Comparing noninvasive sampling techniques with standard cannula sampling method for ruminal microbial analysis.

Rumen microbes play an important role in the conversion of indigestible plant material to energy and protein in dairy cows. Sampling for ruminal contents via cannula is considered the gold standard technique for microbial analysis, but the technique requires ruminally cannulated animals and specialized animal facilities. The purpose of this study was to determine whether other sampling methods and locations along the digestive tract may serve as noninvasive proxies to the cannula method for microbial analysis. Six ruminally cannulated lactating Holstein dairy cows were adapted to a standard total mixed ration for 2 wk and sampled during the third week. Sampling locations and methods included salivary content, rumination bolus (regurgitated digesta collected from the cow's mouth), feces, and rumen contents via stomach tube and cannula. Stomach tube and cannula samples differ in proportions of solid and liquid material and were therefore separated into whole (as collected), liquid, and solid fractions. Samples were collected at 0 (before feeding), 2, 4, 6, 8, and 12 h after feeding over 2 d. All samples were extracted for total genomic DNA and selected samples for metabolically active DNA (RNA), PCR-amplified for the V1-V2 region of the 16S rRNA bacterial gene, and analyzed for bacterial diversity using the QIIME2 pipeline followed by statistical analysis in R (https://www.R-project.org/). In DNA-based analysis, at the community level, saliva, rumination bolus, and fecal samples clustered in separate groups, whereas all fractions of stomach tube and cannula samples clustered together, indicating that microbial communities of stomach tube and cannula samples were homogeneous. Rumination bolus samples at 6, 8, and 12 h after feeding clustered with stomach tube and cannula samples, indicating that rumination bolus samples may be an alternative for cannula samples; however, time of sampling is critical for sampling of bolus digesta. Results of the RNA-based analysis of rumination bolus samples and solid samples from cannula and stomach tube at 0 and 6 h after feeding were similar. We concluded that the solid fraction of samples obtained via the stomach tube method may serve as a proxy for the solid fraction of whole ruminal contents obtained via cannula for DNA-based microbial investigations. Both rumination bolus and stomach tube solid samples may serve as proxies for cannula solid samples for RNA-based microbial analysis.

Erysipelothrix rhusiopathiae isolates recovered from fish, a harbour seal (Phoca vitulina) and the marine environment are capable of inducing characteristic cutaneous lesions in pigs.

In order to determine the diversity and pathogenicity of Erysipelothrix spp. isolates recovered from marine fish, a harbour seal (Phoca vitulina) and the marine environment, 14 isolates were characterized by genotyping, serotyping, determination of the surface protective antigen (spa) gene type and assessment of virulence in a pig bioassay. All 14 isolates were Erysipelothrix rhusiopathiae. Isolates were determined to be of serotypes 2 (n = 3), 3 (n = 1), 4 (n = 1), 12 (n = 1), 15 (n = 1) or 21 (n = 6), and one isolate cross-reacted with serotypes 5 and 21. The spa gene analysis determined that 64.3% (n = 9) were spaA and 35.7% (n = 5) were spaB1. In pigs, 10/14 isolates induced small plaques to diamond-shaped cutaneous lesions consistent with Erysipelothrix spp. infection. The results of this study indicate that the marine E. rhusiopathiae isolates have greater genetic and antigenic diversity than pig isolates and are capable of inducing classical skin lesions in pigs.

Characterization of Erysipelothrix species isolates from clinically affected pigs, environmental samples, and vaccine strains from six recent swine erysipelas outbreaks in the United States.

