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Daniel S Malach,1 John Michael Guest,1 Christopher Adam,1 Jonah Joffe,2 Kim Le,2 Chaesik Kim,1 Xihui Lin1 1Kresge Eye Institute/Wayne State University Department of Ophthalmology, Detroit, MI, USA; 2Henry Ford Hospital Department of Ophthalmology, Detroit, MI, USACorrespondence: Xihui Lin, Kresge Eye Institute/Wayne State University Department of Ophthalmology, 4717 St. Antoine, Detroit, MI, 48201, USA, Email xihui.lin@wayne.eduPurpose: To analyze visual outcomes and accuracy of intraocular lens (IOL) calculation formulas in predicting postoperative outcomes in patients undergoing flanged intrascleral IOL fixation.Design: Case Series.Subjects: Twenty-three patients who had undergone secondary IOL placement using flanged intrascleral fixation technique.Methods: Retrospective chart review.Main Outcome Measures: Corrected distance visual acuity (CDVA) and postoperative spherical equivalent based on manifest refraction.Results: Visual acuity improved from 20/577 to 20/58. Overall, the actual refraction was 0.06 D more myopic than predicted. Holladay 2, Sanders Retzlaff Kraff/Theoretical (SRK/T) and Barrett Universal II resulted in mild myopic surprise (− 0.55, − 0.18 and − 0.20 D). Haigis and Hill-RBF (Radial Basis Function) resulted in mild hyperopic surprise (+0.28 and +0.28 D). Hoffer Q and Holladay 1 were the most accurate (− 0.02D and − 0.08 D).Conclusion: Flanged intrascleral IOL fixation improved vision even in patients with other posterior segment pathologies. The effective lens positioning is likely similar to in-the-bag positioning. Hoffer Q and Holladay 1 formulas with in-the-bag calculations were the most accurate.Keywords: aphakia, cataract, flanged technique, refractive, secondary intraocular lens

Purpose: Poor eye-health knowledge and health literacy are pervasive, contributing to worse outcomes. This study aims to examine short- and long-term eye-health knowledge retention following eye-health education interventions in adults., Methods: Vision Detroit was an outreach vision screening program that integrated a 5-Point Teaching Intervention (5PTI), at a Southwest Community Center (SW-CC) from 2015-2017. The 5PTI consists of eye-health learning points developed to verbally educate patients. During vision screenings, eye-health knowledge tests were administered before and after 5PTI (Test 1 and Test 2, respectively). In 2016, Community Eye-Health Education Interventions (CHEI) were initiated at the SW-CC. During CHEI, bilingual healthcare students taught voluntary SW-CC members the 5PTI learning points, regardless of participant interest to attend future screenings. CHEI sessions occurred on separate dates prior to vision screening events. Test 1 and Test 2 scores were compared for all participants. Test 1 scores were compared for those who underwent CHEI prior to vision screening (CHEI positive) versus those who did not (CHEI negative)., Results: Two-hundred-seventeen adult patients met inclusion criteria, with 75.8% women, 82.6% Hispanic, mean age 50.4 ± 16.2 years, 74.6% had high school or less education, and 49.2% had health insurance. Test 1 to Test 2 scores improved after 5PTI (71.2 ± 26.4% vs. 97.2 ± 9.9%, p < .00001). Forty-eight participants attended CHEI and subsequent vision screening. Test 1 scores were higher among those CHEI positive versus CHEI negative (81.1 ± 2.1% vs. 68.3 ± 3.4%, p = .0027)., Conclusion: Simple eye-health education interventions, delivered during vision screenings and via community-based education, can improve eye-health knowledge.

Purpose: To show the feasibility while comparing functional and anatomical outcomes of vitrectomy combined with intralesional injection of voriconazole and povidone iodine for recalcitrant fusarium fungal endophthalmitis., Methods: In a noncomparative interventional case, vitrectomy combined with intralesional injection of voriconazole and povidone iodine was performed in a single patient., Results: Following vitrectomy and intralesional injection, our patient's fungal endophthalmitis stabilized and vision improved to 20/25. He did not require further intravitreal injections or vitrectomy., Conclusions: Vitrectomy and intralesional injection for the treatment of refractory filamentary fungal endophthalmitis proved to be safe and effective for this case., Competing Interests: Disclosure: The authors have no financial disclosures or conflict of interest.

