BACKGROUND & AIMS: OBJECTIVES:To assess the clinical effectiveness and cost-effectiveness of central venous catheters (CVCs) treated with anti-infective agents in preventing catheter-related bloodstream infection (CRBSI). DATA SOURCES:Major electronic databases were searched from 1985 to August 2005. REVIEW METHODS:The systematic clinical and economic reviews were conducted according to accepted procedures. Only full economic evaluations (synthesis of costs and benefits) comparing the use of anti-infective central venous catheters (AI-CVCs) with untreated CVCs or other treated catheters were selected for inclusion in the economic review. RESULTS:A total of 32 trials met the clinical inclusion criteria. Seven different types of AI-CVC were identified, with the most frequently tested being chlorhexidine and silver sulfadiazine (CHSS) (externally treated), CHSS (externally and internally treated) and minocycline rifampicin (internally and externally treated). In general, the trials were of a poor quality in terms of reported methodology, microbiological relevance and control of confounding variables. The pooled result suggests a statistically significant advantage for AI-CVCs in comparison to standard catheters in reducing CRBSI [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.34 to 0.60, 24 studies, I-squared = 0%, fixed effects]. Analysis by subgroups of catheters demonstrates that antibiotic-treated catheters and catheters treated internally and externally decrease CRBSI rates significantly (OR 0.26, 95% CI 0.15 to 0.46, six studies, I-squared = 0%, fixed effects, and OR 0.43, 95% CI 0.26 to 0.70, nine studies, I-squared = 0%, fixed effects, respectively). Catheters treated only externally demonstrate a wider CI and non-significant effect (OR 0.67, 95% CI 0.43 to 1.06, nine studies, I-squared = 0%, fixed effects). A treatment effect was also found for trials with an average duration of between 5 and 12 days, and for the one study with a mean duration of over 20 days. There was a statistically significant treatment effect for both femoral and jugular insertion sites and for those studies reporting a mix of insertion sites. The treatment effect was not observed in trials using exclusively subclavian insertion sites. Of the four trials that compared treated catheters, one reported a benefit of antibiotic-treated catheters over catheters treated externally with CHSS. All three sensitivity analyses testing for study design differences reported a statistically significant treatment effect. The review was limited owing to the quality of the trials included, marked differences in the definitions and methods of diagnosis of CRBSI, and inconsistent reporting of risk factors and patient population factors. Furthermore, two-thirds of trials were commercially funded. The economic performance (cost-effectiveness and potential cost-savings) of using AI-CVCs to reduce the number of CRBSIs in patients requiring a CVC was also reviewed. Results show that the use of AI-CVCs instead of standard CVCs can lead to a reduction in CRBSIs and decreased medical costs. To complement the reviews, a basic decision-analytic model was constructed to explore a range of possible scenarios for the NHS in England and Wales. Results show that for every patient who receives an AI-CVC there is an estimated cost-saving of 138.20 pounds. The multivariate sensitivity analyses estimate potentially large cost-savings, depending on the size of the population, under a wide range of cost and clinical assumptions. However, those considering the purchase of AI-CVCs should ensure that their patient populations and the important characteristics of local clinical practice are indeed similar to those described in this economic evaluation. CONCLUSIONS:Overall, AI-CVCs are clinically effective and relatively inexpensive and therefore their integration into clinical practice can be justified. However, the use of these anti-infective catheters without the appropriate use of other practical care initiatives will have only a limited success on the prevention of CRBSIs. Comparative trials are required to determine which, if any, of the treated catheters is the most effective. Pragmatic research related to the effectiveness of bundles of care that may reduce rates of CRBSI is also warranted.