The aim of this study was to characterize Erysipelothrix sp. isolates from clinically affected pigs and their environment and compare them to the Erysipelothrix sp. vaccines used at the sites. Samples were collected during swine erysipelas outbreaks in vaccinated pigs in six Midwest United States swine operations from 2007 to 2009. Pig tissue samples were collected from 1 to 3 pigs from each site. Environmental samples (manure, feed, central-line water, oral fluids, and swabs collected from walls, feed lines, air inlets, exhaust fans, and nipple drinkers) and live vaccine samples were collected following the isolation of Erysipelothrix spp. from clinically affected pigs. All Erysipelothrix sp. isolates obtained were further characterized by serotyping. Selected isolates were further characterized by PCR assays for genotype (E. rhusiopathiae, E. tonsillarum, Erysipelothrix sp. strain 1, and Erysipelothrix sp. strain 2) and surface protective antigen (spa) type (A, B1, B2, and C). All 26 isolates obtained from affected pigs were E. rhusiopathiae, specifically, serotypes 1a, 1b, 2, and 21. From environmental samples, 56 isolates were obtained and 52/56 were E. rhusiopathiae (serotypes 1a, 1b, 2, 6, 9, 12, and 21), 3/56 were Erysipelothrix sp. strain 1 (serotypes 13 and untypeable), and one was a novel species designated Erysipelothrix sp. strain 3 (serotype untypeable). Four of six vaccines used at the sites were commercially available products and contained live E. rhusiopathiae serotype 1a. Of the remaining two vaccines, one was an autogenous live vaccine and contained live E. rhusiopathiae serotype 2 and one was a commercially produced inactivated vaccine and was described by the manufacturer to contain serotype 2 antigen. All E. rhusiopathiae isolates were positive for spaA. All Erysipelothrix sp. strain 1 isolates and the novel Erysipelothrix sp. strain 3 isolate were negative for all currently known spa types (A, B1, B2, and C). These results indicate that Erysipelothrix spp. can be isolated from the environment of clinically affected pigs; however, the identified serotypes in pigs differ from those in the environment at the selected sites. At one of the six affected sites, the vaccine strain and the isolates from clinically affected pigs were of homologous serotype; however, vaccinal and clinical isolates were of heterologous serotype at the remaining five sites, suggesting that reevaluation of vaccine efficacy using recent field strains may be warranted.

Identification of surface protective antigen (spa) types in Erysipelothrix reference strains and diagnostic samples by spa multiplex real-time and conventional PCR assays.

AIM: To develop spa multiplex real-time and conventional PCR assays to detect and differentiate between spaA, spaB and spaC genes within Erysipelothrix spp. METHODS AND RESULTS: For evaluation of the assays, 28 Erysipelothrix spp. reference strains, 25 tissues from pigs inoculated with reference strains of serotypes 1, 2, 5, 10 or 18, and 15 diagnostic samples were used. SpaA was found to be present in Erysipelothrix rhusiopathiae serotypes 1a, 1b, 2, 5, 9, 12, 15, 16, 17, 23 and N; spaB was detected in E. rhusiopathiae serotypes 4, 6, 8, 11, 19 and 21 and spaC was detected in E. sp. strain 2 serotype 18. Spa-related genes were not detected in E. tonsillarum strains (serotypes 3, 7, 10, 14, 20, 22, 24, 25, 26) or E. sp. strain 1 (serotype 13). With the spa multiplex real-time PCR assay, it was also possible to further differentiate spaB into spaB1 (serotypes 4, 6, 8, 19 and 21) and spaB2 (serotype 11). Overall, spaA was detected in seven experimental tissue samples and six diagnostic tissue samples, and spaC in two experimental tissue samples. The detection limits were determined to be five colony-forming units (CFU) per reaction for the spa multiplex real-time PCR assay and 4000 CFU per reaction for the conventional PCR assay. CONCLUSIONS: Both spa PCR assays were specific and reproducible in the identification of spa types in Erysipelothrix spp. SIGNIFICANCE AND IMPACT OF THE STUDY: The described spa PCR assays may be useful tools for investigating spa prevalence among strains isolated from field tissues and to determine the role of the Spa proteins in vaccine protection and pathogenesis.

Rapid detection and differentiation of Erysipelothrix spp. by a novel multiplex real-time PCR assay.