Background: To evaluate the accuracy of intravitreal injection volume of the pre-filled syringe (PFS) in which aflibercept is packaged compared to the BD Luer-Lok 1-mL syringe., Methods: Ophthalmologists injected their typical intravitreal volume for aflibercept using either the PFS or BD Luer-Lok 1-mL syringe for 5 times each. The injected fluid was weighed using a micro-scale and converted to volume. The volume of fluid injected was also evaluated when the 0.05 mL line on the PFS was lined up to the tip or base of the dome-shaped plunger., Results: Injection volume was measured for 12 physicians. The average injected fluid volume was 74.22 ± 15.87 µL for PFS and 53.42 ± 4.61 µL for the BD Luer-Lok 1-mL syringe (p < 0.0001). The average deviation in volume injected for the PFS was higher compared to the BD Luer-Lok 1-mL syringe (11.36 µL vs. 3.35 µL, p < 0.0001). When the PFS was lined up with the tip of the dome-shaped plunger at the 0.05-mL line, the average injected volume was 71.03% higher., Conclusions: The intravitreal injection volume and variability using the new PFS were significantly higher than the volume injected using the BD Luer-Lok 1-mL syringe previously used, potentially leading to higher rates of visually significant elevation of intraocular pressures., (© 2022. The Author(s).)

Purpose: Vision loss and blindness are among the top ten disabilities in the United States, yet access and utilization of eye care remains low. Vision Detroit aimed to address eye-care disparities via community-based screenings. By investigating burden of eye disease and barriers to eye-care utilization in an underserved urban community, we may direct efforts to improve access., Methods: Twenty-three screenings were conducted from March 2015-November 2017. Patient information gathered at screenings were demographics, medical and social history, eye exam/referral history, insurance status, primary care physician (PCP) status, and patient-perceived eye-care barriers., Results: Three-hundred-eighty patients were screened, 42% African American and 51% Hispanic. Average age was 53 ± 16.4 years, 70% reported vision problems, 50% reported over two years of vision problems, and average habitual visual acuity in best-seeing eye was 20/37. Eye-care underutilization was reported in 61% of type-2 diabetics. Older age and PCP recommendations/referrals were associated with increased utilization in all patients. Insurance was the most common barrier (53%); of the 55% insured, 31% reported financial barriers. Employed patients were more likely than unemployed to report a time barrier (odds ratio = 1.76, 95% confidence interval 1.03-3.01). Those with high school or less education reported "unaware of need", "unsure where to go", "transportation", and "insurance" as barriers more often., Conclusion: Visual burden was pervasive, yet access was suboptimal. Financial, logistical, and awareness barriers were common. PCP referral and older age were associated with increased utilization. Those less educated reported more barriers, highlighting the need to address fiscal concerns and eye-health education.

Diversity of cell-types that collectively shape the cortical microcircuit ensures the necessary computational richness to orchestrate a wide variety of behaviors. The information content embedded in spiking activity of identified cell-types remain unclear to a large extent. Here, we recorded spike responses upon whisker touch of anatomically identified excitatory cell-types in primary somatosensory cortex in naive, untrained rats. We find major differences across layers and cell-types. The temporal structure of spontaneous spiking contains high-frequency bursts (≥100 Hz) in all morphological cell-types but a significant increase upon whisker touch is restricted to layer L5 thick-tufted pyramids (L5tts) and thus provides a distinct neurophysiological signature. We find that whisker touch can also be decoded from L5tt bursting, but not from other cell-types. We observed high-frequency bursts in L5tts projecting to different subcortical regions, including thalamus, midbrain and brainstem. We conclude that bursts in L5tts allow accurate coding and decoding of exploratory whisker touch.

