Search

To investigate whether tirofiban would have been non-inferior to abciximab had the trial completed enrollment and place the termination of this trial in a broader research ethics context.TENACITY was terminated by the sponsor for financial reasons. At the time, event rates for the 2 treatment arms were unknown.TENACITY was designed to compare tirofiban with abciximab in approximately 8,000 patients; however, enrollment was terminated after 383 (4.8%) patients. The primary end-point was a composite of 30-day death, myocardial infarction, and urgent target vessel revascularization. Non-inferiority was defined as the likelihood that tirofiban would preserve at least 50% of the ability of abciximab to reduce the primary end-point at 30 days, based on abciximab's demonstrated ability to reduce such events by 43% (relative risk, 0.573; 95% confidence interval [CI], 0.507-0.648; P 0.001). To determine the probability of non-inferiority given the patients already enrolled, a Bayesian approach was used.The primary composite end-point occurred in 8.8% of patients randomized to abciximab versus 6.9% receiving high-bolus-dose tirofiban (odds ratio, 0.77; 95% CI, 0.37-1.64). The estimated conditional power for the test that tirofiban would be non-inferior to abciximab if all patients been enrolled is 93.7%. Using the estimated predictive power method, the likelihood was 84.8%.TENACITY was well powered to identify non-inferiority with tirofiban versus abciximab, and the patients enrolled strengthened the probability that this would have been the outcome had the trial been completed. When a clinical trial is terminated solely for financial reasons, it is incumbent upon the sponsor to provide proper patient follow-up and publication of the findings.

This study examined the association between patient-reported anxiety and post-cardiac surgery mortality and major morbidity. Frailty ABC'S was a prospective multicenter cohort study of elderly patients undergoing cardiac surgery (coronary artery bypass surgery and/or valve repair or replacement) at 4 tertiary care hospitals between 2008 and 2009. Patients were evaluated a mean of 2 days preoperatively with the Hospital Anxiety and Depression Scale (HADS), a validated questionnaire assessing depression and anxiety in hospitalized patients. The primary predictor variable was high levels of anxiety, defined by HADS score ≥11. The main outcome measure was all-cause mortality or major morbidity (stroke, renal failure, prolonged ventilation, deep sternal wound infection, or reoperation) occurring during the index hospitalization. Multivariable logistic regression examined the association between high preoperative anxiety and all-cause mortality/major morbidity, adjusting for Society of Thoracic Surgeons (STS) predicted risk, age, gender, and depression symptoms. A total of 148 patients (mean age 75.8 ± 4.4 years; 34% women) completed the HADS-A. High levels of preoperative anxiety were present in 7% of patients. There were no differences in type of surgery and STS predicted risk across preoperative levels of anxiety. After adjusting for Society of Thoracic Surgeons predicted risk, age, gender, and symptoms of depression, preoperative anxiety remained independently predictive of postoperative mortality or major morbidity (OR 5.1; 95% CI 1.3, 20.2; p=0.02). In conclusion, although high levels of anxiety were present in a minority of patients anticipating cardiac surgery, this conferred a strong and independent heightened risk of mortality or major morbidity.

Saphenous vein graft (SVG) failure is a common finding in patients following coronary artery bypass graft (CABG) surgery. In the literature SVG failure rates have been reported from 25 to over 50% within 10 years. Although common, it remains unclear to what extent SVG failure affects clinical outcome, due to differences in definition, patient selection and follow-up. Particularly the lack of agreement on a universal definition makes comparisons between studies, and therefore generalizability of associations with outcomes, challenging. We suggest using a definition of SVG failure that is based on imaging as well as clinical parameters, that includes reporting SVG failure on both graft and patient level. The use of non-invasive imaging may help improve follow-up rates, and provide a more accurate picture of the real incidence and clinical impact of SVG failure. Given the lack of supportive evidence showing a consistent association between SVG failure and major adverse cardiovascular events, SVG failure should not be considered a valid surrogate endpoint at this time.