AIM: The aim of this study was to develop a multiplex real-time PCR assay for the identification and discrimination of Erysipelothrix rhusiopathiae, tonsillarum and Erysipelothrix sp. strain 2 for direct detection of Erysipelothrix spp. from animal specimens. METHODS AND RESULTS: A primer set and three species-specific probes with different end labelling were designed from the noncoding region downstream of the 5S rRNA coding region. The sensitivity, specificity and repeatability of the assay were validated by analysing 27 Erysipelothrix spp. reference serotype strains and ten septicemia-associated non-Erysipelothrix spp. bacterial isolates. Cross-reactivity with Erysipelothrix sp. strain 1 was not observed with any of the primer probe combinations. The detection limit was determined to be <10 colony forming units and as low as one genome equivalent per PCR . Further evaluation of the Erysipelothrix spp. multiplex PCR was performed by comparing an enrichment isolation culture method and a conventional differential PCR on 15 samples from pigs experimentally inoculated with Erysipelothrix spp. and 22 samples from pigs with suspected natural infection. CONCLUSION: The multiplex real-time PCR assay was found to be simple, rapid, reliable, specific and highly sensitive. SIGNIFICANCE AND IMPACT OF THE STUDY: The developed real-time multiplex PCR assay does not require cumbersome and lengthy cultivation steps prior to DNA extraction, obtained comparable results to enrichment isolation, and will be useful in diagnostic laboratories for rapid detection of Erysipelothrix spp.

Novel rinse assay for the quantification of oral neutrophils and the monitoring of chronic periodontal disease.

BACKGROUND AND OBJECTIVES: The aim of this study was to develop a single, rapid, noninvasive oral rinse assay to enable the accurate quantification of oral neutrophils. Products released by neutrophils are partly responsible for the destruction observed in periodontitis. Quantification of oral neutrophil levels is important for understanding their role in periodontal diseases. Previous studies have relied on time-consuming serial rinses and cumbersome counting techniques for the collection and quantification of oral neutrophils. MATERIAL AND METHODS: Patients with chronic periodontal disease provided rinse samples before and after phase I periodontal treatment. Cells in the rinse samples were stained with acridine orange, and neutrophil counts were carried out using a fluorescence microscope and a hemocytometer. RESULTS: This assay allowed us to detect a significant difference in pretreatment oral neutrophil counts between periodontal disease and healthy control groups (p < 0.001). Patients who responded favorably to phase I therapy demonstrated a 43% reduction in oral neutrophil counts compared with their pretreatment levels (p = 0.019). Patients who did not respond to phase I periodontal treatment showed no significant difference in oral neutrophil levels (p = 0.39). CONCLUSION: Oral neutrophil levels, as determined by a rapid oral rinse, reflect the severity of periodontal disease and treatment response. A single, rapid, oral rinse assay is an effective means of collecting and quantifying oral neutrophil levels and may serve as an excellent research tool for further study of the role of neutrophils in periodontal diseases.

Laparoscopic surgery in older adults.

This article provides an overview of the current role of laparoscopic surgery in older patients. A retrospective review and analysis of the recent English-language literature on laparoscopic procedures with special attention devoted to those articles focused on geriatric patients was performed. Laparoscopic surgery has rapidly become the fastest-growing discipline within the surgical arena and new applications for laparoscopy continue to be reported. The primary benefits to patients of these developments are smaller scars, decreased postoperative pain, and more-rapid return to normal activity. As society ages, more older patients will present with pathology amenable to laparoscopic intervention. Several aspects of laparoscopy impose unique physiologic stresses and, as such, may alter surgical risk to the geriatric patient. In addition, older patients often have delayed surgical interventions because of more-conservative medical management or unusual symptomatology, which may further complicate the laparoscopic approach. These limitations may alter the risk-to-benefit ratio of laparoscopic versus open procedures. Despite this lack of elucidation of full-risk profiles, laparoscopic approaches should be considered regardless of a patient's age.

Development of an anti-vitellin ELISA for the assessment of reproduction in the ridgeback shrimp, Sicyonia ingentis.

