Objective Stanford type A acute aortic dissection is a life-threatening medical condition with high rates of morbidity and mortality that requires surgical repair, on an emergency basis. The extent of aortic arch repair that should be carried out during emergency surgery of this type is controversial. This study was conducted to report clinical experience on aortic arch repair and determine surgical indication, optimal operative procedures and strategy for Stanford type A acute aortic dissection. Methods 210 consecutive patients with acute Stanford A aortic dissection who underwent aortic arch replacement combined with implantation of stented elephant trunk into the descending aorta between August 2005 and August 2010. Surgical procedures included hemi-aortic arch replacement in 92 patients, subtotal aortic arch replacement in 50 patients and total aortic arch replacement in 68 patients. All operations were performed with the aid of deep hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP). Enhanced computed tomography scanning was performed to evaluate the postoperative outcomes, particularly the fate of the false lumen remaining in the descending thoracic aorta by aortic arch replacement combined with implantation of stented elephant trunk during follow up. Results Average cardiopulmonary bypass time was (146 ±52) min. The average cross clamp time was(93 ±25)min and average selective cerebral perfusion and circulatory arrest time was(35 ±14)min. The overall in-hospital mortality was 4. 8% (10/210) and morbidity was 8. 6% ( 18/210). Postoperative complications included acute renal failure, stroke, mediastinitis and respiratory insufficiency. During the follow-up period [mean (27 ± 18) months, ranged 2 to 60 months], 1 patient underwent reoperation due to the descending thoracic and abdominal aortic aneurysm. There was no late death. Follow-up enhanced CT scanning showed about 74% false lumens obliterated at the level of the distal border of the stent graft post operation. Conclusion Open aortic arch replacement is an effective approach and provides acceptable outcomes for type A acute aortic dissection. Optimal treatment strategy is the key factor to success in emergency surgical intervention.

Objective Mechanisms for the dissection of aorta, a devastating disease, remain unknown. Studies showed that cytokine transforming growth factor (TGF)-131, a multifunctional regulator, was highly expressed in the aneurysms or dis-section of aorta and was responsible for the onset of the diseases. We try to explore the mechanisms of thoracic aortic dissection (TAD) by comparing the expression and distribution of TGF-β1 in the aortic wall and analyzing the association of TGF-β1 with extracellular matrix (ECM) in patients with TAD and control subjects. Methods Aortic specimens taken from surgical pa-tients with TAD( n = 20 ) at Zhongshao Hospital and organ donors ( n = 20, controls) were prepared with paraffin embedded tis-sue slide. ECM was investigated with hematoxylin-eosin, Verhoeff van-Giesen (EVG) and Maason's triehrome (MT) staining.Distribution and expression of TGF-β1 within aortic wall was examined with double immunofluoreseent staining and semi-quan-tiffed by fluoreseent intensity analysis. The expression of TGF-β1 in the two groups and among various layers of the arterial wall was compared. Results TAD was morphologically characterized by decreased and disrupted elastic fibers in the tunica media of the aorta wall with hyperplasia of the collagen fibers. TGF-β1 was expressed unevenly within aortic wall, with highest in the media, followed by intima and adventitia, in both TAD patients and eantrols. Specimen from TAD patients exhibited overall in-creased TGF-β1 expression by 9.56% as compared with that from the controls ( P <0.05 ). TGF-131 expression was increased by 16.09% (P<0.05) in the media and 16.75% (P<0.05) in the adventitia in TAD group as compared with those in the control group, but no difference was detected in intima between the two groups. TGF-β1 distribution histogram analysis dis-closed that TGF-β1 expression in the tunica media was evident in the elastic fibers, and was increased by 34.83% in TAD pa-tients as compared with that in the controls (P <0. 01 ). No significant associations between TGF-β1 expression and age, gen-der, maximal aortic diameter and type of dissection in TAD patients were detected. Conclusion TGF-β1 expression is up-reg-ulated and unevenly distributed in the dissected aortic wall of TAD patients. The finding that TGF-β1 was significantly up-regulated and condensed in the elastic fibers of the tuniea media suggested the crucial role of TGF-β1 in the development of TAD.