Pyramidal tract neurons (PTs) represent the major output cell type of the mammalian neocortex. Here, we report the origins of the PTs' ability to respond to a broad range of stimuli with onset latencies that rival or even precede those of their intracortical input neurons. We find that neurons with extensive horizontally projecting axons cluster around the deep-layer terminal fields of primary thalamocortical axons. The strategic location of these corticocortical neurons results in high convergence of thalamocortical inputs, which drive reliable sensory-evoked responses that precede those in other excitatory cell types. The resultant fast and horizontal stream of excitation provides PTs throughout the cortical area with input that acts to amplify additional inputs from thalamocortical and other intracortical populations. The fast onsets and broadly tuned characteristics of PT responses hence reflect a gating mechanism in the deep layers, which assures that sensory-evoked input can be reliably transformed into cortical output., (Copyright © 2019 The Author(s). Published by Elsevier Inc. All rights reserved.)

Fungal endophthalmitis remains a significant cause of vision impairment and blindness. Moreover, the prognosis is poor, in part due to delay in diagnosis and to limited availability of effective antifungal agents with good ocular penetration. Thus, it is imperative to evaluate the therapeutic efficacy in fungal endophthalmitis of newer antifungal agents. In this study, we assessed the efficacy of isavuconazole in treating Aspergillus fumigatus endophthalmitis in an exogenous mouse model of the disease. Briefly, endophthalmitis was induced by intravitreal (IVT) injection of A. fumigatus spores into immunocompetent C57BL/6 (B6) mouse eyes. Mice were randomized into five groups that received isavuconazole via (i) oral gavage, (ii) IVT injections, (iii) intravenous injection, (iv) IVT injection followed by oral gavage, and (v) IVT injection followed by intravenous injection. Our data showed that isavuconazole treatment via all routes reduced fungal burden in A. fumigatus -infected eyes. This coincided with the preservation of retinal structural integrity (histology analysis) and retinal function (electroretinography [ERG] analysis), resulting in significantly improved disease outcome. Furthermore, isavuconazole treatment reduced the levels of inflammatory cytokines (tumor necrosis factor α [TNF-α], interleukin 1β [IL-1β], and IL-6) and cellular infiltration in the eyes. Notably, oral administration of isavuconazole was as effective in ameliorating endophthalmitis as intravitreal injection of the drug. Collectively, our study demonstrates that isavuconazole is effective in treating A. fumigatus endophthalmitis in mice, indicating its potential use in human ocular infections., (Copyright © 2018 American Society for Microbiology.)

The rodent facial nucleus (FN) comprises motoneurons (MNs) that control the facial musculature. In the lateral part of the FN, populations of vibrissal motoneurons (vMNs) innervate two groups of muscles that generate movements of the whiskers. Vibrissal MNs thus represent the terminal point of the neuronal networks that generate rhythmic whisking during exploratory behaviors and that modify whisker movements based on sensory-motor feedback during tactile-based perception. Here, we combined retrograde tracer injections into whisker-specific muscles, with large-scale immunohistochemistry and digital reconstructions to generate an average model of the rat FN. The model incorporates measurements of the FN geometry, its cellular organization and a whisker row-specific map formed by vMNs. Furthermore, the model provides a digital 3D reference frame that allows registering structural data - obtained across scales and animals - into a common coordinate system with a precision of ∼60 µm. We illustrate the registration method by injecting replication competent rabies virus into the muscle of a single whisker. Retrograde transport of the virus to vMNs enabled reconstruction of their dendrites. Subsequent trans-synaptic transport enabled mapping the presynaptic neurons of the reconstructed vMNs. Registration of these data to the FN reference frame provides a first account of the morphological and synaptic input variability within a population of vMNs that innervate the same muscle., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Pyramidal tract neurons (PTs) represent the major output cell type of the neocortex. To investigate principles of how the results of cortical processing are broadcasted to different downstream targets thus requires experimental approaches, which provide access to the in vivo electrophysiology of PTs, whose subcortical target regions are identified. On the example of rat barrel cortex (vS1), we illustrate that retrograde tracer injections into multiple subcortical structures allow identifying the long-range axonal targets of individual in vivo recorded PTs. Here we report that soma depth and dendritic path lengths within each cortical layer of vS1, as well as spiking patterns during both periods of ongoing activity and during sensory stimulation, reflect the respective subcortical target regions of PTs. We show that these cellular properties result in a structure-function parameter space that allows predicting a PT's subcortical target region, without the need to inject multiple retrograde tracers.The major output cell type of the neocortex - pyramidal tract neurons (PTs) - send axonal projections to various subcortical areas. Here the authors combined in vivo recordings, retrograde tracings, and reconstructions of PTs in rat somatosensory cortex to show that PT structure and activity can predict specific subcortical targets.

