Argiri Sianou

The effect of body mass index on major outcomes after vascular surgery

Objective: Obesity has been associated with an increased risk for cardiovascular morbidity and mortality, although pooled evidence in patients undergoing vascular surgery are lacking. The aim of this systematic review was to evaluate the effect of body mass index (BMI) on major postoperative outcomes in patients undergoing vascular surgery. Methods: A systematic literature review conforming to established criteria to identify eligible articles published before May 2016 was conducted. Eligible studies evaluated major postoperative outcomes in vascular surgery patients of different BMI groups according to the weight classification of the National Institutes of Health criteria: underweight (UW), BMI ≤18.5 kg/m2; normal weight (NW), BMI of 18.6 to 24.9 kg/m2; overweight (OW), BMI of 25 to 29.9 kg/m2; and obese (OB), BMI ≥30 kg/m2. Major outcomes included 30‐day mortality, cardiac complications, and respiratory complications. Secondary outcomes included wound and cerebrovascular complications, renal complications, deep venous thrombosis/pulmonary embolism, and other complications. Results: Overall, eight retrospective studies were eligible including a total of 92,525 vascular surgery patients (2223 UW patients, 29,727 NW patients, 34,517 OW patients, and 26,058 OB patients). Pooled data were as follows: mortality rate, 2.5%; cardiac events, 2.1%; respiratory events, 8.6%; wound complications, 6.4%; cerebrovascular events, 6.4%; renal complications, 3.9%; other infections, 5.3%; deep venous thrombosis/pulmonary embolism, 1.2%; and other complications, 3.7%. Meta‐analysis showed that OB patients were associated with lower mortality (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.541–0.757; P < .0001), cardiac morbidity (OR, 0.81; 95% CI, 0.708–0.938; P = .004), and respiratory morbidity (OR, 0.87; 95% CI, 0.802–0.941; P = .0006) after vascular surgery compared with NW patients. However, OB patients were associated with a higher wound complication rate (OR, 2.39; 95% CI, 1.777–3.211; P < .0001) compared with NW patients. In contrast, UW patients were associated with a higher mortality (OR, 1.71; 95% CI, 1.177–2.505; P = .005) and respiratory morbidity (OR, 1.84; 95% CI, 1.554–2.166; P < .0001) compared with NW patients. Conclusions: The “obesity paradox” does exist in patients undergoing vascular surgery. This paradox refers not only to 30‐day overall mortality but also to 30‐day cardiac and respiratory complications. However, obesity seems to be associated with more wound complications. Surprisingly, UW patients are associated with higher mortality as well as respiratory events postoperatively.

Spontaneous Rectus Sheath Hematoma in the Elderly: An Unusual Case and Update on Proper Management

Spontaneous rectus sheath hematoma (SRSH) is an uncommon medical emergency in the elderly. We present a case of SRSH with an atypical clinical presentation and discuss literature regarding diagnosis and proper management. A 75-year-old female patient was transferred to the emergency department due to acute dyspnoea and confusion. Her medical history revealed a viral infection of the upper respiratory tract, and no coughing or use of anticoagulants. The clinical examination showed tenderness of the left lower abdomen, although palpation was misleading due to patients obesity. Laboratory investigations showed light anaemia. Ultrasonography and computed tomography revealed a large rectus sheath hematoma of the left abdominal wall. Despite further deterioration of the patient, conservative management including bed rest, fluid replacement, blood products transfusion, and proper analgesia was successful. No surgical intervention was needed. Prompt diagnosis and management of SRSH plays significant role in the prognosis, especially in elder patients. Independently of size and severity, conservative management remains the first therapeutic choice. Only by failure of supportive management, progressive and large hematoma or uncontrollable hemodynamic patients, interventional management including surgery or less invasive newer techniques is indicated.

Meta-Analysis of Studies Evaluating the Effect of Cilostazol on Major Outcomes After Carotid Stenting

Purpose: To evaluate the effect of cilostazol on major outcomes after carotid artery stenting (CAS). Methods: A systematic literature review was conducted conforming to established criteria in order to identify articles published prior to May 2015 evaluating major post-CAS outcomes in patients treated with cilostazol vs patients not treated with cilostazol. Major outcomes included in-stent restenosis (ISR) within the observation period, the revascularization rate, major/minor bleeding, and the myocardial infarction/stroke/death rate (MI/stroke/death) at 30 days and within the observation period. Data were pooled for all studies containing adequate data for each outcome investigated; effect estimates are presented as the odds ratios (ORs) and 95 confidence intervals (CI). Results: Overall, 7 studies pertaining to 1297 patients were eligible. Heterogeneity was low among studies so a fixed-effect analysis was conducted. Six studies (n=1233) were compared for the ISR endpoint, showing a significantly lower ISR rate with cilostazol treatment after a mean follow-up of 20 months (OR 0.158, 95% CI 0.072 to 0.349, p<0.001). Five studies (n=649) were compared regarding 30-day MI/stroke/death (OR 0.724, 95% CI 0.293 to 1.789, p=0.484) and 3 studies (n=1076) were analyzed regarding MI/stroke/death within the entire follow-up period (OR 0.768, 95% CI 0.477 to 1.236, p=0.276); no significant difference was found between the groups. Data on bleeding rates and revascularization rates post ISR were inadequate to conduct further analysis. Conclusion: Cilostazol seems to decrease total ISR rates in patients undergoing CAS without affecting MI/stroke/death events, both in the early and late settings.