Contemporary clinical ethics emphasizes informed consent for medical treatment, which in turn is based on the principles of respect for individual self-determination (respect for autonomy), doing what is best for the patient (beneficence), and minimizing harm (nonmaleficence). Information can be presented to patients in various ways during the informed consent process, each of which has different effects on their attitudes, judgments, and decision making. Surgeons minimize potential harms to their patients in many ways, such as maintaining their own knowledge base and technical skills and ensuring that the surgical team is caring and well-prepared. Surgeons can add another protective strategy: minimizing the nocebo effect. The inverse of placebo effects are called nocebo effects—psychologically-generated harmful or undesirable outcomes of medical encounters.[1] Such effects have been acknowledged in the medical literature for decades; however, in clinical practice, they have been largely unrecognized and insufficiently controlled. Both placebo and nocebo effects are known to be associated with surgical interventions as well as with medical therapies. Many factors influence the occurrence of psychologically-generated adverse outcomes, some of which can be controlled or managed by physicians. Understanding these factors can help surgeons minimize such outcomes. Perhaps the most important factor surgeons can control is the way they manage the informed consent process, particularly the way they frame the risks of the procedure.

Context The safety and durability of endoscopic vein graft harvest in coronary artery bypass graft (CABG) surgery has recently been called into question. Objective To compare the long-term outcomes of endoscopic vs open vein-graft harvesting for Medicare patients undergoing CABG surgery in the United States. Design, Setting, and Patients An observational study of 235 394 Medicare patients undergoing isolated CABG surgery between 2003 and 2008 at 934 surgical centers participating in the Society of Thoracic Surgeons (STS) national database. The STS records were linked to Medicare files to allow longitudinal assessment (median 3-year follow-up) through December 31, 2008. Main Outcome Measures All-cause mortality. Secondary outcome measures included wound complications and the composite of death, myocardial infarction, and revascularization. Results Based on Medicare Part B coding, 52% of patients received endoscopic vein-graft harvesting during CABG surgery. After propensity score adjustment for clinical characteristics, there were no significant differences between long-term mortality rates (13.2% [12 429 events] vs 13.4% [13 096 events]) and the composite of death, myocardial infarction, and revascularization (19.5% [18 419 events] vs 19.7% [19 232 events]). Time-to-event analysis for those patients receiving endoscopic vs open vein-graft harvesting revealed adjusted hazard ratios [HRs] of 1.00 (95% CI, 0.97-1.04) for mortality and 1.00 (95% CI, 0.98-1.05) for the composite outcome. Endoscopic vein-graft harvesting was associated with lower harvest site wound complications relative to open vein-graft harvesting (3.0% [3654/122 899 events] vs 3.6% [4047/112 495 events]; adjusted HR, 0.83; 95% CI, 0.77-0.89; P Conclusion Among patients undergoing CABG surgery, the use of endoscopic vein-graft harvesting compared with open vein-graft harvesting was not associated with increased mortality.

Since United States Food and Drug Administration approval in 2005, the short-term safety and efficacy of thoracic endovascular aortic repair (TEVAR) have been established. However, longer-term follow-up data remain lacking. The objective of this study is to report 6-year outcomes of TEVAR in clinical practice.A prospective cohort review was performed of all patients undergoing TEVAR at a single referral institution between March 2005 and May 2011. Rates of reintervention were noted. Overall and aortic-specific survival were determined using Kaplan-Meier methods. Log-rank tests were used to compare survival between groups.During the study interval, 332 TEVAR procedures were performed in 297 patients. Reintervention was required after 12% of procedures at a mean of 8 ± 14 months after initial TEVAR and was higher in the initial tercile of patients (15.0% vs 9.9%). The 6-year freedom from reintervention was 84%. Type I endoleak was the most common cause of reintervention (5%). Six-year overall survival was 54%, and aorta-specific survival was 92%. Long-term survival was significantly lower than that of an age- and sex-matched United States population (p0.001). Survival was similar between patients requiring a reintervention vs those not (p = 0.26). Survival was different based on indication for TEVAR (p = 0.007), and patients with degenerative aneurysms had the lowest survival (47% at 6 years). Cardiopulmonary pathologies were the most common cause of death (27 of 93 total deaths).Long-term aortic-related survival after TEVAR is high, and the need for reintervention is infrequent. However, overall long-term survival is low, particularly for patients with degenerative aneurysms, and additional work is needed to identify patients unlikely to derive a survival benefit from TEVAR.

