This study demonstrated a nonsignificant lower rate of groin SSI in high-risk revascularization patients with NPWT compared with standard dressing. Owing to a lower than expected infection rate, the study was underpowered to detect a difference at the prespecified level. The NPWT group did show significantly shorter mean hospital duration of stay compared with the standard dressing group.

Despite recent evidence describing prokineticin 2 (PK2)-producing neurons and receptors in the dorsomedial medulla, little is known regarding the potential mechanisms by which this circadian neuropeptide acts in the medulla to influence autonomic function. Using whole cell electrophysiology, we have investigated a potential role for PK2 in the regulation of excitability in neurons of the area postrema (AP), a medullary structure known to influence autonomic processes in the central nervous system. In current-clamp recordings, focal application of 1 microM PK2 reversibly influenced the excitability of the majority of dissociated AP cells tested, producing depolarizations (38%) and hyperpolarizations (28%) in a concentration-dependent manner. Slow voltage ramps and ion-substitution experiments revealed that a PK2-induced Cl(-) current was responsible for membrane depolarization, whereas hyperpolarizations were the result of inhibition of a nonselective cation current. In contrast to these differential effects on membrane potential, nearly all neurons that displayed spontaneous activity responded to PK2 with a decrease in spike frequency. These observations are in accordance with voltage-clamp experiments showing that PK2 caused a leftward shift in Na(+) channel activation and inactivation gating. Lastly, using post hoc single-cell RT-PCR technology, we have shown that 7 of 10 enkephalin-expressing AP neurons were depolarized by PK2 indicating that PK2 may have specific inhibitory actions on this population of neurons in the AP to reduce their sensitivity to homeostatic signals. These data suggest that the level of AP neuronal excitability may be regulated by PK2, ultimately affecting AP autonomic control.

The treatment of leg edema often involves promoting venous blood flow but can be difficult in patients with comorbidities that prevent traditional management strategies such as limb elevation or mechanical compression devices. The geko device is a self-contained neuromuscular stimulation device that adheres to skin over the common peroneal nerve and delivers a low-voltage stimulus that activates the lower-leg musculature resulting in enhanced superficial femoral vein blood flow and velocity. Here we report 2 cases of multifactorial and refractory leg edema successfully treated with the geko device over a period of 4 to 16 weeks. The device also improved pain and chronic wound healing. Although the geko device is costly, it was well tolerated and may provide another treatment strategy for resistant leg swelling.

Polyembolokoilamania is the act of inserting foreign objects into bodily orifices and can be classified as a paraphilia if done for sexual pleasure. Although problematic sexual behaviors are common in dementia, the majority of case reports of urethral polyembolokoilamania in the elderly have occurred in the absence of dementia or cognitive impairment. Little empirical evidence exists for managing problematic sexual behaviors in the elderly and in dementia. Most evidence in the form of case reports demonstrates that behavioral, environmental, and pharmacological interventions can be effective. In this case report, we describe the management of sexually disinhibited behavior in the form of polyembolokoilamania in a 67-year-old man suffering from treatment-resistant depression, obsessive compulsive disorder, and early signs of frontotemporal dementia. The successful treatment included a course of electroconvulsive therapy.

No abstract

The province of Saskatchewan presents unique challenges for ruptured abdominal aortic aneurysms (AAAs), including variable access to health care resources and large transportation distances to tertiary vascular care. The goal of this study was to assess the rates of ruptured and unruptured aneurysms to determine whether there are areas of high aneurysm incidence that would benefit from further study and the possible implementation of a targeted screening protocol to improve management and prevention of aneurysm rupture.Methods: All diagnoses of AAA from 2001 to 2011 in the province of Saskatchewan were reviewed, with patients grouped by health region of residence. Diagnoses of ruptured and unruptured AAA were obtained from the Saskatchewan Discharge Abstract Database, Medical Services Billings Claims data, and Vitals Stats data. International Classification of Diseases, 9th Revision and 10th Revision, codes were used to identify specific patients with the diagnosis of AAA.Results: A total of 6163 AAAs were diagnosed, and 1667 AAAs were repaired over the study period. Mean age at diagnosis was 71.7 years, with 68% of all aneurysm diagnoses in men. Only 2% of patients were aboriginal. The provincial age-adjusted rate of AAA was 54.5 per 100,000 (95% confidence interval [CI],). The highest age-adjusted rate of AAA was found in the Five Hills Health Region (FHHR; 63.1 per 100,000; 95% CI, 57.63-69.03), which was significantly higher than the provincial average (P < .05). The rate of ruptured aneurysms in FHHR was nearly twofold higher than the provincial average (65.8 vs 32.1 per 100,000, respectively). The lowest aneurysm rates were found in the north of the province (age-adjusted rate, 44.6 per 100,000; 95% CI, 34.17-57.32).Conclusions: There are significant geographical variations in the incidence of ruptured and unruptured AAA in the province of Saskatchewan, with the highest incidence of unruptured and ruptured aneurysms localized to the FHHR. Why there is a preponderance of aneurysms in this area is unclear, but it suggests targeted screening may help reduce the number of aneurysms treated emergently for rupture.