Zika virus (ZIKV) is an important pathogen that causes not only neurologic, but also ocular, abnormalities. Thus, it is imperative that models to study ZIKV pathogenesis in the eye are developed to identify potential targets for interventions. Here, we studied ZIKV interactions with human retinal cells and evaluated ZIKV's pathobiology in mouse eyes. We showed that cells lining the blood-retinal barrier (BRB), the retinal endothelium, and retinal pigment epithelium (RPE) were highly permissive and susceptible to ZIKV-induced cell death. Direct inoculation of ZIKV in eyes of adult C57BL/6 and IFN-stimulated gene 15 (ISG15) KO mice caused chorioretinal atrophy with RPE mottling, a common ocular manifestation of congenital ZIKV infection in humans. This response was associated with induced expression of multiple inflammatory and antiviral (IFNs) response genes in the infected mouse retina. Interestingly, ISG15 KO eyes exhibited severe chorioretinitis, which coincided with increased retinal cell death and higher ZIKV replication. Collectively, our study provides the first evidence to our knowledge that ZIKV causes retinal lesions and infects the cells lining the BRB and that ISG15 plays a role in retinal innate defense against ZIKV infection. Our mouse model can be used to study mechanisms underlying ZIKV-induced chorioretinitis and to gauge ocular antiviral therapies., Competing Interests: Conflict of interest: The authors have declared that no conflict of interest exists.

Background: Operative repair of distal biceps tendon ruptures has shown successful outcomes. However, little is known about the amount of tendon or repair site lengthening after repair., Purpose/hypothesis: The purpose of this study was to evaluate distal biceps tendon repair via intratendinous radiostereometric analysis to analyze tendon lengthening at different time intervals of healing. The hypothesis was that there is significant lengthening after repair., Study Design: Case series; Level of evidence, 4., Methods: Eleven patients with distal biceps ruptures requiring operative repair were recruited. During repair, two 2-mm tantalum beads with laser-etched holes were sutured to the distal biceps tendon. Beads were evaluated via computed tomography scans immediately postoperatively and at 16 weeks. Radiographs were obtained at time 0 and then at 4, 8, and 16 weeks postoperatively. Measurements were made using the button-to-bead and bead-to-bead distances to assess repair site elongation as well as tendon elongation over time. After final follow-up, patients filled out the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and underwent ultrasound to confirm the integrity of the tendon., Results: Ten patients had complete ruptures, with 1 having a partial rupture that underwent completion of the tear and subsequent repair. All patients showed statistically significant lengthening after surgery. The mean amount of tendon lengthening after surgery was 22.8 mm (range, 11.2-30.9 mm; P < .05), and the repair site lengthened a mean 17.0 mm (range, 9.6-30.6 mm; P < .05) from surgery to final follow-up. The greatest change in lengthening was noted between time 0 and week 4 (mean, 11.3 mm; P < .05), with the least amount of lengthening between weeks 8 and 16 (mean, 2.6 mm; P < .05). The mean DASH score was 11.2. Final ultrasound evaluations found all tendons to be in continuity., Conclusion: All patients undergoing distal biceps tendon repair have significant elongation after surgery, with the greatest amount of lengthening seen in the early postoperative period., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This project was supported by a general medical education (GME) grant at Henry Ford Hospital to cover the cost of supplies and radiographic studies. Funding was provided by the Henry Ford Hospital Medical Education Department directly.