Numerous studies have supported the effectiveness of recombinant activated factor VII (rFVIIa) for the control of bleeding after cardiac procedures; however safety concerns persist. Here we report the novel use of intraoperative low-dose rFVIIa in thoracic aortic operations, a strategy intended to improve safety by minimizing rFVIIa exposure.Between July 2005 and December 2010, 425 consecutive patients at a single referral center underwent thoracic aortic operations with cardiopulmonary bypass (CPB); 77 of these patients received intraoperative low-dose rFVIIa (≤60 μg/kg) for severe coagulopathy after CPB. Propensity matching produced a cohort of 88 patients (44 received intraoperative low-dose rFVIIa and 44 controls) for comparison.Matched patients receiving intraoperative low-dose rFVIIa got an initial median dose of 32 μg/kg (interquartile range [IQR], 16-43 μg/kg) rFVIIa given 51 minutes (42-67 minutes) after separation from CPB. Patients receiving intraoperative low-dose rFVIIa demonstrated improved postoperative coagulation measurements (partial thromboplastin time 28.6 versus 31.5 seconds; p=0.05; international normalized ratio, 0.8 versus 1.2; p0.0001) and received 50% fewer postoperative blood product transfusions (2.5 versus 5.0 units; p=0.05) compared with control patients. No patient receiving intraoperative low-dose rFVIIa required postoperative rFVIIa administration or reexploration for bleeding. Rates of stroke, thromboembolism, myocardial infarction, and other adverse events were equivalent between groups.Intraoperative low-dose rFVIIa led to improved postoperative hemostasis with no apparent increase in adverse events. Intraoperative rFVIIa administration in appropriately selected patients may correct coagulopathy early in the course of refractory blood loss and lead to improved safety through the use of smaller rFVIIa doses. Appropriately powered randomized studies are necessary to confirm the safety and efficacy of this approach.

Objectives The purpose of this study was to characterize operative outcomes for ascending aorta and arch replacement on a national scale and to develop risk models for mortality and major morbidity. Background Contemporary outcomes for ascending aorta and arch replacement in North America are unknown. Methods We queried the Society of Thoracic Surgeons Database for patients undergoing ascending aorta (with or without root) with or without arch replacement from 2004 to 2009. The database captured 45,894 cases, including 12,702 root, 22,048 supracoronary ascending alone, 6,786 ascending plus arch, and 4,358 root plus arch. Baseline characteristics and clinical outcomes were analyzed. A parsimonious multivariable logistic regression model was constructed to predict risks of mortality and major morbidity. Results Operative mortality was 3.4% for elective cases and 15.4% for nonelective cases. A risk model for operative mortality (c-index 0.81) revealed a risk-adjusted odds ratio for death after emergent versus elective operation of 5.9 (95% confidence interval: 5.3 to 6.6). Among elective patients, end-stage renal disease and reoperative status were the strongest predictors of mortality (adjusted odds ratios: 4.0 [95% confidence interval: 2.6 to 6.4] and 2.3 (95% confidence interval: 1.9 to 2.7], respectively; p Conclusions Current outcomes for ascending aorta and arch replacement in North America are excellent for elective repair; however, results deteriorate for nonelective status, suggesting that increased screening and/or lowering thresholds for elective intervention could potentially improve outcomes. The predictive models presented may serve clinicians in counseling patients.

