METHODS

Sixty-nine limbs in 55 patients with chronic venous insufficiency by Society for Vascular Surgery/International Society for Cardiovascular Surgery Classification were compared in three groups: classes 1 and 2 with no history of ulceration (19 limbs); class 3 with healed ulceration (20 limbs); and class 3 with active ulcers (30 limbs). Air plethysmography measurements of outflow fraction, venous volume, venous filling time, venous filling index, ejection fraction, ejection volume, residual volume fraction, and residual volume were made. In 62 of the 69 limbs, color-flow duplex ultrasonography was used to determine the pattern of reflux.

RESULTS

The outflow fraction was normal in 84%, 75%, and 77% of nonulcerated, healed, and ulcerated limbs. The venous filling index was abnormal in most limbs (nonulcerated 95%, healed 90%, ulcerated 98%) but not significantly different among groups. Differences in calf muscle pump function were significant. Ulcerated limbs had significantly poorer ejection fractions (p = 0.0002) and greater residual volume fractions (p = 0.0006) than nonulcerated or healed limbs. By ultrasonography, deep and superficial vein incompetence was present in most limbs and was not statistically different among groups. Although venous insufficiency was not measurably different among groups, limbs with active venous ulcers had significantly poorer calf muscle pump function than those with healed ulcers or with no history of ulceration.

CONCLUSION

Venous insufficiency is necessary but not sufficient to cause ulceration, and a deficiency of the calf muscle pump is significant to the severity of venous ulceration.

Carotid endarterectomy for asymptomatic carotid stenosis: a ten-year experience with 120 procedures in a fellowship training program

Performance of carotid endarterectomy for asymptomatic carotid stenosis has been restricted during recent years because of concern of reported complications in as high as 10-15% of patients, as well as limited long-term data on stroke protection. During the last 10 years, we have studied immediate and long-term results of carotid endarterectomy for asymptomatic disease in 120 patients. Operations were performed by a clinical vascular fellow with a staff surgeon in attendance in 113 (94%) cases with the remainder performed by the staff surgeon. Patients' mean age was 66 years; 82% were men. Risk factors included hypertension (56%), smoking (52%), coronary artery disease (32%), diabetes (24%), and hypercholesterolemia (6%). Arteriographic severity of stenoses was 80-99% in 74%, 60-79% in 22%, and 40-59% in 4% of cases. Postoperative complications included two transient neurological events (1.7%). No permanent strokes or deaths occurred. Using the life table method, cumulative stroke rate was 4.5% for ipsilateral events and 7.3% for contralateral events, confirming the high degree of stroke protection afforded by carotid endarterectomy in this population. Since these results were accomplished in a fellowship training program, we regard adequacy of this experience as the most influential factor in accomplishing this record. Surgeons who are unable to achieve comparable results should consider abandonment of the procedure or an extended period of additional training.

Intravascular ultrasonography: validation studies and preliminary intraoperative observations

Intravascular ultrasonography is emerging as an important imaging modality to assess the presence, distribution, and extent of atherosclerotic vascular disease. To determine the accuracy and clinical utility of intravascular ultrasonography, a flexible catheter-based system was used to generate two-dimensional, cross-sectional vascular images. In 23 arteries of 11 sheep 206 in vivo images demonstrated an echo-free lumen surrounded by three distinct concentric acoustic transitions corresponding to intima, media, and adventitia. Ultrasound measurements of lumen diameter and area correlated significantly with those of corresponding arteriographic measurements obtained by use of digital calipers (r = 0.91, r = 0.86). To evaluate clinical feasibility, intraoperative images (n = 160) were obtained in 10 patients undergoing vascular bypass or hemodialysis access procedures. The images depicted luminal configuration and arterial wall morphologic characteristics. Measurements of lumen diameter and lumen area correlated closely with corresponding intraoperative arteriography (r = 0.81, r = 0.79). The ultrasound images demonstrated arterial stenoses, intimal hyperplasia, intraluminal thrombus, polytetrafluoroethylene graft material, and anastomotic sites. We conclude that flexible catheter-based ultrasonography produces images that accurately demonstrate arterial wall architecture, lumen diameter, and area. Intraoperative application can produce images that provide unique information thus expanding the clinical potential of ultrasonography as a guidance system for vascular procedures.

