Comparison of the utility of clinical breast examination and MRI in the surveillance of women with a high risk of breast cancer.

AIM: To review surveillance magnetic resonance imaging (MRI) and clinical breast examinations (CBE) performed for women at high risk of breast cancer in order to determine recall and cancer-detection rates. MATERIALS AND METHODS: Data were collected on all surveillance MRI examinations performed at St James's Hospital in 2016 for women at high risk of developing breast cancer. Data collected included age, indication for MRI, MRI score, ultrasound indications and scores, and histology findings. Ultrasound scores were recorded from CBEs that received a score of ≥3. RESULTS: A total of 385 breast surveillance MRI examinations and CBEs were performed for women at high risk of breast cancer. A recall rate of 11.2% was documented for breast MRI examinations, whereas a recall rate of 6.2% was identified for CBEs. The biopsy rate was 6.2% for MRI and 0.2% for CBE. The cancer detection rate was 1.6% or 16 per 1,000 for MRI screening and 0% for CBE. CONCLUSION: The high cancer detection rate in the present study supports the unparalleled sensitivity of breast MRI surveillance. Furthermore, the present study did not identify any breast cancers through CBE, suggesting it is not a critical component of the surveillance programme of high-risk women. The current UK guidelines recommending a target recall rate of 7% were not met in the present study or by other studies in the literature, collectively suggesting the guidelines may not be reflective of what is attainable in clinical practice.

Portal Hypertensive Colopathy with Pelvic Varices presenting as Severe Lower GI Bleed treated with TIPSS.

We present the case of a 71-year-old lady with a background of significant alcohol intake who presented with frank lower gastrointestinal (GI) bleeding, lower abdominal pain and haemoglobin 6.3g/dL. CT abdominal angiogram showed right-sided colonic thickening, atrophic liver and enlarged superior mesenteric vein (SMV) and right-sided pelvic varix. This lead to a diagnosis of portal hypertensive colopathy secondary to alcoholic liver cirrhosis. The patient failed conservative management and underwent a Transjugular Intrahepatic Portosystemic Shunt (TIPSS) procedure. This lead to an immediate resolution of her lower-GI bleeding. Repeat CT at three weeks showed a decompressed SMV and resolution of the right-sided pelvic varix. The patient was discharged after three months following optimization of medical condition and social circumstances.

When do we think it is Safe to Drive after Hand Surgery? - Current Practice and Legal Perspective.

Patients recovering from hand surgery frequently ask when it is safe to drive and it is unclear where the responsibility lies; the surgeon, the patient or the insurance company. An eight-question survey looking at various aspects of clinical practice was circulated to consultant and trainee plastic and orthopaedic surgeons in Ireland and the UK. Of the 89 surgeons who replied, (53%) felt the decision when to drive was the patient's compared with the insurance company (40%) and the surgeon (7%). 80% advised patients to contact their insurance company. 87% were unaware of current regulations or guidelines. National guidelines were vague and left the decision with the treating doctor. Similarly, major insurers advise patients to contact their doctor for advice. From a legal standpoint, the patient has a duty of care to other road users to be in full control of his vehicle prior to driving, regardless of any advice received.

Chemical characteristics of wildfire ash across the globe and their environmental and socio-economic implications.