背景与目标：

BACKGROUND & AIMS: :Percutaneous large bore cannula placement during orthotopic liver transplantation (OLT) for use in venovenous bypass (VVB) has been reported to be a rapid and simple technique. It is, however, a technique that carries its own risks. The aim of the study was to investigate the incidence of complications related to the placement of a percutaneous venous return cannula and subsequent VVB in OLT. A retrospective review of 360 consecutive adult OLT patients during a period of 18 months (January 1, 2003 to June 30, 2004) was performed. The percutaneous venous cannula (18 Fr) was placed by an attending transplant anesthesiologist. The cannulation was attempted in 326 patients (90.6%). No cannulation was attempted on the subclavian veins. Internal jugular venous cannula placement was attempted but aborted in 6 patients (1.8%) due to technical difficulties. In 320 patients who received an internal jugular venous cannula, 313 (97.8%) underwent OLT without complication. The remaining 7 patients (2.2%) had complications. The operation was delayed for 1 patient due to suspected hemomediastinum. The other 6 complications were related to VVB: air embolism (2 patients), low flow rate (2 patients), hypotension (1 patient), and atrial fibrillation (1 patient). Successful OLT was eventually carried out in all the 7 patients and no mortality associated with internal jugular venous cannula placement or VVB was noted. In conclusion, percutaneous placement of a large bore venous return cannula for VVB during adult OLT can be performed with acceptable risk using a flexible 18-Fr cannula via the right internal jugular vein (IJV) by experienced attending transplant anesthesiologists.

背景与目标： : 据报道，在原位肝移植 (OLT) 中用于静脉旁路 (VVB) 的经皮大口径套管放置是一种快速而简单的技术。然而，这是一种自担风险的技术。该研究的目的是调查与OLT中经皮静脉回流套管和随后的VVB放置有关的并发症的发生率。对18个月 (2003年1月1日2004年6月30日) 的360例成人OLT患者进行了回顾性研究。由主治的移植麻醉师放置经皮静脉插管 (18 Fr)。在326例患者中尝试插管 (90.6%)。未尝试对锁骨下静脉进行插管。尝试放置颈内静脉插管，但由于技术困难而中止了6例 (1.8%)。在接受颈内静脉插管的320例患者中，313 (97.8%) 接受了OLT，没有并发症。其余7名患者 (2.2%) 有并发症。1例患者因怀疑有纵隔血而延迟手术。其他6种并发症与VVB有关: 空气栓塞 (2例)，低流速 (2例)，低血压 (1例) 和房颤 (1例)。最终在所有7例患者中成功进行了OLT，没有发现与颈内静脉插管或VVB相关的死亡率。总之，经验丰富的主治移植麻醉师可以通过右颈内静脉 (IJV) 使用柔性18-fr套管在成人OLT期间经皮放置VVB大口径静脉回流套管，风险可接受。

BACKGROUND & AIMS: -2

背景与目标： -2

BACKGROUND & AIMS: OBJECTIVE:We describe the angiographic diagnosis and significance of persistence of the primitive hepatic venous plexus with underdevelopment of the infrahepatic inferior vena cava. CONCLUSION:We recommend that inferior venacavography be performed in routine assessment before surgery of patients with azygos or hemiazygos continuation of the inferior vena cava, in whom redirection of systemic venous blood to the pulmonary artery is contemplated.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Glycyrrhizin is an agent with the capacity to bind to selectin molecules expressed on vascular endothelial cells and potentially prevent the adherence of neutrophils to the vascular endothelial surface. It has been found to prevent intravenous thrombus formation. METHODS:Venous thrombosis was induced in male rats by ligation of the inferior vena cava (IVC) for 6 h. Before the ligation, the study rats were given intravenous injections of glycyrrhizin through the IVC. After 6 h of venous ligation, the rats were sacrificed and the IVC segments were harvested. Thrombus within the IVC was collected to measure the wet weight. Gene expression of P-, L-, and E-selectin was detected by reverse transcriptase polymerase chain reaction using extracts of mRNA from the IVC vein wall. As baseline controls, IVC samples without ligation were harvested immediately after laparotomy. Neutrophil adhesion to the luminal surface of IVC was assessed on histological sections stained with hematoxylin and eosin. Blood samples were collected through the IVC proximal to the ligation after 6 h to estimate activated partial thromboplastin time (APTT) and prothrombin time (PT). To investigate the effect of glycyrrhizin on binding capacity of P-selectin to human neutrophils, real-time biospecific interaction analysis was performed with the Biacore 2000 system. RESULTS:The mean weight of thrombus in the glycyrrhizintreated group was 12.9 +/- 11.1 mg, which is significantly lower than that of the saline-treated control group (21.3 +/- 12.5 mg). The expression level of P-and L-selectin mRNA in both saline-and glycyrrhizin-treated groups was significantly higher than that of the baseline control. Histological studies of cross sections of IVC showed significantly fewer neutrophils adhering to the luminal surface with glycyrrhizin treatment than in the saline-treated controls. There was no significant difference in the values of coagulation parameters with or without glycyrrhizin treatment. In vitro analysis showed that glycyrrhizin caused a dose-dependent reduction of neutrophils binding to immobilized recombinant P-selectin. CONCLUSIONS:Preoperative treatment with glycyrrhizin is potentially useful for preventing venous thrombosis by suppressing the adherence of neutrophils to the venous endothelium during the initial phase of thrombus formation without reducing coagulation capacity and the subsequent risk for increased bleeding.

