Carotid artery occlusion (CAO) is a risk factor for stroke ipsilateral to the occlusion and puts patients in a high-risk category when contralateral endarterectomy is performed. The purpose of this study was to evaluate the long-term outcomes of patients with internal CAO and to determine risk factors predictive of subsequent neurological event, contralateral carotid intervention, or death. Patients with internal CAO shown by duplex ultrasonography were retrospectively identified and followed between January 2002 and June 2010 (follow-up: 1-101 months, mean: 52 months) at a tertiary care hospital. All had multiple duplex examinations available for review. Chi-square analysis was used to determine risk factors for neurologic event, contralateral intervention, or all-cause morality. Multivariate Cox proportional hazard analysis was conducted using univariate risk factors with P values <0.1. Survival was estimated using the Kaplan-Meier method (P<0.05 significant). Eighty patients with internal CAO were identified and available for analysis. On initial encounter, 30 (38%) were symptomatic, with 26 (87%) having symptoms referable to the side of the occluded internal carotid artery. During follow-up, seven (9%) had a neurologic event, of which six (86%) were referable to the occluded side; 14 (18%) patients underwent a contralateral operation. Nineteen (24%) patients died during the period of study. Although numerous variables of multivessel disease were significant with chi(2) analysis, there was no significant risk factor associated with neurologic event on multivariate analysis. However, the development of a hemodynamically significant stenosis (>50%) or occlusion of the external carotid artery (ECA) ipsilateral to the occlusion on follow-up (P < 0.027) was associated with increased risk of death. Kaplan-Meier analysis showed 7-year survival for patients with ECA disease at follow-up was significantly worse (16.2% +/- 10.3% [n = 21] vs. 79% +/- 8.7% [n = 59]; P < 0.00001). Frequently, patients present with neurological symptoms referable to the side of the internal CAO. Eighty-six percent of neurologic events that occur in follow-up are attributable to the side of the occluded carotid, indicating that the occluded side continues to contribute to neurologic morbidity over time. Multivariate analysis revealed no single factor to be predictive of subsequent neurologic events. With significant risk of death in patients found to have ipsilateral ECA stenosis during follow-up, it seems reasonable to continue surveillance of the occluded carotid.

Objective: This study evaluated the long-term outcomes of patients with carotid artery occlusion and determined risk factors predictive of death, neurologic event, or contralateral carotid intervention. Methods: Patients with carotid occlusion shown by duplex ultrasound imaging were retrospectively identified and followed-up between January 2002 and June 2010 (mean, 52 months; range, 1-93 months) at a tertiary care hospital. All had a minimum of three duplex examinations available for review. Analysis by χ2 was used to determine risk factors for death, neurologic event, or contralateral intervention. Multivariate Cox proportional hazard analysis was conducted with P values < 0.1. Survival was estimated using the Kaplan-Meier method (P < .05 significant). Results: Eighty patients with comorbidities commensurate for a tertiary care center were identified and available for analysis. At the initial encounter, 30 (38%) were symptomatic, with 23 (29%) having symptoms referable to the occluded carotid. During follow-up, 7 (9%) had a neurologic event, of which 6 (86%) were referable to the occluded side; 14 (18%) underwent a contralateral operation, and 19 (24%) died. Multivariate analysis revealed amaurosis fugax at initial presentation was a risk factor for contralateral operation (P = .05). Although numerous variables of multivessel disease were significant with χ2 analysis, there was no significant risk factor associated with neurologic event upon multivariate analysis. Neck radiation (P = .05) and stenosis or occlusion of the external carotid ipsilateral to the occlusion on follow-up (P < .027) were associated with increased risk of death. Kaplan-Meier analysis showed 7-year survival for patients with ECA disease at follow-up was significantly worse (16.2% ± 10.3% vs 79% ± 8.7%; P < .00001). Conclusions: Patients with carotid occlusion frequently present with symptoms referable to the occlusion. Eighty-six percent of neurologic events originated from the occluded carotid, indicating that the process is not benign. Multivariate analysis revealed no factor, specifically, concurrent extracranial arterial disease, predictive of subsequent neurologic events. With significant risk of death in patients found to have ipsilateral ECA stenosis during follow-up, it seems reasonable to continue surveillance of the occluded carotid.TableRisk factors and outcomeRisk factorContralateral operationNeurologic event in follow-upDeathPrior neck irradiation0.0680.170.054aP = .05;At presentation Amaurosis fugax0.078aP = .05;0.760.44 Ipsilateral ECA0.170.190.005 Contralateral ECA0.0050.560.014In follow-up Ipsilateral vert0.30.0190.29 Ipsilateral ECA0.0330.073<0.000bP < .05 in multivariate analysis. Contralateral ECA0.620.460.061ECA/vertebral stenosis or occlusion At presentation0.0530.0980.007 Progression in follow-up0.290.4270.31a P = .05;b P < .05 in multivariate analysis. Open table in a new tab

Background: Cost of treatment is an important consideration in antimicrobial agent selection for intra-abdominal infection. We analyzed the relation between the total cost of inpatient stay and the initial selection of antimicrobial agent.Methods: Actual costs of inpatient care were calculated for 1,234 patients treated at 22 hospitals with one of five antimicrobial regimens: Ampicillin/sulbactam (n = 428), ertapenem (n = 143), ceftriaxone (n = 101), levofloxacin (n = 245), or piperacillin/tazobactam (n = 317) for intra-abdominal infections. Length of stay (LOS), demographic data, diagnosis, disease severity index, intensive care unit (ICU) stay, and total and specific costs were obtained from a large hospital-based, service level, comparative database for five types of infection (appendicitis, cholecystitis, diverticulitis, pancreatitis, and postoperative infection).Results: The LOS was shorter for appendicitis (3.8 days) and cholecystitis (4.6 days) than for diverticulitis (11.4 days), pancreatitis (8.1 days), or postoperative infection (8.4 days). Length of stay and total cost were most closely related to severity index (p < 0.01) and ICU days (p < 0.01). When patient and hospital characteristics and correlations within hospitals were accounted for in the model, piperacillin/tazobactam was associated with significantly higher cost than ertapenem, ampicillin/sulbactam, and levofloxacin.Conclusions: In assessing pharmacoeconomic outcomes in the treatment of intra-abdominal infection, cost of treatment, although lower with certain antimicrobial agents, is dependent on severity-of-illness indicators.

PURPOSE: Postoperative thrombotic thrombocytopenic purpura (pTTP) is an uncommon clinical entity in the cardiac surgery patient. If left undiagnosed and untreated, it has a mortality rate as high as 90%. Early recognition and diagnosis of this syndrome may improve the prognosis.

Combined burn and trauma injuries represent a rare injury pattern that results in an increased morbidity and mortality. Treatment algorithms in this patient population can be complex. Healthcare providers must be able to appropriately prioritize therapy in order to achieve optimal outcomes. This review will discuss the initial assessment and management of patients with combined burn and trauma. Current treatment modalities and resuscitation principles of the burn patient will be reviewed. Recognition and management of inhalation injuries, air bag injuries, and other motor vehicle-related burns will also be discussed.

Hepatic cystic lesions are rare; however, their management and treatment is dependent on early recognition and diagnosis.In this report, the authors discuss a 72-year-old woman who presented to their clinic for treatment of a hepatocystadenoma.The history, physical examination, and diagnostic modalities lead to surgical intervention despite an unclear diagnosis.This case illustrates an unusual hepatic lesion in which the diagnosis was not known until the time of laparotomy. However, diagnostic modalities were important in establishing the need for surgical intervention. The authors offer a pertinent review of the literature and discuss current treatment modalities.