Ralph G. DePalma

Recurrent Varices after Surgery (REVAS), a Consensus Document

Report of the meeting† held in Paris on 17th & 18th July 1998 with participation oft: Ugo Baccaglini, Italy; Pierre Barthelemy. France; Jean-Claude Couffinhal. France: Denis Creton. France: Simon Darke, United Kingdom; Ralph De Palma, United States of America; Bo Eklof, United States of America; Ermenegildo Enrici, Argentina; Gilbert Franco, France; Jean Pierre Gobin, France; Louis Grondin, Canada; Jean-Jerome Guex. France; Georges Jantet. France; Claude Juhan. France; Jordi Maeso y Lebrun. Spain; Philippe Nicolini. France; Andreas Oesch, Switzerland; Marcelo Paramo-Diaz. Mexico; Michel Perrin. France; Paul Puppinck, France; Eberhard Rabe, Germany: Rene Rettori, France; John Royle, Australia; Vaughan Ruckley, United Kingdom; Michel Schadeck, France; Jean Claude Schovaerdts, Belgium; John Scurr, United Kingdom; Georgio Spreafico, Italy; Jan Struckman, Denmark; Frederic Vin, France Recurrent varicose veins after surgery (REVAS) are a common, complex and costly problem. The frequency of REVAS is stated to be between 20 and 80% depending on the definition of the condition. A consensus meeting on the topic (Paris 1998, July) decided to adopt a clinical definition: the presence of varicose veins in a lower limb previously operated on for varices. The pathology of recurrent varicose veins has been poorly correlated with clinical examination and operative findings. Clinical diagnosis remains essential but does not allow a precise assessment of REVAS. Consequently, the use of imaging investigations is essential. Duplex scan is considered as the method of choice. Both clinical diagnosis and imaging investigations allow the development of a classification for every day usage and future studies. This new classification of CEAP needs to be expanded to define the sites, nature and sources of recurrence, the magnitude of the reflux and other (possible) contributory factors. Methods for REVAS treatment include compression, drugs, sclerotherapy and redo surgery. There was no general consensus in favour of sclerotherapy, surgery or both to treat REVAS. Very few data were available to assess the results of treatment. Factors responsible for recurrence and recommendations for primary prevention were debated and are presented in this article. Guidelines for well-planned prospective studies have been produced.

Blast induced mild traumatic brain injury/concussion: A physical analysis

Currently, a consensus exists that low intensity non-impact blast wave exposure leads to mild traumatic brain injury (mTBI). Considerable interest in this “invisible injury” has developed in the past few years but a disconnect remains between the biomedical outcomes and possible physical mechanisms causing mTBI. Here, we show that a shock wave travelling through the brain excites a phonon continuum that decays into specific acoustic waves with intensity exceeding brain tissue strength. Damage may occur within the period of the phonon wave, measured in tens to hundreds of nanometers, which makes the damage difficult to detect using conventional modalities.

Linking blast physics to biological outcomes in mild traumatic brain injury: Narrative review and preliminary report of an open-field blast model.

HighlightsBlast exposures are associated with traumatic brain injury (TBI); during recent conflicts most of these have been classified as mild TBI (mTBI).The role and mechanisms of primary blast wave injury remain controversial. We review blast models of TBI including shock tubes and open‐field blast.Our analyses of behavioral and pathological findings show that low level blast exposures (peak pressure < 100 kPa) induced lower mortality rates, fewer motor disabilities, and absence of lung injuries as compared to high level blast (peak pressure > 200 kPa).We present preliminary findings obtained from a reproducible open‐field blast murine model of mTBI representing a primary low level blast injury. Within scalability limits, this model closely mimics low level battlefield blast exposures and offers opportunities to advance the understanding of blast physics, resulting neuropathology, and underlying mechanisms leading to chronic effects of mTBI. ABSTRACT Blast exposures are associated with traumatic brain injury (TBI) and blast‐induced TBIs are common injuries affecting military personnel. Department of Defense and Veterans Administration (DoD/VA) reports for TBI indicated that the vast majority (82.3%) has been mild TBI (mTBI)/concussion. mTBI and associated posttraumatic stress disorders (PTSD) have been called “the invisible injury” of the current conflicts in Iraq and Afghanistan. These injuries induce varying degrees of neuropathological alterations and, in some cases, chronic cognitive, behavioral and neurological disorders. Appropriate animal models of blast‐induced TBI will not only assist the understanding of physical characteristics of the blast, but also help to address the potential mechanisms. This report provides a brief overview of physical principles of blast, injury mechanisms related to blast exposure, current blast animal models, and the neurological behavioral and neuropathological findings related to blast injury in experimental settings. We describe relationships between blast peak pressures and the observed injuries. We also report preliminary use of a highly reproducible and intensity‐graded blast murine model carried out in open‐field with explosives, and describe physical and pathological findings in this experimental model. Our results indicate close relationships between blast intensities and neuropathology and behavioral deficits, particularly at low level blast intensities relevant to mTBI.