背景与目标：

BACKGROUND & AIMS: CONTEXT:Adrenal vein sampling (AVS) is recommended in all patients with hyperaldosteronism to whom surgery would be offered if the results indicated unilateral hypersecretion. OBJECTIVE:To assess the performance of AVS against radiological findings and to evaluate the Endocrine Society's Practice Guidelines for diagnostic cut-offs. PATIENTS:Retrospective study of 41 patients with hyperaldosteronism who underwent both AVS and computed tomography (CT) imaging. RESULTS:CT and AVS results were concordant in 73.7%. Unilateral lesions on CT had a greater positive predictive value (85%) than non-unilateral lesions (50%). In patients with subsequently confirmed adrenal adenomas, a lateralisation ratio >2 when comparing cortisol-corrected aldosterone ratios from the affected versus unaffected side was 100% sensitive. Patients who were managed surgically experienced significant reductions in blood pressure and medication burden and 46% were cured. CONCLUSIONS:AVS is important in establishing unilateral or bilateral adrenal secretion of aldosterone in patients with primary hyperaldosteronism. However, it may not be essential for the work-up in patients below the age of 40, in whom adrenal incidentalomas adrenal incidentalomas are known to be rarer, and a unilateral lesion on CT therefore has a greater positive predictive value.

背景与目标：

BACKGROUND & AIMS: :Thrombosed arteriovenous malformations (AVMs) are the predominant type of occult vascular malformation and do not seem to differ significantly in clinical or radiographic presentation from other types of occult vascular malformations. Thrombosed AVMs and occult vascular malformations occasionally present with symptoms secondary to subacute or occult hemorrhage that requires operation. The histopathology of thrombosed AVMs and occult vascular malformations does not seem to have prognostic significance. Five patients with histologically verified thrombosed AVMs are reported. Two patients had previous incomplete resection of histologically proven thrombosed AVMs and presented with recurrence and bleeding. Two patients presented with seizures and headaches, and one patient presented with hemiparesis and headache. All histology specimens had evidence of hemorrhage. The pathological findings of these lesions seem variable; two specimens contained a mixture of cavernous angioma and AVM. Two previously resected lesions had been defined histologically as thrombosed AVMs. Successful excision of the lesions was accomplished in four patients, and one patient had stereotactic biopsy. The magnetic resonance imaging characteristics of lesions seem to add a degree of specificity over computed tomography and angiography. We have found that the literature poorly describes the natural history and histology of these lesions. Conservative management for seizures and headaches due to thrombosed AVMs may not be warranted because of a propensity for hemorrhage and recurrence.

背景与目标： : 血栓形成的动静脉畸形 (avm) 是隐匿性血管畸形的主要类型，在临床或影像学表现上似乎与其他类型的隐匿性血管畸形没有显着差异。血栓形成的avm和隐匿性血管畸形偶尔出现继发于需要手术的亚急性或隐匿性出血的症状。血栓形成的avm和隐匿性血管畸形的组织病理学似乎没有预后意义。据报道，有5例经组织学证实的血栓形成的avm患者。两名患者先前未完全切除经组织学证实的血栓形成的avm，并出现复发和出血。两名患者出现癫痫发作和头痛，一名患者出现偏瘫和头痛。所有组织学标本都有出血的证据。这些病变的病理发现似乎是可变的; 两个标本包含海绵状血管瘤和AVM的混合物。先前切除的两个病变在组织学上被定义为血栓形成的avm。四名患者成功切除了病变，一名患者进行了立体定向活检。病变的磁共振成像特征似乎比计算机断层扫描和血管造影增加了一定程度的特异性。我们发现文献对这些病变的自然史和组织学描述不佳。由于出血和复发的倾向，可能不需要对血栓形成的avm引起的癫痫发作和头痛进行保守治疗。