Reduced dependency on arteriography for penetrating extremity trauma: influence of wound location and noninvasive vascular studies

Indications for arteriography in penetrating extremity trauma remain controversial. We reviewed our clinical experience in 454 patients (514 extremities) with penetrating trauma admitted during a prior 3 1/2-year period. Injuries were caused by stab wounds in 60 (11.7%) extremities and by gunshot wounds in 454 (88.3%) extremities. Thirty-three of the 60 stab wounds (55%) required urgent exploration, and 27 underwent arteriography. No arteriograms were positive for unsuspected arterial injury in this group. Forty-two of 454 gunshot wounds (9.3%) underwent mandatory exploration; arteriograms were performed on 412 extremities. Forty-four arteriograms (10.7%) demonstrated evidence of unsuspected arterial injuries. During the last year, randomly selected extremities (n = 23) have been studied with B-mode ultrasonography and segmental Doppler pressure measurements. Using the subsequent arteriography as the "gold" standard, sensitivity was 83% and specificity was 100%. Gunshot wounds were categorized according to location and positive arteriograms. Injuries to the lateral thigh and arm resulted in no positive arteriograms, while positive studies were observed in 11% of medial and posterior arm, 14% of antecubital fossa, 25% of forearm, 7.5% of medial and posterior thigh, 8% of popliteal fossa, and 26% of calf injuries. We recommend arteriography for gunshot injuries to identified high-risk areas, while clinical evaluation alone is accurate in all stab wounds to the extremities and gunshot wounds to the lateral thigh and outer arm. Preliminary data suggest expanded use of B-mode ultrasonography may further reduce our dependency on arteriography in these cases.

Penetrating extremity trauma: identification of patients at high-risk requiring arteriography

Indications for arteriography in patients with penetrating trauma to the extremities remain controversial. Some clinicians have recommended universal use of arteriography, whereas others prefer to rely on physical findings alone. To better define our indications for contrast studies, we reviewed clinical data on 306 patients (349 extremities) with penetrating trauma who were admitted during a prior 2-year period (1985 to 1987). Injuries were caused by stab wounds in 50 (14.3%) extremities and by gunshot wounds in 299 (85.7%) extremities. Twenty-seven of the 50 stab wounds (54%) required urgent exploration based on physical findings, whereas 23 underwent arteriography. None of these studies showed unsuspected arterial injury. Twenty-nine of 299 gunshot wounds (9.7%) underwent mandatory exploration, and arteriograms were performed on 270 extremities; findings in 30 studies (11.1%) were positive for unsuspected arterial injuries. Gunshot wounds were categorized according to location and number of arteriograms with positive results. Arteriograms of lateral thigh and upper arm injuries resulted in no positive outcomes. Positive study results were recorded in 22.9% of calf injuries, 20% of forearm and antecubital injuries, 9.5% of popliteal fossa injuries, 9.0% of medial and posterior thigh injuries, and 8.3% of medial and posterior upper arm injuries. We recommend arteriography for penetrating injuries to these high-risk areas. However, clinical evaluation alone is accurate for identification of arterial trauma with lateral thigh or upper arm wounds and stab wounds to the extremities.

Diagnosis of acute deep venous thrombosis

This article outlines the application of continuous-wave Doppler, plethysmographic techniques, and B-mode ultrasonography to the diagnosis of suspected deep venous thrombosis in ambulatory patients. Methodology is evaluated, and the diagnostic accuracy and application of these studies are reviewed. The authors' current algorithm for the application of these noninvasive studies also is presented.

Studies on the allergenicity of the developing spores of Pteris vittata L

Ninety patients were investigated with intradermal testing of developing stages of Pteris vittata L., whole spores, and their fractions. Allergenic principles were found to be present in both protoplasm and spore wall of the fertile tissue.