As our understanding of the pathophysiological underpinnings of reperfusion injury has increased, many therapies directed at preventing the detrimental effects of this phenomenon have been tested. For primary PCI, this has ranged from mechanical protection from distal embolization of plaque material, preventing calcium overload after reperfusion, to the inhibition of specific inflammatory mediators. Although most have shown promise in smaller mechanistic clinical trials, only mechanical thrombectomy has thus far been shown to be of clinical benefit in larger investigations.

Femoral head fractures are rare injuries. The Pipkin classification is a well-accepted system used to describe these fractures. Pelvic roentgenograms and a computerized tomography scan will provide the information necessary to classify and thereby develop a management plan for these injuries. Although there is general agreement regarding the treatment of associated fractures of the femoral neck and acetabulum, treatment of the femoral head fracture varies depending on the size and location of the fragment. Options range from closed reduction and traction for some nondisplaced fractures to arthrotomy with excision or open reduction and internal fixation of the femoral head fragment. Stabilization can be obtained using a variety of fixation devices. The hip joint may be approached anteriorly or posteriorly depending on the location of the femoral head fragment. The classification, treatment options, operative techniques, postoperative management, and potential complications associated with femoral head fractures are presented.

Intervertebral disc and facet joints are the two primary load-bearing structures of the lumbar spine, and altered loading to these structures may be associated with frontal plane spinal deviations.To determine the load on the lumbar facet joint and intervertebral disc under simulated frontal plane pelvic obliquity combined loading, an in vitro biomechanical study was conducted.An in vitro biomechanical study using a repeated-measures design was used to compare L4-L5 facet joint and intervertebral disc loading across pure moment and combined loading conditions.Eight fresh-frozen lumbosacral specimens were tested under five loading conditions: flexion/extension, lateral bending, axial rotation using pure moment bending (±10 Nm), and two additional tests investigating frontal plane pelvic obliquity and axial rotation (sacrum tilted left 5° and at 10° followed by a ±10-Nm rotation moment). Three-dimensional kinematics, facet load, and intradiscal pressures were recorded from the L4-L5 functional spinal unit.Sagittal and frontal plane loading resulted in significantly smaller facet joint forces compared with conditions implementing a rotation moment (p.05). The facet joint had the highest peak load during the 10° combined loading condition (124.0±30.2 N) and the lowest peak load in flexion (26.8±16.1 N). Intradiscal pressure was high in lateral flexion (495.6±280.9 kPa) and flexion (429.0±212.9 kPa), whereas intradiscal pressures measured in rotation (253.2±135.0 kPa) and 5° and 10° combined loading conditions were low (255.5±132.7 and 267.1±127.1 kPa, respectively).Facet loading increased during simulated pelvic obliquity in frontal and transverse planes, whereas intradiscal pressures were decreased compared with sagittal and frontal plane motions alone. Altered spinopelvic alignment may increase the loads experienced by spinal tissue, especially the facet joints.

The use of selective cerebral perfusion with warmer temperatures during circulatory arrest has been increasingly used for arch replacement over concerns regarding the safety of deep hypothermic circulatory arrest (DHCA). However, little data actually exist on outcomes after arch replacement and DHCA. This study examines modern results with DHCA for proximal arch replacement to provide a benchmark for comparison against outcomes with lesser degrees of hypothermia. Between July 2005 and June 2010, 245 proximal arch replacements ("hemiarch") were performed using deep hypothermia; mean minimum core and nasopharyngeal temperatures were 18.0 ± 2.1°C and 14.1 ± 1.6°C, respectively. Adjunctive cerebral perfusion was used in all cases. Concomitant ascending aortic replacement was performed in 41 per cent, ascending plus aortic valve replacement in 23 per cent, and aortic root replacement in 32 per cent. Mean age was 58 ± 14 years; 36 per cent procedures were urgent/emergent. Mean duration of DHCA was 20.4 ± 6.2 minutes. Thirty-day/in-hospital mortality was 2.9 per cent. Rates of stroke, renal failure, and respiratory failure were 4.1 per cent (0.8% for elective cases), 1.2 per cent, and 0.4 per cent, respectively. Deep hypothermia with adjunctive cerebral perfusion for circulatory arrest during proximal arch replacement affords excellent neurologic as well as nonneurologic outcomes. Centers using lesser degrees of hypothermia for arch surgery, the safety of which remains unproven, should ensure comparable results.