Historically, patient perceptions of surgeon reimbursement have been exaggerated compared with actual reimbursement. There is limited information about patient perceptions of physician reimbursement for arthroscopic meniscectomy and anterior cruciate ligament (ACL) reconstruction. This study evaluated patient perceptions of physician reimbursement for these procedures and compared perceptions of health care reform between urban and suburban clinics. Surveys were given to 231 consecutive patients, and patients were asked how much they believed a surgeon should be reimbursed for arthroscopic meniscectomy and ACL reconstruction as well as their perception of actual Medicare reimbursement to physicians. Patients were then informed of the actual reimbursement rates and asked additional questions about health care reform. Survey responses were compared in an urban setting vs a suburban setting. On average, patients reported that surgeons should receive $8096 for meniscectomy and $11,794 for ACL reconstruction. Patients estimated that Medicare paid physicians $5442 for meniscectomy and $6667 for ACL reconstruction. In addition, 65% of patients believed that reimbursement for meniscectomy was too low, and 57% of patients believed that reimbursement for ACL reconstruction was too low. Fewer than 2% of patients believed that surgeon salaries should be cut, and 75% believed that orthopedic surgeons should be paid more for subspecialty training. No differences were found in patients' perceptions of reimbursement or health care reform between urban and suburban settings. Patients perceived that the values of meniscectomy and ACL reconstruction were substantially higher than current Medicare reimbursement values and that surgeon salaries should not be cut. [Orthopedics. 2016; 39(5):e904-e910.]., (Copyright 2016, SLACK Incorporated.)

Background: The number of Major League Baseball (MLB) pitchers requiring ulnar collateral ligament (UCL) reconstructions is increasing. Recent literature has attempted to correlate specific stresses placed on the throwing arm to risk for UCL injury, with limited results., Methods: Eighty-three MLB pitchers who underwent primary UCL reconstruction were evaluated. Pitching velocity and percent of pitch type thrown (fastball, curve ball, slider, and change-up) were evaluated 2 years before and after surgery. Data were compared with control pitchers matched for age, position, size, innings pitched, and experience., Results: The evaluation of pitch velocity compared with matched controls found no differences in pre-UCL reconstruction pitch velocities for fastballs (91.5 vs. 91.2 miles per hour [mph], P = .69), curveballs (78.2 vs. 77.9 mph, P = .92), sliders (83.3 vs. 83.5 mph, P = .88), or change-ups (83.9 vs. 83.8 mph, P = .96). When the percentage of pitches thrown was evaluated, UCL reconstructed pitchers pitch significantly more fastballs than controls (46.7% vs. 39.4%, P = .035). This correlated to a 2% increase in risk for UCL injury for every 1% increase in fastballs thrown. Pitching more than 48% fastballs was a significant predictor of UCL injury, because pitchers over this threshold required reconstruction (P = .006)., Conclusion: MLB pitchers requiring UCL reconstruction do not pitch at higher velocities than matched controls, and pitch velocity does not appear to be a risk factor for UCL reconstruction. However, MLB pitchers who pitch a high percentage of fastballs may be at increased risk for UCL injury because pitching a higher percent of fastballs appears to be a risk factor for UCL reconstruction., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Glycoprotein-deleted rabies virus (RABV ∆G) is a powerful tool for the analysis of neural circuits. Here, we demonstrate the utility of an anterograde RABV ∆G variant for novel neuroanatomical approaches involving either bulk or sparse neuronal populations. This technology exploits the unique features of RABV ∆G vectors, namely autonomous, rapid high-level expression of transgenes, and limited cytotoxicity. Our vector permits the unambiguous long-range and fine-scale tracing of the entire axonal arbor of individual neurons throughout the brain. Notably, this level of labeling can be achieved following infection with a single viral particle. The vector is effective over a range of ages (>14 months) aiding the studies of neurodegenerative disorders or aging, and infects numerous cell types in all brain regions tested. Lastly, it can also be readily combined with retrograde RABV ∆G variants. Together with other modern technologies, this tool provides new possibilities for the investigation of the anatomy and physiology of neural circuits.