The mobilisation of potentially harmful chemical constituents in wildfire ash can be a major consequence of wildfires, posing widespread societal risks. Knowledge of wildfire ash chemical composition is crucial to anticipate and mitigate these risks. Here we present a comprehensive dataset on the chemical characteristics of a wide range of wildfire ashes (42 types and a total of 148 samples) from wildfires across the globe and examine their potential societal and environmental implications. An extensive review of studies analysing chemical composition in ash was also performed to complement and compare our ash dataset. Most ashes in our dataset had an alkaline reaction (mean pH 8.8, ranging between 6 and 11.2). Important constituents of wildfire ash were organic carbon (mean: 204 g kg-1), calcium, aluminium, and iron (mean: 47.9, 17.9 and 17.1 g kg-1). Mean nitrogen and phosphorus ranged between 1 and 25 g kg-1, and between 0.2 and 9.9 g kg-1, respectively. The largest concentrations of metals of concern for human and ecosystem health were observed for manganese (mean: 1488 mg kg-1; three ecosystems > 1000 mg kg-1), zinc (mean: 181 mg kg-1; two ecosystems > 500 mg kg-1) and lead (mean: 66.9 mg kg-1; two ecosystems > 200 mg kg-1). Burn severity and sampling timing were key factors influencing ash chemical characteristics like pH, carbon and nitrogen concentrations. The highest readily dissolvable fractions (as a % of ash dry weight) in water were observed for sodium (18 %) and magnesium (11.4 %). Although concentrations of elements of concern were very close to, or exceeded international contamination standards in some ashes, the actual effect of ash will depend on factors like ash loads and the dilution into environmental matrices such as water, soil and sediment. Our approach can serve as an initial methodological standardisation of wildfire ash sampling and chemical analysis protocols.

Extreme rainstorms drive exceptional organic carbon export from forested humid-tropical rivers in Puerto Rico.

Extreme rainfall events in the humid-tropical Luquillo Mountains, Puerto Rico export the bulk of suspended sediment and particulate organic carbon. Using 25 years of river carbon and suspended sediment data, which targeted hurricanes and other large rainstorms, we estimated biogenic particulate organic carbon yields of 65 ± 16 tC km-2 yr-1 for the Icacos and 17.7 ± 5.1 tC km-2 yr-1 for the Mameyes rivers. These granitic and volcaniclastic catchments function as substantial atmospheric carbon-dioxide sinks, largely through export of river biogenic particulate organic carbon during extreme rainstorms. Compared to other regions, these high biogenic particulate organic carbon yields are accompanied by lower suspended sediment yields. Accordingly, particulate organic carbon export from these catchments is underpredicted by previous yield relationships, which are derived mainly from catchments with easily erodible sedimentary rocks. Therefore, rivers that drain petrogenic-carbon-poor bedrock require separate accounting to estimate their contributions to the geological carbon cycle.

The JAK inhibitor ruxolitinib reduces inflammation in an ILC3-independent model of innate immune colitis.

Innate immunity contributes to the pathogenesis of inflammatory bowel disease (IBD). However, the mechanisms of IBD mediated by innate immunity are incompletely understood and there are limited models of spontaneous innate immune colitis to address this question. Here we describe a new robust model of colitis occurring in the absence of adaptive immunity. RAG1-deficient mice expressing TNFAIP3 in intestinal epithelial cells (TRAG mice) spontaneously developed 100% penetrant, early-onset colitis that was limited to the colon and dependent on intestinal microbes but was not transmissible to co-housed littermates. TRAG colitis was associated with increased mucosal numbers of innate lymphoid cells (ILCs) and depletion of ILC prevented colitis in TRAG mice. ILC depletion also therapeutically reversed established colitis in TRAG mice. The colitis in TRAG mice was not prevented by interbreeding to mice lacking group 3 ILC nor by depletion of TNF. Treatment with the JAK inhibitor ruxolitinib ameliorated colitis in TRAG mice. This new model of colitis, with its predictable onset and colon-specific inflammation, will have direct utility in developing a more complete understanding of innate immune mechanisms that can contribute to colitis and in pre-clinical studies for effects of therapeutic agents on innate immune-mediated IBD.

Electronic discharge summary and prescription: improving communication between hospital and primary care.