To investigate the reproductive regulation of the ridgeback shrimp, Sicyonia ingentis, vitellin (Vn) synthesis was studied. Using gel filtration chromatography and sodium dodecyl sulfate-polyacrylamide gel electrophoresis, Vn was found to have a molecular mass of 322 kDa and to be composed of three subunits of 182, 91 and 85 kDa. Purified Vn was used to prepare anti-Vn antiserum, which was used to develop an enzyme-linked immunosorbent assay (ELISA) with a dynamic range of 0.3-300 ng. The ELISA was used to measure hemolymph levels of yolk proteins. The mean hemolymph concentrations in fresh caught animals ranged from 256 (+/-36.6 S.E.M.) to 1073 (+/-87.6 S.E.M.) mg/ml in stage 2 and 4 animals, respectively. The ELISA was also used to determine the effects of steroid hormone injections in adult non-reproductive female shrimp. One milligram injections of progesterone, 17alpha-hydroxyprogesterone or 17beta-estradiol were administered for three consecutive days to individual females. There were no changes in hemolymph vitellogenin levels during the successive 7-day period following the first injection of any steroid.

Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection.

OBJECTIVE: To examine the association of surgeon and hospital case volumes with the short-term outcomes of in-hospital death, total hospital charges, and length of stay for resection of colorectal carcinoma. METHODS: The study design was a cross-sectional analysis of all adult patients who underwent resection for colorectal cancer using Maryland state discharge data from 1992 to 1996. Cases were divided into three groups based on annual surgeon case volume--low (< or =5), medium (5 to 10), and high (>10)--and hospital volume--low (<40), medium (40 to 70), and high (> or =70). Poisson and multiple linear regression analyses were used to identify differences in outcomes among volume groups while adjusting for variations in type of resections performed, cancer stage, patient comorbidities, urgency of admission, and patient demographic variables. RESULTS: During the 5-year period, 9739 resections were performed by 812 surgeons at 50 hospitals. The majority of surgeons (81%) and hospitals (58%) were in the low-volume group. The low-volume surgeons operated on 3461 of the 9739 total patients (36%) at an average rate of 1.8 cases per year. Higher surgeon volume was associated with significant improvement in all three outcomes (in-hospital death, length of stay, and cost). Medium-volume surgeons achieved results equivalent to high-volume surgeons when they operated in high- or medium-volume hospitals. CONCLUSIONS: A skewed distribution of case volumes by surgeon was found in this study of patients who underwent resection for large bowel cancer in Maryland. The majority of these surgeons performed very few operations for colorectal cancer per year, whereas a minority performed >10 cases per year. Medium-volume surgeons achieved excellent outcomes similar to high-volume surgeons when operating in medium-volume or high-volume hospitals, but not in low-volume hospitals. The results of low-volume surgeons improved with increasing hospital volume but never equaled those of the high-volume surgeons.

Utility of magnetic resonance cholangiography in the evaluation of biliary obstruction.

BACKGROUND: Evaluation of suspected biliary obstruction has traditionally involved a variety of imaging modalities including ultrasound, CT, and invasive cholangiography. These techniques have limitations because of poor visualization of intraductal stones (ultrasound and CT) and the need for an invasive procedure (ERCP and percutaneous transhepatic cholangiography). Magnetic resonance cholangiography (MRC) is a noninvasive imaging modality that provides good visualization of the hepatobiliary system. The aim of the present study was to determine the utility of MRC in evaluating patients with suspected biliary obstruction. STUDY DESIGN: One hundred forty-three patients were identified with suspected acute biliary obstruction and underwent MRC. Patient selection was based on clinical criteria including an elevation in serum liver chemistries or evidence of biliary ductal dilatation on conventional imaging. MRC was performed using a half-Fourier acquisition single-shot turbo spin-echo sequence involving single breath-hold rapid image acquisition. A final diagnosis was determined in each patient based on invasive cholangiography, findings at surgery, and clinical course. RESULTS: Of the 143 patients, 73 had an obstructing biliary lesion. A malignant process was identified in 25 patients with final diagnoses of pancreatic cancer (n = 15), ampullary cancer (n = 4), cholangiocarcinoma (n = 3), and hepatic or nodal metastases (n = 3). MRC correctly identified biliary obstruction in all these patients and accurately identified the level of biliary obstruction in 24 of 25 patients. Based on the MRC images alone, a malignant process was suspected in 21 of the 25 patients. Forty patients were found to have common bile duct stones and eight patients had a benign distal bile duct stricture. MRC correctly identified common bile duct stones in 37 patients with one false-positive exam (sensitivity = 92%; specificity = 99%). MRC also correctly identified distal biliary strictures in eight patients. In the remaining 70 patients, no definite biliary obstruction was identified by MRC, and in all patients the absence of mechanical obstruction was confirmed by invasive cholangiography or overall clinical course. CONCLUSIONS: This study demonstrates that MRC is able to accurately identify the level and cause of biliary obstruction in both malignant and benign disease. MRC may prove to be an important noninvasive tool in preoperative evaluation of patients with suspected biliary obstruction and identification of patients most likely to benefit from an invasive radiologic or surgical procedure.