Objective: Patients with severe chronic kidney disease (CKD) and peripheral vascular disease are at increased risk of major adverse limb events (MALEs) and death; however, patients with end-stage renal disease have been excluded in current objective performance goals. We evaluated the effect of severe (class 4 and 5) CKD on outcomes after infrainguinal endovascular arterial interventions., Methods: All primary peripheral vascular interventions (PVIs) performed at a single institution (January 2002 through December 2009) were included. End points were defined by Society for Vascular Surgery objective performance goals for critical limb ischemia (CLI), which include all-cause mortality, reintervention, and composite end points of death or amputation and MALEs (reintervention or amputation). Univariate and multivariable analysis was used to examine the effect of severe CKD on study end points., Results: A total of 879 PVIs were performed, with severe CKD in 125 (14%). Severe CKD patients were significantly (P < .05) more likely to have diabetes (64% vs 46%), CLI (72% vs 11%), and need a multilevel PVI (34% vs 19%) or tibial intervention (35% vs 20%) compared with the remainder of the cohort. Distribution of TransAtlantic Inter-Society Consensus C and D lesions were similar (19% severe CKD vs 15%; P = .2). Severe CKD predicted perioperative (30-day) reintervention (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.5-4; P = .05), amputation or death (OR, 3.1; 95% CI, 1.1-9; P = .04), and MALEs (OR, 2.8; 95% CI, 1.3-6.1; P = .04), which was independent of CLI in multivariable regression analysis. On Kaplan-Meier analysis, severe CKD was significantly (log-rank P < .05) associated with death (31% ± 4% vs 7% ± 1%), amputation (14% ± 3% vs 3% ± 1%), and MALEs (40% ± 5% vs 26% ± 2%) at 1 year. Freedom from reintervention was similar at 1 year (70% ± 5% severe CKD vs 75% ± 2%; P = .23). Risk-adjusted (age, CLI, diabetes, coronary artery disease) Cox proportional hazards regression showed that severe CKD increased the risk of late mortality (hazard ratio [HR], 2.4; 95% CI, 1.8-3.2; P < .01), amputation (HR, 2.1; 95% CI, 1.1-3.9; P = .02), and death or amputation (HR, 1.8; 95% CI, 1.3-2.4; P = .04), without increasing the risk of late reinterventions or MALEs., Conclusions: CKD independently predicts early and late adverse events after a PVI, in particular, excessive mortality. CKD should figure prominently in clinical decision making for patients with peripheral vascular disease., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

The cellular organization of the cortex is of fundamental importance for elucidating the structural principles that underlie its functions. It has been suggested that reconstructing the structure and synaptic wiring of the elementary functional building block of mammalian cortices, the cortical column, might suffice to reverse engineer and simulate the functions of entire cortices. In the vibrissal area of rodent somatosensory cortex, whisker-related "barrel" columns have been referred to as potential cytoarchitectonic equivalents of functional cortical columns. Here, we investigated the structural stereotypy of cortical barrel columns by measuring the 3D neuronal composition of the entire vibrissal area in rat somatosensory cortex and thalamus. We found that the number of neurons per cortical barrel column and thalamic "barreloid" varied substantially within individual animals, increasing by ∼2.5-fold from dorsal to ventral whiskers. As a result, the ratio between whisker-specific thalamic and cortical neurons was remarkably constant. Thus, we hypothesize that the cellular architecture of sensory cortices reflects the degree of similarity in sensory input and not columnar and/or cortical uniformity principles.