Intestinal obstruction: still a lethal clinical entity

A retrospective analysis of 70 consecutive patients with a clinical diagnosis of intestinal obstruction from January 1983 to September 1985 was reviewed. Mean age was 62 years. Etiological factors included adhesions 50 percent, malignancy 24 percent, volvulus 12 percent, diverticulitis 7 percent, hernias 4 percent, and radiation enteritis, mesenteric infarction, and perforation of the cecum in the remaining 3 percent. Complications included wound infection 9 percent (n = 6), intra-abdominal sepsis 7 percent (n = 5), and recurrent small bowel obstruction 4 percent (n = 3). Overall mortality was 24 percent (n = 7).Results of the univariant analysis showed no association between the clinical signs of intestinal obstruction, that is, fever, tachycardia, leukocytosis, and local tenderness, and gangrenous bowel. A multiple regression analysis showed, however, that only 14 percent of the variance was able to predict the gangrenous bowel based on clinical signs. In conclusion, the classical signs of intestinal obstruction are poor indicators for compromised bowel, and early surgical intervention will reduce the incidence of ischemic bowel and mortality.

Carotid restenosis: long-term noninvasive follow-up after carotid endarterectomy

Recurrent stenosis has not been a primary consideration in the selection of patients for carotid endarterectomy. We have studied the incidence of postoperative restenosis retrospectively in 265 patients following 310 carotid endarterectomies. Two hundred fourteen patients (248 endarterectomies) were examined at 6-12 month intervals using ocular pneumoplethysmography, spectral analysis, and B-mode imaging. The absolute incidence of recurrent carotid disease was 28% (69 of 248), with a 13% (33 of 248) incidence of hemodynamically significant restenosis and a 15% (36 of 248) incidence of hemodynamically insignificant disease. Life table analysis of the data projected a 32% incidence of hemodynamically significant restenosis after 7 years and a 40% incidence of hemodynamically insignificant recurrence. These data demonstrate a progressively increasing rate of restenosis. The incidence of ipsilateral neurologic events was 8% (24 of 310); 12 occurred in association with noninvasively evident recurrent disease (12 of 69, 17%), whereas 11 occurred in noninvasively determined normal arteries (11 of 179, 6%). Noninvasive follow-up was not available in 1 patient. Of the 12 events associated with recurrent disease, 5 occurred in association with hemodynamically significant restenosis (5 of 33, 15%), whereas 7 occurred in association with hemodynamically insignificant disease (7 of 36, 19%). Carotid endarterectomy is a durable operative procedure with 92% (286 of 310) of arteries remaining asymptomatic over the period of clinical follow-up. However, absolute and life table projections of the incidence of asymptomatic restenosis are high, and this factor should be considered in the selection of patients for carotid endarterectomy, particularly in the absence of lateralizing symptoms.

Digital subtraction angiography versus noninvasive testing in the vascular assessment of the ischemic foot

This report discusses the role of digital subtraction angiography as well as noninvasive vascular testing in the evaluation of the ischemic foot. A case history is described presenting the diagnostic modalities and surgical management of an insulin-dependent diabetic man with gangrene.

The value of laser Doppler velocimetry and transcutaneous oxygen tension determination in predicting healing of ischemic forefoot ulcerations and amputations in diabetic and nondiabetic patients

The ability to predict successful healing of ulcerations and amputations of the ischemic forefoot continues to be a major clinical challenge, particularly in diabetic patients whose systolic Doppler ankle pressures are often artifactually elevated. We have used the techniques of laser Doppler velocimetry (LD) and transcutaneous oxygen tension monitoring (tcPO2) to quantitatively measure skin blood flow in the distal foot. Fifty-nine limbs were studied (48 patients), of which 37 (63%) were in diabetic and 22 (37%) in nondiabetic patients. All patients were admitted with ischemic ulcerations or gangrenous changes of the forefoot or digit. Twenty transmetatarsal or digital amputations were performed; the remainder of the lesions were débrided and allowed to heal by secondary intention or were covered by a skin graft. Before operation, the systolic pressure (expressed in millimeters of mercury, mean +/- SEM) was measured by Doppler technique at the ankle, and the ankle/arm index calculated (n = 59 limbs). The tcPO2 (also expressed in millimeters of mercury, mean +/- SEM) was measured from the dorsal foot (n = 56). The baseline skin blood flow velocity (SBFV) and pulse wave amplitude (PWA) were measured with the LD (expressed in millivolts, mean +/- SEM) on the plantar aspect of the foot (n = 53 limbs). Criteria for successful healing included a tcPO2 of more than 10 mm Hg, the combination of an LD-SBFV of more than 40 mV and an LD-PWA of more than 4 mV, and an ankle systolic pressure of more than 30 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)