Combat blast related traumatic brain injury (TBI): Decade of recognition; promise of progress

HighlightsBetween 2007–2015, out of the one million combat veterans screened for traumatic brain injury (TBI), 8.4% of these Veterans received a diagnosis of TBI after comprehensive evaluation, the majority are characterized as mTBI/Concussion (mTBI) and, in great proportion, related to blast exposures.Mild traumatic brain injury called ‘a signature injury’ also known as ‘the invisible injury’ of war received increased attention during current conflicts.Specific clinical and research challenges in mTBI include identification and assessment of neuropathological, cellular and resulting cognitive, emotional, behavioral and neurological consequences.Enhanced research support for understanding TBI promises opportunities for advances in its diagnosis, management as well as for understanding pathogenesis of degenerative brain disease and other brain related disorders. ABSTRACT Between April 2007 and December 2015, the Veterans Health Administration (VHA) screened one million combat veterans for traumatic brain injury (TBI), among 2.6 million deployed during operations Enduring Freedom, Iraqi Freedom and New Dawn (OEF/OIF/OND). Since 2007, among those reporting, screened and referred for definitive evaluation, approximately 8.4% of these Veterans received a diagnosis of TBI, the majority characterized as mTBI/Concussion (mTBI) and, in great proportion, related to blast exposures. Mild Traumatic brain injury called “a signature injury” is also known as ‘the invisible injury’ of these conflicts. Identifying and assessing neuropathological, cellular and resulting cognitive, emotional, behavioral and neurological consequences of mTBI comprise vast clinical and research challenges. We provide a brief overview of current history, injury mechanisms related to blast exposure, coordinated research support, and the need to understand specific cellular and neurological changes occurring with blast injury, particularly mTBI.

Preclinical modelling of militarily relevant traumatic brain injuries: Challenges and recommendations for future directions

ABSTRACT As a follow-up to the 2008 state-of-the-art (SOTA) conference on traumatic brain injuries (TBIs), the 2015 event organized by the United States Department of Veterans Affairs (VA) Office of Research and Development (ORD) analysed the knowledge gained over the last 7 years as it relates to basic scientific methods, experimental findings, diagnosis, therapy, and rehabilitation of TBIs and blast-induced neurotraumas (BINTs). The current article summarizes the discussions and recommendations of the scientific panel attending the Preclinical Modeling and Therapeutic Development Workshop of the conference, with special emphasis on factors slowing research progress and recommendations for ways of addressing the most significant pitfalls.

Health care trends and vascular specialists: The good, the bad, and the ugly

Current health care trends include movements toward general health care reform and rapidly evolving changes affecting treatment of vascular disease. Government-sponsored programs and private coalitions increasingly influence practice management and patient care. Emerging organizational influences derive from public perceptions, policies, laws, and regulations intended to make health care safe, effective, patient centered, timely, efficient, and equitable. These trends energized methods of quality assessment, cost containment, and practice protocols over individual judgments and seek to exert increasing direction over clinical practice. Some evolving measures are good, some controversial, and some, without deliberate intent, may be harmful. This review considers evolving initiatives in the context of ethics of practice and practicalities of managing patients with vascular disease. Key issues include compliance with purely process-based measures, pay for performance, and assessment of quality outcomes. Strengths, weaknesses, opportunities, and potential threats to vascular practice are outlined.