BACKGROUND & AIMS: BACKGROUND:Oral anticoagulants present multiple practical problems for patients undergoing chemotherapy. To assess the practice implications of anticoagulation therapy, a review was carried out. METHODS:A review of all patients with cancer treated with warfarin for venous thromboembolism (VTE) over a 1-year-period was carried out. Adverse events and therapeutic efficacy were assessed and the extra volume of work involved in monitoring was quantified. RESULTS:Fifty-five patients with cancer and VTE were treated with warfarin from 07/04 to 06/05. Twenty-one invasive interventions required disruption of anticoagulation. There were eight admissions for haemorrhage. Nine patients died while on warfarin. A total of 1,379 coagulation tests were performed. There were 382 extra dayward visits attributable to warfarin monitoring. On treatment, 13 patients (24%) were changed from warfarin therapy to low molecular weight heparin (LMWH). CONCLUSIONS:This study identifies and quantifies the extra resource utilization with warfarin therapy in patients undergoing chemotherapy.

背景与目标：

BACKGROUND & AIMS: :The prevention of venous thromboembolism is a major concern in cancer patients undergoing pelvic surgery. Radical retropubic prostatectomy is a common treatment for localized prostate cancer and has been identified as a high risk procedure for postoperative venous thromboembolism. However, most patients diagnosed with prostate cancer in the current era have clinically localized, low volume disease and the risk of venous thromboembolism is very low. Multiple guidelines exist for the prevention of venous thromboembolism in patients undergoing radical retropubic prostatectomy and pharmacological venous thromboembolism prophylaxis is recommended. Most urological surgeons in the USA however, do not routinely utilize pharmacological prophylaxis. A major concern arises when radical retropubic prostatectomy is performed with a concomitant pelvic lymphadenectomy. Pharmacological prophylaxis is known to increase the rate of lymph drainage and the rate of lymphocele formation. Evidence suggests that lymphocele may be an independent risk factor for venous thromboembolism in the postoperative period. These factors raise concern over current guidelines calling for routine use of pharmacological venous thromboembolism prophylaxis in radical retropubic prostatectomy especially when lymphadenectomy is performed simultaneously.

背景与目标： : 预防静脉血栓栓塞是接受骨盆手术的癌症患者的主要关注点。耻骨后前列腺根治术是局部前列腺癌的常见治疗方法，已被确定为术后静脉血栓栓塞的高风险手术。但是，当今时代诊断为前列腺癌的大多数患者都具有临床局限性，低体积的疾病，并且发生静脉血栓栓塞的风险非常低。在接受根治性耻骨后前列腺切除术的患者中，有多种预防静脉血栓栓塞的指南，建议使用药物预防静脉血栓栓塞。然而，美国大多数泌尿外科医生并不常规使用药物预防。当进行根治性耻骨后前列腺切除术并同时进行盆腔淋巴结清扫术时，会引起主要关注。已知药物预防会增加淋巴引流率和淋巴囊肿形成率。有证据表明，淋巴囊肿可能是术后静脉血栓栓塞的独立危险因素。这些因素引起了人们对当前指南的关注，该指南要求在根治性耻骨后前列腺切除术中常规使用药理学静脉血栓栓塞预防，尤其是同时进行淋巴结清扫术时。

BACKGROUND & AIMS: -2

背景与目标： -2

BACKGROUND & AIMS: BACKGROUND: A pial arteriovenous fistula (PAVF) is a rare neurovascular pathology consisting of a direct connection between one or more arterial feeders and a single venous channel. A PAVF was previously considered a subtype of an arteriovenous malformation (AVM). In the current literature these are distinguished as two independent entities with different clinical, physiopathologic, and structural characteristics. We report a case of a surgically treated 37-year-old woman with an extremely rare combination of an unruptured PAVF and AVM. PATIENT: The AVM was mainly supplied by feeders of the middle cerebral artery and drained into the sigmoid sinus via an abnormally dilated and tortuous vein. Following its resection, intraoperative digital subtraction angiography (DSA) in the hybrid operating room revealed the presence of a PAVF that had not been noted during the preoperative planning. Hence the PAVF was completely disconnected as confirmed by DSA again. CONCLUSION: This is the second reported case of an AVM-associated PAVF. Without the intraoperative DSA in the hybrid operating room, this unusual complex cerebrovascular entity would likely have been missed.