BACKGROUND: The discharge letter is a key component of the communication pathway between the hospital and primary care. Accuracy and timeliness of delivery are crucial to ensure continuity of patient care. Electronic discharge summaries (EDS) and prescriptions have been shown to improve quality of discharge information for general practitioners (GPs). The aim of this study was to evaluate the effect of a new EDS on GP satisfaction levels and accuracy of discharge diagnosis. METHODS: A GP survey was carried out whereby semi-structured interviews were conducted with 13 GPs from three primary care centres who receive a high volume of discharge letters from the hospital. A chart review was carried out on 90 charts to compare accuracy of ICD-10 coding of Non-Consultant Hospital Doctors (NCHDs) with that of trained Hopital In-Patient Enquiry (HIPE) coders. RESULTS: GP satisfaction levels were over 90 % with most aspects of the EDS, including amount of information (97 %), accuracy (95 %), GP information and follow-up (97 %) and medications (91 %). 70 % of GPs received the EDS within 2 weeks. ICD-10 coding of discharge diagnosis by NCHDs had an accuracy of 33 %, compared with 95.6 % when done by trained coders (p < 0.00001). CONCLUSION: The introduction of the EDS and prescription has led to improved quality of timeliness of communication with primary care. It has led to a very high satisfaction rating with GPs. ICD-10 coding was found to be grossly inaccurate when carried out by NCHDs and it is more appropriate for this task to be carried out by trained coders.

Risk factors for early or delayed stroke after cardiac surgery.

BACKGROUND: Stroke after cardiac surgery is a devastating complication that leads to excess mortality and health resource utilization. The purpose of this study was to identify risk factors for perioperative stroke, including strokes detected early after cardiac surgery or postoperatively. METHODS AND RESULTS: Data were obtained from 2972 patients undergoing coronary artery bypass graft and/or valve surgery. Patients >/=65 years old and those with a history of symptomatic neurological disease underwent preoperative carotid artery ultrasound scanning. Intraoperative epiaortic ultrasound to assess for ascending aorta atherosclerosis was performed in all patients. New strokes were considered as a single end point and were categorized with respect to whether they were detected immediately after surgery (early stroke) or after an initial, uneventful neurological recovery from surgery (delayed stroke). Strokes occurred in 48 patients (1.6%); 31 (65%) were delayed strokes. By multivariate analysis, prior neurological event, aortic atherosclerosis, and duration of cardiopulmonary bypass were independently associated with early stroke, whereas predictors of delayed stroke were prior neurological event, diabetes, aortic atherosclerosis, and the combined end points of low cardiac output and atrial fibrillation. Female sex was associated with a 6.9-fold increased risk of early stroke and a 1.7-fold increased risk of delayed stroke. In-hospital mortality of patients with early (41%) and delayed (13%) strokes was higher than that of other patients (3%, P=0.0001). CONCLUSIONS: Most strokes after cardiac surgery occurred after initial uneventful recovery from surgery. Women were at higher risk to suffer early and delayed perioperative strokes. Atrial fibrillation had no impact on postoperative stroke rate unless it was accompanied by low cardiac output syndrome.

Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality.

OBJECTIVES: This study was undertaken to determine whether atherosclerosis of the ascending aorta is a predictor of long-term neurologic events and mortality. BACKGROUND: Atherosclerosis of the thoracic aorta has been recently considered a significant predictor of neurologic events and peripheral embolism, but not of long-term mortality. METHODS: Long-term follow-up (a total of 5,859 person-years) was conducted of 1,957 consecutive patients > or =50 years old who underwent cardiac surgery. Atherosclerosis of the ascending aorta was assessed intraoperatively (epiaortic ultrasound) and patients were divided into four groups according to severity (normal, mild, moderate or severe). Carotid artery disease was evaluated (carotid ultrasound) in 1,467 (75%) patients. Cox proportional-hazards regression analysis was performed to assess the independent effect of predictors on neurologic events and mortality. RESULTS: A total of 491 events occurred in 472 patients (neurologic events 92, all-cause mortality 399). Independent predictors of long-term neurologic events were: hypertension (p = 0.009), ascending aorta atherosclerosis (p = 0.011) and diabetes mellitus (p = 0.015). The independent predictors of mortality were advanced age (p < 0.0001), left ventricular dysfunction (p < 0.0001), ascending aorta atherosclerosis (p < 0.0001), hypertension (p = 0.0001) and diabetes mellitus (p = 0.0002). There was >1.5-fold increase in the incidence of both neurologic events and mortality as the severity of atherosclerosis increased from normal-mild to moderate, and a greater than threefold increase in the incidence of both as the severity of atherosclerosis increased from normal-mild to severe. CONCLUSIONS: Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality. These results provide additional evidence that in addition to being a direct cause of cerebral atheroembolism, an atherosclerotic ascending aorta may be a marker of generalized atherosclerosis and thus of increased morbidity and mortality.