Outcomes following coronary artery bypass grafting (CABG) continue to improve, despite the fact that the recipient patient population is older and has more comorbidities, compared to previous years. Advances in perioperative processes of care continue to play an important role in these improvements.1, 2 However, while many perioperative processes of care have been defined and linked to improvements in outcomes, data is lacking with regards to inotrope and vasopressor use for treatment of low cardiac output syndrome (LCOS) in the early postoperative period following CABG. Several clinical studies have examined the factors associated with the development of LCOS and the subsequent need for inotropic support.3–5 Commonly defined as low cardiac output (confidence interval [CI]

Background— Some prior studies have suggested that the time to cardiac surgery after cardiac catheterization is inversely related to postoperative acute kidney injury (AKI). However, these studies, because of the small number of patients, were unable to adequately account for patient case-mix and included both those undergoing elective surgery and those undergoing urgent surgery. Methods and Results— We examined data on 2441 consecutive patients undergoing elective coronary artery bypass surgery (CABG) after cardiac catheterization. The association of post-CABG AKI (defined as increase in post-CABG serum creatinine ≥50% above baseline or the need for new dialysis) and time between cardiac catheterization and CABG was evaluated using multivariable logistic regression modeling. AKI occurred in 17.1% of CABG patients. The risk of AKI was highest in patients in whom CABG was performed ≤1 day after cardiac catheterization (adjusted mean rates [95% CI]: 24.0% [18.0%, 30.9%], 18.4% [14.8%, 22.5%], 17.3% [13.3%, 21.9%], 16.4% [12.6%, 20.8%], and 15.8% [13.7%, 18.0%] for days ≤1, 2, 3, 4, and ≥5, respectively; P =0.019 for test of trend). Post-CABG AKI was associated with increased risk of long-term death (hazard ratio 1.268, 95% CI 1.093, 1.471). Conclusions— The risk of post-CABG AKI was inversely and modestly related to the time between cardiac catheterization and CABG, with the highest incidence in those operated ≤1 day after cardiac catheterization despite their lower risk profile. Whether delaying elective CABG >24 hours of exposure to contrast agents (when feasible) has the potential for decreasing post-CABG AKI remains to be evaluated in future studies.

A 55-year-old man with critical aortic coarctation, aortic root aneurysm, and aortic insufficiency underwent median sternotomy for ascending–descending aortic bypass and aortic root replacement. The patient was found to have a salvageable trileaflet aortic valve, allowing for valve-sparing root replacement (VSRR). Aortic bypass with VSRR has not previously been reported and may be the ideal operation for repair of coarctation with concomitant aortic root aneurysm.