Objective: Several trials have reported early superior patency of stenting over isolated angioplasty (plain old balloon angioplasty [POBA]) for infra-inguinal occlusive disease, yet long-term data are sparse. The purpose of this study was to contrast long-term clinical outcomes and costs of angioplasty alone vs angioplasty with selective stenting in the treatment of femoropopliteal occlusive disease., Methods: Patients undergoing primary endovascular treatments of the native femoropopliteal arteries from 2002 to 2009 were divided into two groups, POBA alone or stenting based on final treatment received at their index procedure. Study end points included actuarial 5-year primary patency (using strict criteria of any hemodynamic deterioration or return of symptoms), 5-year limb salvage, and 5-year survival and hospital costs., Results: Eight hundred twenty-four primary procedures were performed during the study interval; 517 (63%) were POBA and 307 (37%) were stenting. The mean follow-up duration was 33 months (range, 0-98 months). The indication for intervention in the stenting group was claudication in 71% of the patients, whereas the remaining 29% had critical limb ischemia (CLI). In the POBA cohort, the indication for treatment was claudication in 59% of the patients and CLI in the remaining 41%. A higher percentage of POBA lesions were TransAtlantic Inter-Society Consensus (TASC) II A & B when compared to stenting (91% POBA vs 73% stenting; P < .001). There was no difference in overall 5-year primary patency (POBA 36% ± 3%; stenting 41% ± 4%; P = .31), nor was there a difference in patients with claudication (POBA 42% ± 4%; stenting 45% ± 4%; P = .8). In patients with CLI, the 4-year primary patency was 27% ± 5% (POBA) vs 36% ± 8% (stenting), P = .22; the 4-year limb salvage was 80% ± 4% (POBA) vs 90% ± 5% (stenting), P = .18. There was no difference in survival between the two groups (claudication: 83% ± 3% POBA vs 84% ± 4% stenting at 5 years (P = .65), CLI: 44% ± 4% POBA vs 49% ± 6% stenting at 4 years (P = .40). Subgroup analysis by lesion anatomy showed similar primary patency between POBA and stenting for TASC II A & B lesions, while the primary patency was significantly higher at 5 years after stenting of TASC II C & D lesions (34% ± 6% vs 12% ± 9%; P < .05). Stenting increased the procedural cost by 57% when compared to POBA (P < .001) regardless of treatment indication. In addition, stenting added 45% (P < .001) to the overall hospital cost of patients treated for claudication., Conclusion: Stenting resulted in equivalent long-term outcomes compared to POBA when stratified by indications. However, stenting yielded statistically better primary patency in patients with TASC II C & D lesions. The lack of improved clinical outcomes and significantly higher cost of stenting supports a posture of selective use of stents (especially in TASC II A & B) in the endovascular treatment of femoropopliteal occlusive disease., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Endovascular Abdominal Aortic Aneurysm Repair (EVAR) has been criticized because of the need for frequent secondary interventions (2ndINT) to maintain effective abdominal aortic aneurysm (AAA) exclusion. The study goal is to detail such interventions and determine their effect on clinical outcomes., Methods: From January 1997 to December 2007, 832 patients underwent EVAR. Those requiring 2ndINT were stratified according to the indications and specific nature of 2ndINT and treatment. Study endpoints included freedom from 2ndINT, aneurysm-related and overall survival., Results: There were 91 (11%) patients who underwent 131 2ndINT (mean follow-up 35 months). No demographic features (age, gender, etc) predicted the need for 2ndINT. Actuarial 5-year freedom from 2ndINT was 80%. Indications for 2ndINT included: sac rupture 5 (4%), graft migration/ type I endoleak 37 (28%), persistent type II endoleak 40 (38%), endotension with sac growth 5 (4%), and limb occlusion/kinking 24 (18%). The majority of 2ndINT were accomplished with an endovascular approach (76%) with a >80% initial success rate for all indications except type II endoleak in which the initial intervention was successful only 34% of the time. Initial 2ndINT were successful in 62% and 35 (38%) patients underwent more than one 2ndINT. Multivariate predictors of 2ndINT were AAA sac size >5.5cm (OR = 2.1, P = 0.004), and preprocedure coil embolization (hypogastric or inferior mesenteric artery) (OR = 2.1, P = 0.008). The actuarial survival was 70% at 5 years and the aneurysm-related survival was 97.5% with no difference in either parameter in patients who underwent 2ndINT compared with those who did not., Conclusions: Although 2ndINT are common after EVAR, most were addressed through an endovascular approach; technical success thereof varies widely with the specific indication for 2ndINT. Secondary intervention did not adversely affect aneurysm-related or overall actuarial 5-year survival.

Sodium nitroprusside is an antihypertensive agent used frequently in the critical care setting. Recently, the Food and Drug Administration (FDA) published a report that led to a labeling change emphasizing the pharmacokinetics of nitroprusside with metabolism to highly toxic cyanide. Although evidence validates that cyanogenesis occurs with nitroprusside administration, prevention and treatment of cyanide poisoning is rarely instituted in clinical practice. Simultaneous infusion of thiosulfate with nitroprusside provides the sulfur donor necessary to prevent cyanide accumulation. Cyanide combines with thiosulfate to form the less toxic sodium thiocyanate, which is then excreted. A 10:1 ratio of nitroprusside to thiosulfate in the infusion eliminates the possibility of cyanide intoxication without altering the efficacy of nitroprusside.