Myasthenia gravis in identical twins.

The literature records myasthenia gravis in five sets of monozygous twins; we report another pair in which monozygosity was determined by blood group analysis, HLA typing, and mixed lymphocyte culture. Acetylcholine receptor antibodies were strongly positive in both twins. Poor response to anticholinergic medication and thymectomy necessitates low-dose daily maintenance prednisone for a normal life-style. The probability of myasthenia developing in the unaffected monozygotic twin is highest soon after diagnosis in the proband and an unaffected twin should be followed indefinitely.

Single-stage reoperative repair of chronic type A aortic dissection by means of the arch-first technique.

OBJECTIVE: Management of the enlarged, chronically dissected aorta after previous repair of acute aortic dissection or after a previous cardiac operation may present a formidable technical challenge. Marked enlargement of the proximal descending thoracic aorta precludes safe use of staged procedures, including the elephant trunk technique. METHODS: Sixteen patients with chronic type A aortic dissection (mean age, 56 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. We used single-stage replacement, with perfusion of the aortic arch first to minimize the duration of brain ischemia, with a bilateral anterior thoracotomy (clamshell) incision. Eleven patients had undergone previous repair of acute type A dissection. Five patients had type A dissection after aortic valve replacement (2 patients) and coronary artery bypass (3 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a 2-stage repair. The mean interval between the initial and reoperative procedures was 62 months (range, 5-137 months). RESULTS: There was 1 (6.2%; 70% confidence limits, 0.3%-24.7%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Six patients required assisted ventilation for more than 72 hours, and 3 patients required a tracheostomy. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome. CONCLUSION: The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.

Management of the severely atherosclerotic ascending aorta during cardiac operations. A strategy for detection and treatment.

Embolization of atheroma from the ascending aorta is a principal cause of stroke after cardiac operations. We have previously shown that intraoperative ultrasonographic scanning of the aorta rapidly, safely, and accurately identifies atheromatous disease in the ascending aorta. Intraoperative ultrasonography of the ascending aorta was performed in 500 of a consecutive series of 540 patients 50 years of age or older (mean 68 years) who underwent a variety of cardiac operations. Eighty-nine percent required bypass grafting. Sixty-eight patients (13.6% of the total) with a mean age of 72 years (range 55 to 85 years) had significant atheromatous disease in the ascending aorta and were considered to be at increased risk for embolization. Palpation identified the atheromatous disease in only 26 (38%) of these patients and underestimated its severity. A total of 168 modifications in the standard techniques for cannulation and clamping of the aorta were implemented in the 68 patients (mean 2.5 per patient) and included alterations in the sites of aortic cannulation (50 patients), aortic clamping (54 patients), attachment of the vein grafts (35 patients), and cannulation for infusion of cardioplegic solution (29 patients). Ten patients with severe diffuse atheromatous disease underwent graft replacement of the ascending aorta with hypothermic circulatory arrest without aortic clamping. Fourteen patients with symptoms or with high-grade carotid artery occlusive disease were treated by concomitant carotid endarterectomy. Thirty-day mortality for the entire group was 3.4% (17 patients). Permanent neurologic deficits occurred in five (1.0%) of the patients in the entire group but in none of the 68 patients with significant atheromatous disease in whom modifications in technique were used. One patient in the latter group had a reversible ischemic neurologic deficit. Modification of standard cannulation and clamping techniques based on ultrasonography may reduce the frequency of stroke related to atheromatous embolization.

Hypothermic bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta.