背景与目标：

BACKGROUND & AIMS: :Eighty-five limbs in 73 patients with a healed venous ulcer were assessed by ascending and descending phlebography, foot volume plethysmography and transcutaneous oxygen measurements. Forty-four limbs had post-thrombotic changes on ascending phlebography. In 24 (28 per cent) these extended into the femoral vein, while in 20 (24 per cent) only the calf veins were involved. In the 41 limbs (48 per cent) with normal deep veins on ascending phlebography, 11 had evidence of localized incompetence of the calf communicating veins, 14 had either long saphenous incompetence, deep vein reflux to the level of the knee or below, or both of these abnormalities, and 16 limbs had no phlebographic abnormalities. However all limbs had a decreased half volume refilling time on foot volume plethysmography. Limbs with post-thrombotic changes extending into the femoral vein were associated with a significantly longer history of ulceration and more ulcer recurrences than limbs with calf vein damage (P less than 0.05 for each) and limbs with normal deep veins (P less than 0.01 for each). However, these limbs did not have lower transcutaneous oxygen ratios or longer times to achieve ulcer healing. Ascending phlebography identified a group of limbs with extensive post-thrombotic changes in which there was a higher incidence of ulcer breakdown, but this was not associated with a delay in ulcer healing.

背景与目标： : 通过上升和下降静脉造影，足体积体积描记术和经皮氧气测量，评估了73例静脉溃疡愈合患者的85个肢体。上升静脉造影时，四十四个肢体有血栓后变化。在24 (28%) 中，这些延伸到股静脉，而在20 (24%) 中，仅涉及小腿静脉。在上升静脉造影的41条正常深静脉的肢体 (48%) 中，有11条有小腿连通静脉局部无能的证据，14条有长隐无能，深静脉反流至膝盖或以下水平，或这两种异常，16条肢体无静脉造影异常。然而，在脚部体积描记术上，所有肢体的填充时间都减少了一半。血栓后改变延伸到股静脉的肢体与小腿静脉损伤的肢体 (每条P小于0.05) 和正常深静脉的肢体 (每条P小于0.01) 相比，溃疡病史明显更长，溃疡复发更多。但是，这些肢体没有较低的经皮氧气比率或更长的时间来实现溃疡愈合。上升静脉造影发现了一组具有广泛血栓后变化的肢体，其中溃疡破裂的发生率更高，但这与溃疡愈合的延迟无关。

BACKGROUND & AIMS: :Axial migration of red blood cells in small glass tubes can cause blood viscosity to be effectively independent of shear rate. However, this phase separation may not occur to the same degree in the venous network due to infusion of cells and aggregates at branch points. To investigate this hypothesis, we followed trajectories of fluorescently labeled red blood cells in the venular network of the rat spinotrapezius muscle at normal and reduced flow with and without red blood cell aggregation. Cells traveling near the wall of an unbranched venular segment migrated approximately 1% of the longitudinal path length without aggregation and migrated slightly more with aggregation. Venular segment length between branch points averaged three to five times the diameter. Cells in the main vessel were shifted centrally by up to 20% of diameter at branch points, reducing the migration rate of cells near the opposite wall to <1% even in the presence of aggregation. We conclude that formation of a cell-free marginal layer in the venular network is attenuated due to the time dependence of axial migration and the frequent branching of the network.