CEAP in Clinical Practice

A recent classification and grading system for chronic venous disease (CEAP) has become available. CEAP was prepared by an ad hoc committee of the American Venous Forum; it provides quantification of disease severity as well as allowing quantitative analysis of results in relationship to etiology. Pretreatment and posttreatment severity disability scores can be calculated for specific time intervals, permitting before/after matchedsubjects designs for interval data. In brief: The acronym CEAP stands for Clinical signs (grades 0-6); Etiologic classification : (Congenital, Primary, and ~econdary); Anatomic distribution (Superficial, Deep, Perforator, alone or in combination); Pathologic dysfunction (Reflux or Obstruction alone or in combination) . Current controversy exists regarding nonoperative versus operative therapy for treatment of the complications of venous hypertension. The CEAP classification permits acquisition of quantitative data to assess treatment efficacy. In a re-

Ultrastructural brain abnormalities and associated behavioral changes in mice after low-intensity blast exposure

HighlightsAnalyzed comprehensive physical data from an open‐field primary blast model in mice.Observed low intensity blast (LIB) induced nanoscale brain abnormalities in mice.The ultrastructural damages occurred in the absence of necrosis and astrogliosis.Reported associated neurobehavioral dysfunctions resulting from LIB exposure.Provide insights into the pathogenesis of primary blast injury. ABSTRACT Explosive blast‐induced mild traumatic brain injury (mTBI), a “signature wound” of recent military conflicts, commonly affects service members. While past blast injury studies have provided insights into TBI with moderate‐ to high‐intensity explosions, the impact of primary low‐intensity blast (LIB)‐mediated pathobiology on neurological deficits requires further investigation. Our prior considerations of blast physics predicted ultrastructural injuries at nanoscale levels. Here, we provide quantitative data using a primary LIB injury murine model exposed to open field detonation of 350 g of high‐energy explosive C4. We quantified ultrastructural and behavioral changes up to 30 days post blast injury (DPI). The use of an open‐field experimental blast generated a primary blast wave with a peak overpressure of 6.76 PSI (46.6 kPa) at a 3‐m distance from the center of the explosion, a positive phase duration of approximate 3.0 milliseconds (ms), a maximal impulse of 8.7 PSI × ms and a sharp rising time of 9 × 10−3 ms, with no apparent impact/acceleration in exposed animals. Neuropathologically, myelinated axonal damage was observed in blast‐exposed groups at 7 DPI. Using transmission electron microscopy, we observed and quantified myelin sheath defects and mitochondrial abnormalities at 7 and 30 DPI. Inverse correlations between blast intensities and neurobehavioral outcomes including motor activities, anxiety levels, nesting behavior, spatial learning and memory occurred. These observations uncover unique ultrastructural brain abnormalities and associated behavioral changes due to primary blast injury and provide key insights into its pathogenesis and potential treatment.

Evolution of quality and surgical risk assessment in the USA.

As health-care reforms progress, quality and risk assessment in the health-care system of the USA surface as critical issues. This review considers past, present and possible future changes in quality assessment along with formal programs of complication reduction and pay for performance (PFP) as related to surgery and vascular interventions. Strategies for quality improvement include aggregate and risk-adjusted outcome measurement, process compliance with the Surgical Complication Improvement Program, oversight and PFP, now policies of the Centers for Medicare and Medicaid Services (CMS). Advantages, disadvantages and unintended consequences of these policies are discussed. While ongoing system changes will influence vascular surgical practice, unique opportunities and obligations exist for vascular surgeons to contribute to quality assessment of their interventions, to evaluate long-term outcomes and to devise strategies for comprehensive cost-effective care for the conditions affecting patients with vascular disease.

The Best Treatment for Impotence

Drugs for impotence: Do they work? Intense interest in drug therapy for impotence was stimulated by the recent availability of sildenafil (Viagra®), a selective inhibitor of cGMP-specific phosphodiesterase type 5 (PDE5) available in oral form. The inhibition of PDE5, specific for cavernosal smooth muscle, potentiates smooth muscle relaxation, a crucial process in penile erection.1 The initial evaluation of this drug (Nov 1995-October 1996) by the Center for Drug Evaluation and Research2 calculated overall efficiency of this agent in a Clinical Review involving 23 investigators in a multicenter study. Results were assessed as percentage of attempts resulting in successful intercourse as reported by subjects receiving the drug in fixed or titrated doses and followed up for 24 weeks. The drug was to be taken 1 hour before planned sexual activity and not more than once per day. The subjects logged their results as successful or unsuccessful. The results were calculated as a percentage of successful attempts and compared with a placebo among 1,958 total overall men in the initial evaluation. Overall, the drug was effective in 40% of the attempts as compared with 20% of the attempts in the placebo group. When doses were titrated (N = 315) the drug was effective in 59% of the attempts compared with 20% in the placebo group. In diabetics (N = 268) in the Joint Clinical Review the intercourse rates were 30% for the active drug and 7% for the placebo. Visual disturbances were reported by about half the sub-