Bicuspid aortic valve (BAV) disease is associated with an aortopathy resulting in aneurysmal dilatation spanning the root, ascending, and arch segments. To date, no large series of proximal aortic replacement in this population has been reported. The study aim was to report contemporary surgical outcomes for proximal aortic replacement in BAV disease, and to examine the relationships between valve morphology, valve pathophysiology, and pathology of the thoracic aorta.Between September 2005 and December 2009, a total of 100 consecutive patients (mean age 54 +/- 13 years; range: 29-80 years) with BAV and proximal aortic enlargement underwent aortic replacement at a single referral institution. Of these patients, 16% had undergone prior aortic valve replacement (AVR). The aortic repair was individually tailored to treat the aortic valve and thoracic aortic pathology, and included supracoronary ascending aortic (AA) replacement (n = 17), AVR with separate supracoronary AA replacement (n = 39), aortic root replacement (n = 42), and valve-sparing root replacement (n = 2). Concomitant arch replacement was performed in 82 patients (80 hemi-arch, two full arch). Other concomitant cardiac procedures were performed in 28 patients.The 30-day/in-hospital rates of death and stroke were both 1%. The predominant aortic valve pathophysiology was aortic stenosis (AS; 33%), aortic insufficiency (AI; 29%), mixed AS/AI (17%), normally functioning BAV (17%), and unknown (4%). Valve morphology included Sievers Type I, R/L (75%), Type I, R/N (9%), Type I, L/N (2%), Type 0 (7%), and Type II (7%). BAV patients with predominantly AI had more frequent root dilatation (62%) than those with either AS (30%) or normal valve function (35%). Based on BAV morphology, there were no significant differences in maximal thoracic aortic diameters between groups. At a mean follow up of 16 months, there were no late deaths or valve-related complications.Proximal aortic replacement in patients with BAV can be performed with low rates of mortality and morbidity. The pathologic anatomy of the thoracic aorta was not predicted by the aortic valve morphology, although dilation of the aortic root was most common in BAV patients with a predominant AI pathophysiology. These findings convey the safety and feasibility of treating concomitant aortopathy, including arch replacement as needed, and may help tailor the specific operation needed to the patient's pathology.

Patients with prosthetic heart valves require chronic oral anticoagulation. In this clinical scenario, physicians must be mindful of the thromboembolic and bleeding risks related to chronic anticoagulant therapy. Currently, only vitamin K antagonists are approved for this indication. This paper reviews the main heart valve guidelines focusing on the use of oral anticoagulation in these patients.

In 1976 Mina Shaughnessy invoked the phrase "converting the natives" (235) to describe an undesirable attitude for a teacher of composition. In her article "Diving In: An Introduction to Basic Writing," she outlines four stages of development for composition teachers, of which "converting the natives" is the second. The tendency of teachers at this stage is to see themselves as missionaries who initiate the unenlightened into the true path of correct writing. At this stage the teacher's goal is "to carry the technology of advanced literacy to the inhabitants of an underdeveloped country" (235). Joseph Harris also mentions the term conversion in his 1989 critique of the use of discourse communities in the composition classroom (16). We have, Harris suggests, pictured various discourse communities as fundamentally different, in fact, so fundamentally different that we are at a loss to explain how students make the break with former communities in order to enter new communities. Harris describes the way we have tended to think of students

Background— Despite evidence supporting the use of aspirin, β-blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering therapies in eligible patients, adoption of these secondary prevention measures after coronary artery bypass grafting has been inconsistent. We sought to rigorously test on a national scale whether low-intensity continuous quality improvement interventions can be used to speed secondary prevention adherence after coronary artery bypass grafting. Methods and Results— A total of 458 hospitals participating in the Society of Thoracic Surgeons National Cardiac Database and treating 361 328 patients undergoing isolated coronary artery bypass grafting were randomized to either a control or an intervention group. The intervention group received continuous quality improvement materials designed to influence the prescription of the secondary prevention medications at discharge. The primary outcome measure was discharge prescription rates of the targeted secondary prevention medications at intervention versus control sites, assessed by measuring preintervention and postintervention site differences. Prerandomization treatment patterns and baseline data were similar in the control (n=234) and treatment (n=224) groups. Individual medication use and composite adherence increased over 24 months in both groups, with a markedly more rapid rate of adherence uptake among the intervention hospitals and a statistically significant therapy hazard ratio in the intervention versus control group for all 4 secondary prevention medications. Conclusions— Provider-led, low-intensity continuous quality improvement efforts can improve the adoption of care processes into national practice within the context of a medical specialty society infrastructure. The findings of the present trial have led to the incorporation of study outcome metrics into a medical society rating system for ongoing quality improvement.