Cerebral hyperperfusion syndrome and intracranial hemorrhage after carotid endarterectomy or carotid stenting: A meta-analysis

INTRODUCTION Cerebral hyperperfusion syndrome (CHS) and intracranial hemorrhage (ICH) after carotid revascularization have been associated with significant morbidity and mortality, although pooled data comparing these outcomes between open and endovascular treatment are lacking. Aim of this meta-analysis is to compare CHS and ICH risk between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS). METHODS A systematic literature review was conducted conforming to established criteria, in order to identify eligible articles published prior to February 2017. Eligible studies compared CHS and/or ICH between patients undergoing CEA and CAS. Other outcomes evaluated in this review included stroke and death due to ICH. Outcome risks are presented as odds ratios (OR) and 95% confidence intervals (CI). RESULTS Overall, 6 studies (5 studies reporting on CHS and 4 studies reporting on ICH) included 236,537 procedures (218,144 CEA; 18,393 CAS) in total. CEA was associated with a higher risk for CHS compared to CAS (pooled OR=1.432 [95% CI=1.078-1901]; P=0.015), although this difference was generated mainly from older studies (prior to 2012). However, no difference was found regarding ICH risk between the two methods (pooled OR=0.544 [95% CI=0.111-2.658]; P=0.452). Regarding stroke incidence, no difference was found between the two methods as well, although this resulted mainly from studies with a higher volume of CAS procedures (pooled OR=0.964 [95% CI=0.741-1.252]; P=0.833). Finally, death rate was significantly higher among patients with ICH compared to patients without ICH (pooled OR=386.977 [95% CI=246.746-606.906]; P<0.0001). Pooled data were not adequate to calculate potential risk factors for CHS/ICH after CEA compared to CAS. CONCLUSIONS CEA seems to be associated with a higher risk for CHS compared to CAS, although this difference was generated mainly from older studies. However, there seems to be no difference regarding ICH risk between the two methods, with ICH being associated with a significantly higher risk for death.

Risk factors for postoperative delirium in patients undergoing vascular surgery

Objective: Postoperative delirium (PODE) remains a common complication after vascular surgery procedures although the exact pathogenesis remains unclear, mainly because of its multifactorial character. The aim of this systematic review was to evaluate pooled data on potential risk factors for PODE in patients undergoing vascular surgery procedures. Methods: A systematic literature review was conducted conforming to established criteria to identify eligible articles published from 1990 to 2016. Eligible studies evaluated potential risk factors for PODE after vascular surgery procedures, using both univariate and multivariate analysis. PODE was defined as a disturbance of consciousness with reduced ability to focus, sustain, or shift attention after vascular surgery procedures and was diagnosed in all studies using well‐established criteria. Only risk factors reported in at least four studies were included in this review. Pooled results were calculated, and further multivariate regression analysis was conducted. Results: Overall, nine studies (published from 2003 to 2015) including 2388 patients in total were evaluated (457 with and 1931 without PODE). Patients with PODE were older (73.27 vs 69.87 years; P < .0001) and showed a higher male sex rate (78.1% vs 73.5%; P = .043). Open aortic surgery was the most frequent procedure in this analysis, followed by lower limb revascularization. Patients with PODE also showed higher rates of diabetes mellitus, hypertension, cardiac disease, and neurologic disease; lower hemoglobin level; larger duration of surgery; longer hospital and intensive care unit stay; and higher blood loss. Mean age (odds ratio [OR], 3.44; 95% confidence interval [CI], 2.933‐4.034; P < .0001), hypertension (OR, 1.94; 95% CI, 1.469‐2.554; P < .0001), cardiac disease (OR, 3.16; 95% CI, 2.324‐4.284; P < .0001), open aortic surgery (OR, 1.74; 95% CI, 1.421‐2.143; P < .0001), blood loss (OR, 1.01; 95% CI, 1.007‐1.010; P < .0001), hospital stay (OR, 2.26; 95% CI, 1.953‐2.614; P <. 0001), and intensive care unit stay (OR, 6.12; 95% CI, 4.699‐7.957; P < .0001) were identified as the strongest risk predictors for PODE, followed by male sex, diabetes mellitus, neurologic disease, and history of smoking. However, body mass index, renal failure, preoperative hemoglobin level, and general anesthesia were not found to be risk factors for PODE in such patients. Conclusions: This study has confirmed that PODE after vascular surgery procedures is a multifactorial disease, and several independent risk factors have been identified. However, pooled data regarding the effect of PODE on primary outcomes after vascular surgery procedures are still lacking. The results of this review could contribute to the designation of future prediction models and improve prevention of PODE in these patients.

Traumatic Carotid Artery Dissection: A Different Entity without Specific Guidelines.