The daily insertion of endotracheal tubes, laryngeal mask airways, oral/nasal airways, gastric tubes, transesophageal echocardiogram probes, esophageal dilators and emergency airways all involve the risk of airway structure damage. In the closed claims analysis of the American Society of Anesthesiologists, 6% of all claims concerned airway injury. Among the airway injury clams, the most common cause was difficult intubation. Among many other causes, esophageal stethoscope is a relatively noninvasive monitor that provides extremely useful information. Relatively not many side effects that hardly is ratable. Some of that was from tracheal insertion, bronchial insertion resulting in hypoxia, hoarseness due to post cricoids inflammation, misguided surgical dissection of esophagus. Also oropharyngeal bleeding and subsequent anemia probably are possible and rarely pharyngeal/esophageal perforations are also possible because of this device. Careful and gentle procedure is necessary when inserting esophageal stethoscope and observations for injury and bleeding are needed after insertion.
Anemia ; Anoxia ; Bivalvia ; Bronchoscopes ; Emergencies ; Esophagus ; Foreign Bodies* ; Hemorrhage ; Hoarseness ; Inflammation ; Insurance Claim Review ; Intubation ; Laryngeal Masks ; Stethoscopes

INTRODUCTION: To evaluate the mid-term outcomes of regular surveillance venography with or without percutaneous transluminal angioplasty (PTA) in haemodialysis patients presenting with central venous occlusive disease. MATERIALS AND METHODS: A single-centre retrospective analysis of haemodialysis patients who presented with central vein occlusion (CVO) and central vein stenosis (CVS) between January 2008 and December 2011 was performed. CVO and significant CVS were defined as 100% and >50% luminal narrowing, respectively. Upon successful angioplasty on first presentation, patients were followed up with regular surveillance venography within 3-6 months of the intervention and were re-treated when a significant stenosis or occlusion was demonstrated. Data on patient's demographics, comorbidities, presenting symptoms, type of upper limb dialysis access, lesion characteristics and complications were collected. Technical success, primary patency and primary assisted patency were analysed. RESULTS: Thirty-five patients with CVO and 77 patients with CVS were enrolled. The technical success of initial PTA was 77% and 73% for the CVO and CVS groups, respectively. The primary patency at 3 months was 65% and 55% for the CVO group and CVS group, respectively ( = 0.32). The primary assisted patency at 1 year was 88% and 99% for the CVO group and CVS group, respectively ( = 0.009). At 2 years, the primary assisted patency were 77% and 90%, respectively ( = 0.07). There was significant difference in the overall primary assisted patency ( = 0.048) between the CVO and CVS groups. CONCLUSION CVOs are more difficult to treat than CVS. High primary assisted patency rates can be achieved with surveillance venography, albeit at the expense of increased number of interventions. Further cost effectiveness studies need to be performed to study the true benefit of our surveillance programme.

INTRODUCTIONWe aimed to compare the malignancy risk stratification of histologically proven thyroid nodules using the 2015 American Thyroid Association (ATA) Management Guidelines, 2014 British Thyroid Association (BTA) Guidelines for the Management of Thyroid Cancer and the Thyroid Imaging Reporting and Data System (TIRADS).

METHODSThyroid nodules measuring > 1 cm resected over 5.5 years were retrospectively studied. Demographic information as well as cytology and histopathology results were collected. Static ultrasonography (US) images and radiologists' reports of each resected nodules were reviewed and classified based on the above risk classification systems.

RESULTSA total of 167 thyroid nodules from 150 patients were examined. More malignant nodules were solid (78.4% vs. 62.5%; p = 0.049) or hypoechoic (70.6% vs. 28.6%; p < 0.001), and had irregular margins (35.3% vs. 8.0%; p < 0.001), taller-than-wide morphology (9.8% vs. 2.7%; p = 0.031), microcalcifications (33.3% vs. 8.0%; p < 0.001), disrupted rim calcifications (9.8% vs. 0.9%; p = 0.012) or associated abnormal cervical lymphadenopathy (13.7% vs. 0.9%; p = 0.001) compared with benign nodules. The guidelines' diagnostic performance was: ATA - sensitivity 98.0%, specificity 17.3%, positive predictive value (PPV) 35.0%, negative predictive value (NPV) 95.0%; BTA - sensitivity 90%, specificity 50.9%, PPV 45.5%, NPV 91.8%; and TIRADS - sensitivity 94.0%, specificity 28.2%, PPV 37.3%%, NPV 91.2%.

CONCLUSIONSonographic patterns outlined by the three guidelines displayed high sensitivity and NPV. Although isolated suspicious US features cannot predict malignancy risk, they should be considered when risk stratifying nodules that do not fit into particular sonographic patterns based on current guidelines.