Michael F. Bath

Systematic review of cardiovascular disease and cardiovascular death in patients with a small abdominal aortic aneurysm.

Screening for abdominal aortic aneurysm (AAA) has reduced the rate of AAA rupture. However, cardiovascular disease is still a major cause of death in men with an AAA. The aim of this study was to assess cardiovascular risk in patients with a small AAA.

Long-Term Renal Function after Endovascular Aneurysm Repair

BACKGROUND AND OBJECTIVES Endovascular repair (EVAR) is a common treatment for abdominal aortic aneurysm (AAA). However, its long-term effects on renal function remain unclear. We aimed to assess long-term renal dysfunction after EVAR using a contemporary estimate of GFR and to compare long-term renal outcomes in patients after EVAR with open aneurysm repair (OAR) and in patients without an AAA. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS We performed a nested case-matched analysis of 726 patients (using a prospectively maintained database for repairs that took place between January 2000 and May 2010 in a tertiary center): 121 patients undergoing OAR (with data at baseline and 5 years postrepair) were case matched (age, sex, smoking, diabetes, baseline eGFR) to patients undergoing suprarenal and infrarenal fixation EVAR (242 in each group) and to 121 patients undergoing carotid endarterectomy (CEA) without AAA. Changes in eGFR were compared (1 and 5 years). RESULTS The OAR patients lost an average of 7.4 ml/min per 1.73 m2 at 5 years (95% confidence interval [95% CI], 4.8 to 10.6), compared with 8.2 ml/min per 1.73 m2 (95% CI, 6.5 to 10.8; P<0.001) for infrarenal-fixation EVAR, 16.9 ml/min per 1.73 m2 (95% CI, 13.0 to 21.9, P<0.001) for suprarenal-fixation EVAR, and 5.4 ml/min per 1.73 m2 (95% CI, 1.7 to 7.5; P<0.001) for CEA. The decrease in eGFR was steeper during the first postoperative year, with each group losing -2.2 ml/min per 1.73 m2 (infrarenal-fixation EVAR), -10.7 ml/min per 1.73 m2 (suprarenal-fixation EVAR), and -4.6 ml/min per 1.73 m2 (OAR), compared with -1.9 ml/min per 1.73 m2 for CEA. CONCLUSIONS Elective EVAR is associated with a significant decline in eGFR after 5 years, which is steeper in the first postoperative year and more pronounced compared with a similar population with atherosclerotic disease.

Exploring LPS-induced sepsis in rats and mice as a model to study potential protective effects of the nociceptin/orphanin FQ system

The nociceptin receptor (NOP) and its ligand nociceptin/orphanin FQ (N/OFQ) have been shown to exert a modulatory effect on immune cells during sepsis. We evaluated the suitability of an experimental lipopolysaccharide (LPS)-induced sepsis model for studying changes in the nociceptin system. C57BL/6 mice BALB/c mice and Wistar rats were inoculated with different doses of LPS with or without a nociceptin receptor antagonist (UFP-101 or SB-612111). In C57BL/6 mice LPS 0.85 mg/kg injection produced no septic response, whereas 1.2mg/kg produced a profound response within 5h. In BALB/c mice, LPS 4 mg/kg produced no response, whereas 7 mg/kg resulted in a profound response within 24h. In Wistar rats LPS 15 mg/kg caused no septic response in 6/10 animals, whereas 25mg/kg resulted in marked lethargy before 24h. Splenic interleukin-1β mRNA in BALB/c mice, and serum TNF-α concentrations in Wistar rats increased after LPS injection in a dose-dependent manner, but were undetectable in control animals, indicating that LPS had stimulated an inflammatory reaction. IL-1β and TNF-α concentrations in LPS-treated animals were unaffected by administration of a NOP antagonist. Similarly NOP antagonists had no effect on survival or expression of mRNA for NOP or ppN/OFQ (the N/OFQ precursor) in a variety of tissues. In these animal models, the dose-response curve for LPS was too steep to allow use in survival studies and no changes in the N/OFQ system occurred within 24h. We conclude that LPS-inoculation in rodents is an unsuitable model for studying possible changes in the NOP-N/OFQ system in sepsis.

