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BACKGROUND In October 2018, a measles (rubeola) outbreak was identified in New York City and Rockland County, and a public health campaign and hospital policy changes were made to increase awareness of the importance of vaccination and increase vaccination rates. OBJECTIVE We describe the prevalence of rubeola immunity in pregnant women and the change in uptake of postpartum measles, mumps, and rubella vaccination before and during the measles outbreak. STUDY DESIGN A multipronged intervention was developed by the health system with the intent of raising awareness of the outbreak, identifying patients at risk of contracting measles during pregnancy, and limiting exposure of inpatients to the disease. This was a quality improvement study to assess the impact of the intervention and public health policy on the rates of documentation of rubeola immunity and rubeola vaccination rates in nonimmune women. Women who delivered at New York University Langone Health before the outbreak July 1, 2016 to July 1, 2017 were compared with women who delivered during the outbreak July 1, 2018 to July 1, 2019. The primary outcome was acceptance of measles, mumps, and rubella vaccination in nonimmune women during the postpartum period. Analysis was conducted using logistic regression and chi-square tests, and alpha was set at 0.05. RESULTS A total of 19,585 patients were analyzed; 9162 women delivered before the outbreak and 10,423 delivered during the outbreak. Of these, 2589 (13.2%) were documented as living in a high-risk zone improvement plan code, which were areas at the epicenter of the measles outbreak. Notably, 14,731 women (75.2%) were tested for rubeola immunity and 3270 of those tested (22.2%) were not immune. In the year of the outbreak, a higher proportion of women had rubeola immunity documented with serum titers than in the year before the outbreak (81% vs 69%; P

Objective: Ischemia-reperfusion injury is a pathologic event characterized by tissue damage. It is mediated by tumor necrosis factor (TNF) and other cytokines that activate complement and proteases and stimulate fibrinolysis, degranulation of white blood cells, and free radical production. We recently reported that vagus nerve stimulation (VNS) suppresses endotoxin-induced cytokine synthesis through α bungarotoxin-sensitive cholinergic receptors. VNS protects against endotoxin-induced shock by inhibiting hepatic and cardiac synthesis of TNF. Here, the effects of VNS on suppression of ischemia-reperfusion injury and cytokine release were studied in a rat model of aortic occlusion. Methods: Adult male Lewis rats were subjected to laparotomy and suprarenal aortic clamping for 15 minutes followed by reperfusion. Blood pressure, heart rate, and respiratory rate were recorded every 3 minutes for 90 minutes. Exposed cervical vagus nerves in the experimental group were stimulated for 5 minutes before and after aortic occlusion, with constant voltage (1 V, 2 ms, 5 Hz); sham-operated animals received no stimulation. TNF levels in serum and organs were measured with enzyme-linked immunosorbent assay ELISA (BioSource International, Camarillo, Calif). Data analysis was performed with the Student t test. Results: Control animals had shock develop (mean, 59% decrease in blood pressure) whereas blood pressure in the stimulated animals did not decrease (control versus stimulated animals, P < .05). VNS significantly inhibited TNF levels in serum (7 ± 1 ng/mL versus 45 ± 6 ng/mL; P = .0008), heart (21 ± 11 ng/g protein versus 85 ± 15 ng/g protein; P = .01), and liver (16 ± 2 ng/g protein versus 42 ± 12 ng/g protein; P = .02). Conclusion: VNS significantly attenuates TNF synthesis and shock during reperfusion injury in a standard model of aortic occlusion. Clinical evaluation of VNS for this condition may be warranted. (J Vasc Surg 2002;36:1231-6.)

Background a retrospective chart review of 94 patients with asymptomatic high-grade carotid stenosis undergoing coronary bypass (and valve replacement in some cases) was performed to determine whether significant carotid lesions can be safely ignored in patients undergoing cardiac surgical procedures. These operations were performed during a 2-year period. Patients and methods there were 55 men and 39 women, with an age range of 37–89 years. Seventy-one patients had unilateral high-grade carotid stenosis, 17 patients had bilateral high-grade lesions, and six patients had unilateral high-grade stenosis and contralateral occlusion. Associated medical problems were recorded and short-term follow-up was obtained. Results there was one perioperative stroke and no deaths in this group of patients. Conclusions although these data indicate that high-grade carotid stenoses may be safely ignored during cardiac surgical procedures, a multicentre prospective randomised trial is needed to determine the appropriate treatment of the patient with coexisting carotid and coronary artery disease.

Background. The purpose of this study was to compare the long-term results of Dacron and polytetrafluoroethylene (PTFE) aortic bifurcation grafts in a prospective randomized manner. Methods. Sixty patients with aortoiliac occlusive disease were randomized to receive Dacron or PTFE bifurcation grafts. Preoperative risk factors, perioperative blood loss and fluid requirements, and postoperative complications were compared. A mean follow-up of 57 months was achieved. Results. The immediate postoperative morbidity and mortality rates were similar in the two groups, and the long-term complications were low in number and comparable. The cumulative patency rate for Dacron graft limbs was 86% versus 95% for PTFE graft limbs. Conclusions. No significant differences were noted between the results achieved with Dacron and PTFE aortic bifurcation grafts.

Exposed or infected peripheral vascular grafts pose a significant challenge to the vascular surgeon. Although graft removal and extraanatomic bypass is feasible in selected circumstances, this procedure is generally not applicable for bypass to the pedal vessels. Preservation of patent grafts is almost always required for limb salvage. We present a case report of an exposed vein graft to the dorsalis pedis artery. We conclude that a local fasciocutaneous flap is an excellent treatment option, and describe the procedure in detail.