BACKGROUND: Hypothermic cardiopulmonary bypass with intervals of circulatory arrest is a useful adjunct during operations on the descending thoracic aorta and distal aortic arch when severe aortic disease precludes placement of clamps on the aorta. Hypothermia also has a marked protective effect on spinal cord function during periods of aortic occlusion. METHODS: Fifty-one patients (age range, 22 to 79 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the diseased aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest in situations where the location, extent, or severity of disease precluded placement of clamps on the proximal aorta (8 patients) or (in 43 patients) when extensive thoracic (11) or thoracoabdominal (32) aortic disease was present and the risk for development of spinal cord ischemic injury and renal failure was judged to be increased. Patent intercostal (below T-6) and upper lumbar arteries were attached to the graft whenever possible. RESULTS: Thirty-day mortality was 9.8% (5 patients). Paraplegia occurred in 2 and paraparesis in 1 of the 46 30-day survivors (6.5%). Among the 27 operative survivors with thoracoabdominal aneurysms, paraplegia occurred in 1 of 12 with Crawford type I (8%), 0 of 10 with type II, and 1 of 5 with type III aneurysms (20%). Paraplegia occurred in none of the 12 patients with aortic dissection and in 2 of the 15 patients with degenerative aneurysms. Renal failure requiring dialysis occurred in 1 (2.2%) of the 46 30-day survivors. CONCLUSIONS: Hypothermic circulatory arrest is a valuable adjunct for the treatment of complex aortic disease involving the aortic arch and thoracoabdominal aorta. In patients with thoracoabdominal aneurysms, its use has been associated with a low incidence of renal failure and an incidence of paraplegia/paraparesis in traditionally high-risk subsets (type I and II aneurysms, aortic dissection), which may be less than that observed with other surgical techniques.

Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta.

BACKGROUND: Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch and the descending thoracic and thoracoabdominal aorta. Its safety and efficacy compared with other techniques (eg, simple aortic clamping, partial cardiopulmonary bypass, and regional hypothermia) are not clearly established. METHODS: One hundred sixty-one patients (ranging from 20 to 83 years old) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass usually with intervals of circulatory arrest (mean interval, 38 minutes). RESULTS: The 30-day mortality rate was 6.2% (10 patients). It was 41% (7 of 17) for patients having emergent operations (rupture or acute dissection) and 2.1% (3 of 144) for all other patients (p < 0.001). The 90-day mortality rate was 11.8% (19 patients). Paraplegia occurred in 4 and paraparesis in 1 of the 156 operative survivors whose lower limb function could be assessed postoperatively (3.2%). Among the 91 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 33 patients with Crawford type I disease, 0 of 34 with type II disease, and 2 of 24 with type III disease. One patient (type II disease) had development of paraplegia on the tenth postoperative day. None of the 50 patients with aortic dissection experienced paralysis. Renal dialysis was required in 4 (2.5%) of the 157 operative survivors, prolonged inotropic support (> 48 hours) in 17 (11%), reoperation for bleeding in 8 (5%), mechanical ventilation (> 48 hours) in 31 (20%), and tracheostomy in 13 (8%). Three patients (1.9%) sustained a stroke. CONCLUSIONS: Hypothermic cardiopulmonary bypass provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.

Risks of bilateral internal mammary artery bypass grafting.

Although use of one internal mammary artery (IMA) for coronary artery bypass grafting does not appear to be associated with increased risk, the results with both IMAs are less certain; the potential for a higher incidence of sternal wound infection as a result of devascularization of the sternum is a major concern. During a 42-month interval ending July 1988, 1,566 patients had coronary artery bypass grafting alone or in combination with other procedures: 633 received only vein grafts, 687 had unilateral IMA grafting, and 246 had bilateral IMA grafting. The IMA patients were younger, were more often male, had better cardiac function, and underwent fewer emergent, urgent, or combined procedures than the patients receiving vein grafts (p less than 0.05). Thirty-day mortality was lower among the IMA patients (unilateral IMA group, 2.8%; bilateral IMA group, 3.7%; and vein graft group, 7.9%; p = 0.001). With the exception of sternal wound problems, occurrence rates for postoperative complications among the IMA patients did not differ significantly from or were lower (p less than 0.05) than those among the patients with vein grafts. Sternal infections occurred with greater frequency among the bilateral IMA patients (6.9%) than among the unilateral IMA (1.9%) or vein graft (1.3%) patients (p = 0.001). By univariate analysis, obesity, diabetes, bilateral IMA grafting, and need for prolonged (greater than 48 hours) mechanical ventilation were associated with a significantly higher incidence of sternal infection (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Strategy for the reduction of stroke incidence in cardiac surgical patients.