Objectives: Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluated the mid to late follow-up of patients treated using one preservation technique, the endovascular external-to internal iliac artery (EIA-IIA) bypass.Methods: All patients undergoing retrograde EIA-IIA endovascular bypass were retrospectively reviewed from 2006 to 2016. Anatomic inclusion criteria were common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliac bifurcation angle >45 . Procedures were performed using aortouniiliac (AUI) endografts extended to one EIA, cross femoral artery bypass, and retrograde placement of covered stent grafts into the contralateral IIA. For patients with prior open repair, AUI placement was not required. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively, and annually thereafter with computed tomography CT scan (with selective contrast usage) 1 month postoperatively and annually thereafter.Results: Seventeen patients (mean age, 70 years; 93% male) were treated over the period. Most were treated for primary disease (n ¼ 11), while the remainder underwent secondary interventions following open repair (n ¼ 4) or endovascular repair (n ¼ 2). Nine patients had bilateral common iliac aneurysms, one had bilateral IIA aneurysms, and the remainder had unilateral iliac aneurysmal degeneration with occluded or severely diseased ipsilateral hypogastric arteries. There was no preference for laterality (right iliac, n ¼ 8; left iliac, n ¼ 9). Retrograde bypasses were performed using Fluency (n ¼ 1), Viabahn (n ¼ 13), or Gore Excluder (n ¼ 3) grafts. Hypogastric embolization with AUI extension to the EIA was required in six patients. Proximal extension requiring snorkel/fenestration was present in five patients. Technical success was 100%, with a mean operative time of 168 minutes (range, 50-300 minutes), and 71 mL contrast usage (range, 30-115 mL). Mean preoperative iliac artery aneurysm size was 4.0 cm with iliac bifurcation angle 71 (range, 51 -102 ). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 25.7 months, there were no aortic related deaths, one EIA-IIA bypass occlusion (asymptomatic), and one reintervention (for type II endoleak). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, paralysis, and bowel/bladder dysfunction was zero in the series.Conclusions: Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation.

between surgeon and patient. Use of these tools, however, can be timeconsuming and logistically challenging. We investigated whether simply showing patients their images from preoperative computed tomography (CT) or angiography would improve patient satisfaction with the preoperative discussion. We also examined whether this improved patient knowledge and patient trust and whether it contributed to increased preoperative anxiety. Methods: Consecutive patients undergoing either elective abdominal aortic aneurysm repair or lower limb revascularization were randomly assigned to either standard perioperative discussion or perioperative discussion and review of images (CT or angiography). Randomization was concealed and stratified by surgeon. Primary outcome was patient satisfaction with the preoperative discussion as measured by a validated seven-item scale (score of 0-28), with higher scores indicating improved satisfaction. Secondary outcomes included patient understanding, patient anxiety, patient trust, and length of preoperative discussion. Scores were compared using t-test. Results: Overall, 51 patients were randomized, 25 to the intervention arm (discussion and imaging) and 26 to the control arm. Most patients were male (69%), and average age was 70 years. Patient satisfaction with the discussion was generally high, with no added improvement when preoperative images were reviewed (mean score, 24.9 6 3.02 vs 24.8 6 2.93; P ¼ .88). Similarly, there was no difference in patient anxiety, level of trust, or knowledge when the imaging review was compared with standard discussion. There was a trend toward longer preoperative discussions in the group that underwent imaging review (8.18 vs 6.35 minutes; P ¼ .07). Conclusions: Showing patients their CT or angiography images during the preoperative discussion does not improve patient satisfaction. Similarly, there was no effect on patient trust, knowledge, or anxiety level. Unless patients specifically request imaging review, we would suggest against doing this routinely as it may lengthen the preoperative discussion unnecessarily.