Background Most studies of thoracic endovascular aortic repair (TEVAR) published since the technology gained US Food and Drug Administration (FDA) approval in March 2005 have included multiple applications including dissection, trauma, and "hybrid" approaches, all of which are currently "off-label." However, little post-approval data exist for the only FDA-approved application, namely descending thoracic aneurysm (DTA). The purpose of this study was to examine our experience with TEVAR for aneurysms limited to the descending thoracic aorta. Methods Between March 23, 2005 (date of initial FDA approval) and April 6, 2009, 210 TEVAR procedures were performed at our institution. Of these, 79 (38%) were for saccular (n = 31) or fusiform (n = 48) DTA and form the basis of this report. Patients requiring "hybrid" approaches other than carotid-subclavian bypass were excluded. Devices utilized were Gore TAG (W. L. Gore Associates, Flagstaff, AZ) (n = 67; 85%), Zenith TX2 (Cook Medical Incorporated, Bloomington, IN) (n = 10; 13%), and Medtronic Talent (Medtronic, Inc, Santa Rosa, CA) (n = 5; 6%); 3 (4%) patients received more than one type of device. Results Median patient age was 73 ± 4 years; 35 (44%) were female. Mean aortic diameter was 5.8 ± 1.8 cm. Twenty-four (30%) procedures were urgent-emergent. Thirty-day in-hospital rates of death, stroke, and permanent paraplegia-paresis were 5.1% (n = 4; 1.9% elective mortality), 2.5% (n = 2), and 1.3% (n = 1), respectively. The median postoperative length of stay was 3.0 days (25th and 75th percentiles=2 and 6, respectively). At a mean follow-up of 23 ± 17 months (range, 6 to 55), there were 2 (2.5%) late aortic deaths from graft infection (n = 1) and aneurysm rupture (n = 1). Overall actuarial midterm survival is 73% at 55 months, with an aorta-specific actuarial survival of 86% during this same time interval. Five patients (6.3%) required late (>30 days) secondary endovascular re-intervention for type I (n = 4) or type II (n = 1) endoleak; re-intervention was successful in 4 of 5. Conclusions Despite the advanced age, comorbid conditions, and significant incidence of urgent-emergent status of patients presenting with DTA, on-label application of TEVAR yields excellent 30-day and midterm outcomes, especially when compared with historic rates of morbidity and mortality with open repair. However, "on-label" applications represent a minority of current TEVAR use, likely due to the relative scarcity of DTA. These data appear to support the increasing utilization of TEVAR as a treatment strategy for this pathology.

Deficiencies The lumbar facet joints are the major load bearing elements in the lumbar spine posterior column and they are considered one of the anatomical structures that can cause low back pain. They also contribute to the amount and type of lumbar spine motion.Copyright © 2010 by ASME

A study was conducted to assess the relative accuracy of two measurement techniques commonly used for vehicle measurements in damaged-based accident reconstruction. The traditional technique of hands-on measurement was compared with the use of photogrammetry for measurement of targeted damaged vehicles. Three undamaged vehicles were subjected to 4 impacts, resulting in 4 damaged areas (two front, one side and one rear). The study's intent was only to examine the accuracy of each measurement technique. The influence of other confounding independent variables such as selection of measurement location on the vehicle, reference line location, and definitions of what constitutes “damage”, etc. were controlled for and minimized by using predefined measurement points on the vehicles and prescribed station lines.