Impact of Fenestrated Endovascular Abdominal Aortic Aneurysm Repair on Renal Function

Purpose: To investigate the impact of fenestrated endovascular aneurysm repair (fEVAR) on renal function perioperatively and at midterm. Methods: A case-controlled study was performed involving 58 patients (mean age 75±7 years; 51 men) who underwent elective fEVAR for a juxtarenal or short-necked abdominal aortic aneurysm (AAA) matched on age, sex, smoking, diabetes, and baseline estimated glomerular filtration rate (eGFR) with a contemporaneous group undergoing open aneurysm repair (OAR) for the same indications. Perioperative incidence of acute kidney injury (AKI) and levels of eGFR at 30 days and 1 year were compared. A systematic literature review was performed to identify studies that had used eGFR as renal outcome after fEVAR; the pooled data were meta-analyzed using an eGFR drop >30% at 1 month and the latest follow-up as endpoints. Results are reported as the pooled proportion and 95% confidence interval (CI). Results: The incidence of AKI after fEVAR was 28% compared to 10% after OAR (p=0.03). Following fEVAR, the mean eGFR dropped from 78±8 to 74±9 mL/min/1.73 m2 at 30 days compared to a change from 79±8 to 80±16 mL/min/1.73 m2 after OAR (p<0.01). However, the absolute drop in eGFR between fEVAR and OAR at 1 year was similar (7 mL/min/1.73 m2; p=0.53); 7% of the fEVAR patients had an eGFR drop >30% at that point compared with none for OAR (p=0.12). The systematic literature review identified eGFR outcomes for 193 fEVAR patients. Combining these patients with the 58 from our cohort study, the pooled proportions of eGFR drop >30% were 20% (95% CI 9% to 39%) at 30 days and 8% (95% CI 0.5% to 13%) at the end of follow-up. Conclusion: fEVAR has a significant perioperative impact on renal function, but 1-year results are similar to OAR. fEVAR patients may benefit from targeted AKI prevention strategies that need to be assessed in relevant studies.

Training and trials—building a future

The debate about research training is not confined to postgraduate surgical trainees.1 As medical students, we too would like to learn how to recruit into and participate in clinical trials across all specialties. When we graduate, we will be expected to make diagnoses, order tests, and start treatment. The General Medical Council’s “Tomorrow’s Doctors” guidance emphasises the …

Reporting individual surgeon outcomes does not lead to risk aversion in abdominal aortic aneurysm surgery

INTRODUCTION Reporting surgeons’ outcomes has recently been introduced in the UK. This has the potential to result in surgeons becoming risk averse. The aim of this study was to investigate whether reporting outcomes for abdominal aortic aneurysm (AAA) surgery impacts on the number and risk profile (level of fitness) of patients offered elective treatment. METHODS Publically available National Vascular Registry data were used to compare the number of AAAs treated in those centres across the UK that reported outcomes for the periods 2008‐2012, 2009‐2013 and 2010‐2014. Furthermore, the number and characteristics of patients referred for consideration of elective AAA repair at a single tertiary unit were analysed yearly between 2010 and 2014. Clinic, casualty and theatre event codes were searched to obtain all AAAs treated. The results of cardiopulmonary exercise testing (CPET) were assessed. RESULTS For the 85 centres that reported outcomes in all three five‐year periods, the median number of AAAs treated per unit increased between the periods 2008‐2012 and 2010‐2014 from 192 to 214 per year (p=0.006). In the single centre cohort study, the proportion of patients offered elective AAA repair increased from 74% in 2009‐2010 to 81% in 2013‐2014, with a maximum of 84% in 2012‐2013. The age, aneurysm size and CPET results (anaerobic threshold levels) for those eventually offered elective treatment did not differ significantly between 2010 and 2014. CONCLUSIONS The results do not support the assumption that reporting individual surgeon outcomes is associated with a risk averse strategy regarding patient selection in aneurysm surgery at present.