Patients with abdominal aortic aneurysms (AAAs) often have concomitant coronary artery disease. In patients with large or symptomatic AAAs and symptomatic coronary artery disease, it may be necessary to address both problems simultaneously. We report a case series of five patients undergoing simultaneous off-pump coronary artery bypass and abdominal aortic reconstruction. Our series and a literature review indicate that simultaneous coronary artery bypass grafting on the beating heart and abdominal aortic surgery is safe and effective and has a low perioperative morbidity rate.

Frey's syndrome after carotid endarterectomy (CEA) is due to iatrogenic injury to the auriculotemporal nerve and has not been previously reported. One month after uncomplicated CEA, our patient noted an erythematous flush and copious drainage of clear fluid from the superior portion of his neck wound whenever he ate, or smelled or thought of food. These symptoms lasted for 2 months and eventually resolved without intervention. The cause and treatment of Frey's syndrome is also described.

© SCVIR, 1991 CASE REPORT A 32-year-old right-handed handball player had a I-week history of right upper extremity claudication and fatigue. On admission he noted the acute onset of pain and coolness in the hand and forearm. The patient had no brachial, radial, or ulnar pulses and had decreased sensation and range of motion of the hand; it appeared cool and pale. The patient had been a competitive handball player for almost 20 years. The radial/contralateral brachial index was 0.3. An emergency angiogram demonstrated occlusion of the third portion of the axillary artery anterior to the humeral head (Fig 1). Because of the abrupt worsening of the patient's condition, he was transferred to the operating room, where a thrombectomy restored a weak brachial pulse. An angiogram obtained on the following day revealed a narrow channel through the occluded arterial segment, and percutaneous transluminal angioplasty was performed (Fig 2). This resulted in a strong radial pulse (Fig 3), and a radial/contralateral brachial index of 1.0. Aspirin therapy was initiated, and the patient was advised not to play handball again. After 8 months, the patient is asymptomatic and has a bounding radial pulse. He has resumed handball playing claiming, "I only use my left hand."

We discuss the treatment of a fistula located between the aorta and inferior vena cava which was caused by trauma. Fewer than 30 such cases have been reported in the English literature. A juxtarenal pseudoaneurysm and aortocaval fistula resulting from a gunshot wound, unrecognized upon the initial presentation of the patient, is reported herein.

The advantages of tube versus bifurcation graft replacement of abdominal aortic aneurysms are well known, yet the risk of future development of iliac occlusive or aneurysmal disease still leads many to use bifurcation grafts routinely. Several studies have reported little risk of this development when patients are followed clinically. They suffer, however, from lack of an objective means of identifying iliac aneurysms. Among 83 patients undergoing abdominal aortic aneurysmectomy during a 53 month period, 36 who had received a tube graft were available for follow-up. After a mean of 54 months from the time of surgery, these patients were evaluated by abdominal and pelvic computed tomography to determine the incidence of subsequent iliac aneurysm formation. No patient had developed symptoms or signs of iliac occlusive disease during this interval. In addition, no residual aortic aneurysms or new iliac aneurysms were noted. In the absence of iliac occlusive or aneurysmal disease, straight graft replacement is the preferred therapy for abdominal aortic aneurysms. The risk of future development of these lesions is minimal.

Serum concentrations of high-mobility-group protein 1 (HMG1) were increased during an episode of haemorrhagic shock in a patient who had undergone repair of an abdominal aortic aneurysm. HMG1 may be involved in the pathogenesis of human haemorrhagic shock.

Spinal cord ischemia following abdominal aortic procedures is a rare complication. It occurs most commonly after operations for ruptured abdominal aortic aneurysms but has also been reported secondary to operations for aortoiliac occlusive disease. A 67-year-old man suffered spinal cord infarction following a routine, uncomplicated aortofemoral bypass. Although generally considered a rare and unpredictable complication of aortoiliac reconstruction, measures are discussed which might have prevented its occurrence in this case, and may further reduce its incidence in the future.

The problem of coexisting coronary artery disease in vascular patients is well recognized, because early and late morbidity and mortality rates in patients undergoing peripheral arterial surgery in all locations is overwhelmingly of myocardial origin. In these days of financial constraints on diagnostic resources, ascertaining the extent of coronary artery disease with a reasonable degree of precision may be more difficult than the therapeutic recommendations following the discovery of coronary artery disease. Allan D. Callow, M.D.

Injury can occur to several of the cranial nerves during carotid endarterectomy. Among these, glossopharyngeal nerve injury is an uncommon complication because it is remote from the field of dissection in most carotid procedures. From more than 2000 carotid operations four cases of symptomatic ninth cranial nerve injury were identified. Analysis revealed that dissection cephalad to the level of the hypoglossal nerve was a common feature of each and severe functional disability can result from glossopharyngeal nerve paresis. When mobilization of this nerve and division of the posterior belly of the digastric muscle and styloid process become necessary for additional exposure, the risk of glossopharyngeal nerve injury increases. Specific recommendations are made regarding management and maneuvers to help reduce the incidence of this uncommon, yet potentially serious, complication.

Heavily calcified aortic and iliac arteries are occasionally encountered that will not yield to currently available needles and sutures. The use of the Hall drill to penetrate such arterial walls, stopping short of the adventitial layer, and Teflon strips to buttress the anastomosis, is an effective means of dealing with this problem. Extensive arterial trauma is avoided and a hemostatic anastomosis may be constructed.