Objective This study's objective was to assess knowledge of phosphorus compared with other nutrients in patients undergoing maintenance dialysis (MD). Design We compared knowledge of phosphorus vs. other nutrients important to the MD diet (potassium, sodium, and protein) in patients undergoing hemodialysis (HD) and peritoneal dialysis (PD). We further measured gender, age, education level, and functional health literacy to assess correlations in patient nutrient knowledge. Nutrient knowledge was measured using a 25-item Chronic Kidney Disease Knowledge Assessment Tool for Nutrition (CKDKAT-N), and functional health literacy was measured using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Setting and Patients Patients received maintenance outpatient PD or HD at Wisconsin Dialysis, Inc. (Madison, WI). Main Outcome Measure The main outcome measure was knowledge of phosphorus vs. knowledge of potassium, sodium, and protein. Results Forty-seven MD patients participated in the study (29 undergoing HD, 18 undergoing PD, 30 males, 17 females, average age of 58.6 (SD, 13.8) years, and average grade level of 1.4 (SD, 2.6) years of post-secondary education). Thirty-five participants had adequate health literacy, 4 had marginal health literacy, and 8 had inadequate health literacy. The CKDKAT-N scores ranged from 6–21 for 25 items, with a mean score of 13 (SD, 2.91). Knowledge of phosphorus compared with knowledge of other nutrients was poor (0.38 vs. 0.72, P = .003). In a comparison of HD vs. PD patient knowledge, both phosphorus (0.37 vs. 0.42, P = .231) and other nutrients (0.69 vs. 0.80, P = .115) were the same. Conclusion Despite regular dietary instruction, patients undergoing MD have a poor knowledge of dietary phosphorus content, compared with knowledge of other nutrients important in chronic kidney disease. Interestingly, there was no difference in nutrition knowledge when comparing PD and HD patients, despite differences in education level and health literacy between groups.

Objectives The radial artery (RA) has gained widespread acceptance as a conduit for coronary artery bypass. We analyze patient-based data to determine risk factors for long-term upper limb morbidities associated with RA harvest for coronary artery bypass grafting. Study design/methods Between April 1997 and March 2004, a total of 1030 patients underwent RA harvesting for coronary artery bypass grafting for a total of 1704 harvest sites. Patients were contacted by telephone and asked to report any ongoing severe sensory and functional motor deficits for each harvest site since surgery. Retrospective chart review was performed and preoperative risk factors were evaluated. Patient-based risk factors were evaluated for development of significant long-term local sensorimotor deficits including gender, elderly age (>70 y), diabetes, smoking, and whether the RA was harvested from the dominant hand. Results Successful evaluation of 629 patients for a total of 1048 RA harvest sites was completed. The mean follow-up time was 48.3 mo (range, 2 to 86 mo). The mean age of the patients analyzed was 62.2 y. On statistical analysis, diabetics and elderly did not report significantly greater functional or sensory deficits than nondiabetics and nonelderly, respectively. There was a significantly higher incidence of sensory deficits in smokers compared with nonsmoker patients (4.2% versus 1.4%; P = 0.005) but no difference in their functional impairment was noted. Harvesting from the dominant hand did not influence the occurrence of sensory or motor functional deficits. Conclusions RA harvesting for coronary artery bypass grafting can be done with minimal serious long-term upper limb morbidity in higher risk patients. Based on our findings, harvesting of the RA from the dominant hand is not contraindicated in these patients.

Interest in the mitigation of whiplash associated disorders (WAD) has increased over the last 10 years, and an increasing number of human subject rear-end collision tests have been conducted to assist in the understanding of WAD. Traditionally this testing has examined the effects of variations in occupant characteristics (age, height, gender, etc.), seat characteristics (geometrical and constitutive), and impact severity; however no controlled study has examined the singular effect of incremental velocity change increases on occupant kinematics. Moreover, while vehicle velocity change (Delta V) is typically employed as a singular measure of impact severity, it is of interest to examine whether this or other impact-related parameters, such as energy or acceleration, are also correlated with occupant kinematics. A series of 43 instrumented human subject rear-end impact tests were conducted to monitor the effects of increasing impact severity on occupant accelerations. Target vehicle Delta V, average vehicle acceleration, peak vehicle acceleration, and vehicle kinetic energy change were statistically evaluated for their influence on various occupant response parameters which have been suggested to be associated with WAD causation in prior literature. Significantly (p < .001) strong positive correlations were found between vehicle parameters and human occupant variables.