The changing face of mesenteric infarction.

Intestinal infarction remains a devastating event despite improvements in clinical recognition as well as diagnostic and therapeutic modalities. Recent changes in the etiology of this disease have not been examined. A retrospective review of 121 consecutive patients over a 6-year period was undertaken. Twenty-three patients died without operation, and mortality in the remaining 98 patients was 50 per cent. The only significant predictor of mortality was an elevated serum lactate at the time of diagnosis. Thirty-one patients (26%) developed infarction while hospitalized for another disease process; excluding patients with obstruction as the etiology of infarction caused this number to rise to 39 per cent. Nonocclusive mesenteric infarction was the most common disease process. The increased incidence of nonocclusive mesenteric infarction is likely due to the development of intestinal ischemia in already systemically ill patients. Nearly half of all cases of intestinal infarction due to nonobstructive causes develop in already hospitalized patients. The development of unexplained acidosis in a postoperative or critically ill patient should prompt a search for a reversible cause of mesenteric ischemia. Intestinal infarction may represent another example of the multisystem organ failure syndrome.

Transplantation of single and paired pediatric kidneys into adult recipients.

BACKGROUND: The transplantation of kidneys from cadaveric donors < or = 5 years of age into adult recipients is controversial. The large disparity between donor renal mass and recipient body mass is feared to be problematic. Controversy also exists whether to transplant kidneys from these young donors individually or as a pair into a single recipient. STUDY DESIGN: We retrospectively reviewed our experience from January 1991 to January 1995 with 22 adult renal transplantations using kidneys from cadaveric donors < or = 5 years of age. Ten patients received single allografts. Twelve received organs paired en bloc. Fifty-two adult recipients from cadaveric donors aged 18-55 years served as controls. All patients received cyclosporine-based immunosuppression. Recipient characteristics did not differ significantly between the groups. RESULTS: Actuarial patient and graft survival rates were similar for the two groups. The incidence of urinary complications was higher in the recipients of pediatric kidneys than in the adult-donor group (18.2% versus 3.8%, respectively, p = not significant). No grafts were lost from urinary complications. Renal function, as determined by the calculated creatinine clearance, was significantly greater in the pediatric group (76.1 +/- 4.0 versus 61.4 +/- 23.2 mL/min, p = 0.035) by 6 months after transplantation. Recipients of paired pediatric kidneys initially had better renal function (63.9 +/- 21.4 mL/min) than those receiving single pediatric kidneys (38.2 +/- 11.6 mL/min) (p = 0.004), but by 6 months, no significant difference existed. At 2 years, renal function in the pediatric-donor group remained significantly better than in the adult-donor group. Hematocrit levels as a measure of erythropoiesis were similar for single pediatric, paired pediatric, and adult-donor recipients. CONCLUSIONS: Kidneys from cadaveric donors < or = 5 years of age are suitable for transplantation into adults. Pediatric kidneys provide excellent renal function despite an initially tremendous disparity between renal mass and recipient body mass. Rapid true renal growth probably occurs. No appreciable advantage is achieved by using two pediatric kidneys for a single recipient.

Routine pulmonary artery catheterization does not reduce morbidity and mortality of elective vascular surgery: results of a prospective, randomized trial.