Reporting individual surgeon outcomes does not affect number and characteristics of abdominal aortic aneurysms offered treatment in the UK

Methods: The number and characteristics of patients referred for consideration of electiverepair in one tertiary-unit were analysed yearly between 2010-2014 (University Hospital Coventry and Warwickshire; UHCW). Cardiopulmonary-exercise test (CPET) results were assessed; clinic, casualty and theatre event-codes were searched to obtain all AAAs treated. Subsequently, publically available National Vascular Registry (NVR) data were used to compare the number of AAAs treated in the 91 units that reported outcomes in 2013 (period: 2008-2012) and 2014 (2009-2013) and the 86 units reporting AAA-outcomes in 2013, 2014 and 2015 (2010-2014).Introduction: Abdominal aortic aneurysm (AAA) is a disease with strong genetic background, based on evidence from epidemiological studies. At least four genome-wide association studies (GWAS) have identified genetic loci associated with AAA-presence and several single nucleotide polymorphisms (SNPs) have been identified through candidate-gene studies. However, there is limited evidence regarding the effect of genetics on AAA-growth.

Cardiovascular risk profile and management of risk factors in patients with small abdominal aortic aneurysm

Methods: The number and characteristics of patients referred for consideration of electiverepair in one tertiary-unit were analysed yearly between 2010-2014 (University Hospital Coventry and Warwickshire; UHCW). Cardiopulmonary-exercise test (CPET) results were assessed; clinic, casualty and theatre event-codes were searched to obtain all AAAs treated. Subsequently, publically available National Vascular Registry (NVR) data were used to compare the number of AAAs treated in the 91 units that reported outcomes in 2013 (period: 2008-2012) and 2014 (2009-2013) and the 86 units reporting AAA-outcomes in 2013, 2014 and 2015 (2010-2014).Introduction: Abdominal aortic aneurysm (AAA) is a disease with strong genetic background, based on evidence from epidemiological studies. At least four genome-wide association studies (GWAS) have identified genetic loci associated with AAA-presence and several single nucleotide polymorphisms (SNPs) have been identified through candidate-gene studies. However, there is limited evidence regarding the effect of genetics on AAA-growth.

Regulation of preparation courses for the Situational Judgement Test

Furthermore, one is more likely to be distracted and the social pressure to be polite both to the lecturer and other students is removed. Perhaps this is validated by the fact that a staggering 60% of students in the study viewed lectures more than three times! Although there are undeniable benefits to being able to access lectures remotely in terms of geographical feasibility, we believe that webcast should be considered as a supplement and not a replacement to live teaching.

Impact of hospital volume on outcomes following treatment of thoracic aortic aneurysms and type-B dissections

Previous research suggests an association between hospital volume and outcomes in high-risk surgical pathologies. The association between hospital volume and outcomes in patients with isolated descending thoracic aortic aneurysms (DTAAs) and type-B thoracic aortic dissections (TBADs) is conflicting. We aimed to investigate this in a literature review and meta-analysis. A systematic review of the literature was performed to identify studies reporting mortality and morbidity following repair (elective or emergency) of DTAA and/or TBAD using the Medline and Embase Databases (2000-2015). Hospital volume was assessed based on the number of patients treated per institution: low volume (1-5 cases per year), medium volume (6-10) and high volume (>10). The primary outcome of interest was all-cause mortality during inpatient stay and at 30 days. Eighty-four series of non-dissecting DTAA or TBAD were included in data synthesis (4219 patients; mean age: 62 years; males: 73.5%). For all patients (emergency and elective) undergoing DTAA repair, in-hospital mortality was 8% [95% confidence interval (CI): 6-8%]. Results were not superior in high-volume centres (8 vs 6 vs 11% for high-, medium- and low-volume, respectively). Sub-analyses for emergency and elective repairs showed no significant differences. For TBAD repairs, in the combined population (emergency and elective), results reached borderline significance (P = 0.0475), favouring high-volume centres (6 vs 11 vs 14%), but this association disappeared when emergency and elective repairs were analysed separately. Nine series reported outcomes at 1 year and 5 series followed DTAA and 18 TBAD treatment. No meaningful long-term comparisons were possible due to the lack of data. No significant associations were detected between hospital volume and subsequent mortality following DTAA or TBAD treatment. Data were heterogeneous and long-term results were scarcely reported. A well-designed longitudinal study of sufficient size is required to inform future strategies in this area.