背景与目标： : 小玻璃管中红细胞的轴向迁移会导致血液粘度与剪切速率无关。但是，由于在分支点输注细胞和聚集体，这种相分离可能不会在静脉网络中发生相同程度的分离。为了研究这一假设，我们追踪了在正常和减少的流量下，有或没有红细胞聚集的情况下，大鼠spinotrapezius肌肉的静脉网络中荧光标记的红细胞的轨迹。在未分支的静脉节段的壁附近行进的细胞迁移了纵向路径长度的大约1%，而没有聚集，并且随着聚集而稍微迁移更多。分支点之间的小静脉段长度平均为直径的三到五倍。主血管中的细胞在分支点中心移动高达直径的20%，即使在存在聚集的情况下，也将相对壁附近的细胞的迁移速率降低至 <1%。我们得出的结论是，由于轴向迁移的时间依赖性和网络的频繁分支，小静脉网络中无细胞边缘层的形成会减弱。

BACKGROUND & AIMS: :A new model of soft-tissue infection is used to investigate the effect of the local wound environment on the septic focus. Island pedicle flaps were raised on the buttock of 24 adult ewes and multiply inoculated with Staphylococcus aureus. Flaps with bacterial inoculation, without compromise of venous outflow, showed distal necrosis (mean +/- SEM percent of surface area, 25.8% +/- 8.6%) and developed septic foci with bacterial counts one log less than the amount injected. Flaps with inoculation and venous outflow obstruction underwent subtotal necrosis (mean percent of surface area, 73.3% +/- 11.2%) and had counts two logs higher than the nonobstructed flaps but without discrete septic foci. Flaps without inoculation, with or without venous obstruction, survived completely. Venous outflow obstruction is shown herein to potentiate tissue necrosis by raising bacterial counts in a septic focus and preventing defensive abscess formation by the host.

背景与目标： : 一种新的软组织感染模型用于研究局部伤口环境对脓毒症灶的影响。在24只成年母羊的臀部上举起岛状蒂皮瓣，并多次接种金黄色葡萄球菌。在不影响静脉流出的情况下接种细菌的皮瓣显示远端坏死 (平均表面积的/- SEM百分比，25.8%/- 8.6%)，并形成败血性病灶，细菌计数比注射量少1 log。接种和静脉流出阻塞的皮瓣发生了次全坏死 (平均表面积百分比，73.3%/- 11.2%)，其计数比未阻塞的皮瓣高两个对数，但没有离散的败血症灶。未经接种，有或没有静脉阻塞的皮瓣完全存活。本文显示静脉流出梗阻可通过增加败血症灶中的细菌计数并防止宿主形成防御性脓肿来增强组织坏死。

BACKGROUND & AIMS: BACKGROUND:Complete hepatic venous isolation and extracorporeal charcoal hemoperfusion (HVI.CHP) can limit systemic exposure to high-dose chemotherapeutic agents when given by hepatic arterial infusion (HAI). The purpose of this study was to determine if the concomitant use of sodium thiosulfate (STS) could further expand the advantages of pharmacologic delivery of HVI.CHP for cisplatin (CDDP) during HAI chemotherapy. METHODS:CDDP (4mg/kg) was administered over 20 minutes via HAI under conditions of HVI.CHP in 14 mongrel dogs. HVI.CHP was performed for 30 minutes after initiation of HAI. During CDDP infusion, 7 dogs each received 400 mg/kg STS (a 100-fold molar ratio to CDDP) over 20 minutes via the prefilter (STS group) circuit line, while the remaining 7 dogs (controls) received no STS. Blood samples were taken serially from the prefilter circuit line (hepatic venous blood), postfilter line, and the left carotid artery (systemic blood). The free and total CDDP concentrations in these samples were determined by flameless atomic absorption spectrophotometry. RESULTS:During 20 minutes HAI of CDDP, the mean CDDP extraction ratios (ER) by CHP filter were always higher in the STS group than in the control group, regardless of the form (free or total) of CDDP. The differences between the STS and control groups in the extraction ratios of free and total CDDP were significant at all time points measured (P < .05). Consequently, systemic exposure to CDDP, as assessed by area under the time-concentration curve of total CDDP, was significantly lower in the STS group than in the control group (P < .05). CONCLUSIONS:These results indicated that concomitant STS infusion could further increase the effect of HVI.CHP on CDDP removal after HAI.

背景与目标：