OBJECTIVE: The authors determined whether the preoperative placement of a pulmonary artery catheter (PAC) with optimization of hemodynamics results in outcome improvement after elective vascular surgery. SUMMARY BACKGROUND DATA: The PAC commonly is used not only in patients who are critically ill, but also perioperatively in major elective surgery. Few prospective studies exist documenting its usefulness. METHODS: One hundred four consecutive patients were randomized to have a PAC placed the morning of operation (group I) or to have a PAC placed only if clinically indicated (group II). Group I patients were resuscitated to preestablished endpoints before surgery and kept at these points both intraoperatively and postoperatively. Group II patients received standard care. RESULTS: There was one death in each group. An intraoperative or postoperative complication developed in 13 patients in group I versus 7 patients in group II (p = not significant). Group I patients received more fluid than did group II patients (5137 +/- 315 mL vs. 3789 +/- 306 mL; p < 0.003). There was no significant difference in either overall or surgical intensive care unit length of stay. Only one patient in group II required a postoperative PAC. CONCLUSIONS: Routine PAC use in elective vascular surgery increases the volume of fluid given to patients without demonstrable improvement in morbidity or mortality.

Laparoscopic cholecystectomy: applicability in the geriatric population.

Elderly patients with cholelithiasis are more likely than nonelderly patients to present with an acute complication of gallstone disease such as acute cholecystitis (AC), gallstone pancreatitis (GSP), or common bile duct stones (CBDS). These acute complications may make laparoscopic cholecystectomy (LC) more hazardous, with a potential increase in perioperative morbidity or need for open conversion. The applicability of LC in the geriatric population is, therefore, unclear. We reviewed 283 consecutive patients undergoing attempted LC. Patients were classified as presenting with complicated (AC, GSP, or CBDS) or uncomplicated gallstone disease. Elderly patients were significantly more likely than younger patients to present with AC (40% versus 18%), GSP (19% versus 6%), and CBDS (21% versus 5%) (all P < 0.05). Elderly patients with chronic, uncomplicated gallstone disease (n = 20) and nonelderly patients with uncomplicated disease (n = 159) had similar open conversion rates (5% and 7%, respectively). In contrast, the open conversion rate in elderly patients with complicated gallstone disease (n = 42) was significantly higher (50%) compared to nonelderly patients with complicated disease (n = 62; rate, 16%; P < 0.05). Perioperative morbidity and length of stay were also significantly increased in the elderly group, primarily due to the high percentage of elderly patients with complicated disease. These results suggest that elderly patients with uncomplicated gallstone disease appear to be excellent candidates for LC, and this should be considered before complicated disease develops. Conversely, early conversion or planned open cholecystectomy may be warranted in the elderly presenting with acute complications of cholelithiasis.

Quality and retrieval of obstetrical anaesthesia randomized controlled trials.

PURPOSE: Randomized controlled trials (RCTs) are suitable for meta-analysis and systematic reviews provided they are of high quality and are easy to retrieve. We determined these attributes of RCTs in obstetrical anaesthesia in a sample of available journals that are indexed in MEDLINE. SOURCE: Randomized controlled trials published between January 1985 and December 1994 in seven anaesthetic and three obstetric journals were identified by a MEDLINE search, and by handsearch of the same journals. Each RCT was assigned a quality score by a blinded rater using a reliable and validated scaled. The quality of each RCT was described and compared over time and by journal. The comparative yield of MEDLINE and hand-search was evaluated. PRINCIPAL FINDINGS: Three hundred and forty RCTs were retrieved by MEDLINE and handsearch. Two hundred and twenty seven (65%) were identified by the MEDLINE search and 333 by the handsearch (98%). The median quality score was 3/5. There was no difference in score over time. Anesthesiology had the highest median score, Anaesthesia had the lowest (P < 0.05). CONCLUSIONS: Care must be taken when reviewing obstetrical anaesthesia research. Strategies in addition to a MEDLINE search must be used to identify RCTs since more than one third were missed using MEDLINE alone. Poor quality RCTs are more likely to be biased in favour of a new treatment. Therefore, to increase the validity of reviews sensitivity analyses based on quality should be done.

General surgical care in the nursing home patient: results of a dedicated geriatric surgery consult service.