According to literature data, there are no distinct guidelines regarding the proper diagnostic and therapeutic management of traumatic carotid artery dissection (TCAD). Although most of cases evaluated in research studies refer to spontaneous carotid artery dissection, traumatic cases demand special considerations as far as diagnosis and treatment are concerned. Although both types of dissection share some common characteristics, a patient with TCAD usually presents with several concomitant injuries as well as a higher bleeding risk, thus complicating decision making in such patients. Therefore, aim of this review is to present available data regarding epidemiology, clinical presentation, diagnostics and treatment strategy in cases with TCAD in order to produce useful conclusions for everyday clinical practice.

Squamous cell carcinoma of the hand metastasized to the breast: A unique case

Metastatic squamous cell carcinoma (SCC) to the breast is a very rare entity with a few cases reported in the literature, while the hand as an extra-mammary origin site for this type of malignancy has not been reported before. We describe a unique case of a woman with a SCC lesion excised from the right index finger that metastasized to her ipsilateral breast. A 68-year-old female patient presented with a small palpable lesion of the right breast and without any skin ulceration or malformation. Ultrasonography and computed tomography studies revealed a solitary metastatic lesion of the breast, without any multiple disease or lymphadenopathy diagnosed. Fine Needle Aspiration (FNA) cytology confirmed the correlation of the lesion with the primary site. The patient underwent further surgical and oncological management. The use of FNA cytology is important to distinguish a metastasis from primary breast cancer in order to avoid unnecessary conflicting treatments, even when the medical history is not typical or revealing. SCCs of the hand can give metastases to unusual sites such as the breast and must always be closely followed-up, even if they are successfully excised in healthy margins originally.

Prevalence of vaginitis in different age groups among females in Greece.

Abstract Patients with vaginitis were classified into four groups: Group A (prepubertal under-aged females); Group B (pubertal under-aged females); Group C (reproductive age adult females); Group D (postmenopausal adult females). All vaginal specimens underwent microscopy, amine testing, Gram staining and culturing. Overall, 163 patients were included (33, 14, 81 and 35 patients, respectively). The most common infection was bacterial vaginosis (BV), followed by Ureaplasma infection, aerobic vaginitis (AV) and candidiasis. The most common AV-associated organism was Escherichia coli and the most common BV-associated organism was Gardnerella vaginalis. AV was more frequent in Group A, BV in Group C and Ureaplasma infections in Groups C/D. Decreased lactobacilli concentrations were associated with BV in fertile patients (Groups B–C). Although presentation of vaginitis is similar among females of different age in Greece, type and prevalence of pathogens differ. Normal vaginal flora changes are associated with higher risk of vaginitis in specific age groups. Impact Statement The worldwide incidence of reproductive tract infections has been increasing, with specific pathogens being associated with significant risk of morbidity and complications. However, literature data on the distribution of such infections in different age groups is limited. Therefore, the aim of this study was to provide data on the prevalence and causes of vaginitis in adult and non-adult females of all ages. This study has shown that although presentation of vaginitis is similar among females of different age groups and menstrual status in Greece, type and prevalence of responsible pathogens are different among groups. Changes in normal vaginal flora seem to be associated with higher risk of vaginitis in specific age-groups as well. These findings could contribute in adjusting diagnostic and therapeutic strategies for each age group according to the prevailing pathogens. Further research on antibiotic resistance and treatment outcomes for each age group should be conducted.

Re: Alan J. Wolfe, Linda Brubaker. “Sterile Urine” and the Presence of Bacteria. Eur Urol 2015;68:173–4

We read with great interest the article by Wolfe and Brubaker [1] and their conclusion that the sterile urine paradigm is no longer valid. As highlighted by the authors, newer techniques involving DNA sequence-based analyses can identify bacteria in cases in which traditional culturing methods are not efficient. However, is this really the case? First, to question the dogma that normal urine is sterile, one should be sure that the specimens collected are not contaminated. According to Wolfe and Brubaker [1], urine collection for bacteria detection in several studies—including their own—consisted of suprapubic aspiration or transurethral catheterization to avoid contamination and produce safe results. Moreover, the authors state that transurethral samples are similar to suprapubic samples, bypassing any source of contamination. However, the hypothesis that contamination of the catheter tip while it is being inserted is a possible means by which bacteria gain access to the bladder has been confirmed [2]. Kaye et al [3] noted that even a single bladder catheterization could initiate a urinary tract infection, as insertion of a catheter through the urethra is likely to introduce pathogens from the anterior urethra into the bladder. In this way, bacteria find a suitable culture environment once they reach the bladder. As a result, sensitive detection protocols such as ribosomal RNA gene analysis could easily produce false positive results for bladder colonization. In a previous study we collected urethral swabs and urine specimens for polymerase chain reaction (PCR) analysis [4]. PCR on urethral specimens yielded positive results in 98.3% of symptomatic males with Chlamydia trachomatis infection, which was higher than the 93.1% positivity for simple urine samples. Tosif et al [5] also found that contamination rates were much higher for clean-catch urine specimens than for samples obtained via transurethral and