BACKGROUND: Although recent interest has centered on diseases that require operation in the elderly, few data are available about the effects of surgical intervention on the frail nursing home patient. STUDY DESIGN: A longitudinal study was conducted of the nature of illness requiring operation and intervention in residents of a geriatric center associated with a tertiary care medical center. A unique consult service for the patients was established and all referrals were prospectively followed up. RESULTS: The actuarial 18-month survival of patients referred was 35 percent. Although maintenance care (e.g., decubitus ulcer, stoma, and enteral tube care) made up a substantial number of referrals (32.5 percent), common surgical diseases of the abdomen, breast, and vascular system were routinely encountered (55 percent). In patients undergoing surgery, the 30-day mortality rate was 8.5 percent, and the complication rate 9.4 percent. Although patients undergoing major abdominal and vascular procedures had a higher complication rate (17.6) percent than those undergoing lesser procedures (6.3 percent, p = 0.05), there was no difference in the 30-day mortality (9.8 compared with 6.3 percent, respectively) or 18-month actuarial survival (33 compared with 32 percent, respectively) rates. The overall actuarial survival was adversely affected by the presence of coronary artery disease (relative risk [RR], 3.27) and dementia (Mini-Mental State Examination score less than 24; RR, 2.39) and age older than 70 years (RR, 2.03). The overall survival was unaffected by the actual need for operation, the magnitude of the procedure performed, gender, the number of comorbid conditions, and the preoperative code (resuscitative) status. CONCLUSIONS: Although nursing home patients referred for surgical intervention have poor survival rates, the use of surgical procedures does not adversely affect overall survival. This supports the idea that care for this patient population is not futile, and quality of life, patient dignity, and relief of suffering can provide a alternative to curative therapy.

Will stereotactic breast biopsy achieve results as good as current techniques?

Stereotactic procedures recently have been advocated to replace most needle localization and open biopsy procedures. In order to provide a baseline for comparison at our institution, a retrospective review of our results over the last 3 years was performed. During this time period, 496 biopsies were performed in 480 patients. Needle localization was done in 311 cases, whereas the remaining 185 biopsies were done for palpable masses. There were no significant differences in either the positive rate (19.0% vs 13.5%) or the infection rate (2.6% vs 1.6%) in the two groups. Follow-up of all patients has revealed no missed carcinomas and no referrals to a plastic surgeon for a poor cosmetic result. Current breast biopsy techniques yield good results, with acceptably low morbidity rates. Given that approximately one in five needle localization biopsies detects a malignancy, a negative result following a stereotactic biopsy may not preclude a needle localization procedure. It is therefore unlikely that stereotactic procedures will lead to an overall decrease in health care costs. Surgeon involvement will be crucial to assure best and most cost-effective results.

Transplantation of kidneys from expanded criteria donors.

BACKGROUND: The critical shortage of organs for transplantation has resulted in a controversial expansion of the criteria used to define a suitable cadaveric organ donor. The shortage of kidneys has a particularly hard impact on those patients on the waiting list who have uncommon major histocompatibility antigens or who are highly immunized. METHODS: To determine outcomes between patients receiving grafts from expanded criteria donors (ECDs) and others, a retrospective review of 105 consecutive kidney transplantations performed at a single institution during a 3 1/2 year period was conducted. A total of 44 (41.9%) patients received kidneys from ECDs, 45 (42.9%) from conventional cadaveric donors, and 16 (15.2%) from live donors. All patients were treated by the same physicians and received either triple or quadruple sequential immunosuppressive therapy. In general, high risk recipients did not receive kidneys from ECDs. RESULTS: Actuarial graft survival, incidence of delayed function, length of stay, and hospital charges were not significantly different between the ECD and conventional cadaveric donor groups of recipients. A higher incidence of urinary complications occurred in the ECD group (p=0.03). This incidence was noted primarily in the recipients of kidneys from donors 5 years of age or younger. However, no allografts were lost as a result of urinary complications. ECD kidneys that were imported from outside the local catchment area accounted for approximately 25% of all cadaveric transplantations performed. CONCLUSIONS: With appropriate selection of organs from ECDs, acceptable results can be obtained. ECD organs can serve to partially alleviate the extreme organ shortage. These organs should be procured and made available to those centers willing to use them.