Atherosclerosis of the ascending aorta (AAA) and severe carotid artery disease are risk factors for stroke in cardiac surgical patients. Twelve hundred of a consecutive series of 1,334 patients 50 years of age or older having a cardiac operation were screened for the presence of AAA by intraoperative ultrasonographic scanning and for the presence of carotid artery occlusive disease (791 of 798 patients > or = 65 years of age and younger symptomatic patients) by carotid duplex scanning. Coronary artery disease was present in 88% of the patients. Patients with moderate or severe AAA (n = 231; 19.3% of the total) were treated by ascending aortic replacement (n = 27) or by modified, less extensive techniques (n = 168) to avoid the atherosclerotic areas. Thirty-three patients had combined carotid endarterectomy and cardiac operation. Thirty-day mortality and stroke rates for the 1,200 patients were 4.0% and 1.6%, respectively. The stroke rate was low (1.1%) among the 969 patients with no or mild AAA. It was zero among 27 patients with moderate or severe AAA who had ascending aortic replacement and among the 33 patients who had carotid endarterectomy. The stroke rates were higher for 111 patients with moderate or severe ascending aortic disease who had only minor interventions (6.3%) and for 16 patients with severe carotid artery disease who did not have carotid endarterectomy (18.7%). Screening for AAA and carotid artery disease and aggressive surgical treatment of moderate or severe AAA and severe or symptomatic carotid artery disease appears to reduce the frequency of stroke in older cardiac surgical patients.

Previous coronary artery bypass grafting is not a risk factor for aortic valve replacement.

BACKGROUND: The risk of aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG) is controversial. Its magnitude influences the threshold for recommending this procedure and has been cited in arguments regarding the optimal management of mild aortic stenosis at primary CABG. We therefore reviewed our experience with reoperative AVR +/- CABG and the primary combined procedure. METHODS: Between January 1, 1985, and June 30, 1996, 427 patients underwent primary AVR+CABG, and 52 underwent AVR +/- CABG after prior CABG. Demographics, operative characteristics, and operative results were compared between groups. Data for all patients were pooled and analyzed collectively for risk factors influencing mortality. RESULTS: The extent of native coronary artery disease and the incidence of prior myocardial infarction and stroke were greater in the reoperative group. Aortic cross-clamp and cardiopulmonary bypass times were slightly shorter, and fewer distal anastomoses were performed in the reoperative group. Operative mortality (primary group, 6.3% versus reoperative group, 7.4%) and morbidity were similar. Stepwise multivariate logistic regression analysis identified age, perioperative myocardial infarction, intraaortic balloon support, ventricular arrhythmia, perioperative stroke, and development of renal failure or acute respiratory distress syndrome, but not reoperative status, as predictors of mortality. CONCLUSIONS: The risk of AVR after previous CABG is similar to that for primary AVR+CABG. Valve replacement should, therefore, be pursued despite prior CABG when hemodynamically significant aortic stenosis develops. Furthermore, a circumspect approach to "prophylactic" AVR for mild aortic stenosis at primary CABG seems warranted.

Renal dysfunction and intravascular coagulation with aprotinin and hypothermic circulatory arrest.

High-dose aprotinin was used in 20 patients undergoing primary or repeat operations on the thoracic or thoracoabdominal aorta using cardiopulmonary bypass and hypothermic circulatory arrest. The activated clotting times immediately before the establishment of hypothermic circulatory arrest exceeded 700 seconds in all but 1 patient. Three patients (15%) required reoperation for bleeding. Seven patients died during hospitalization, and 5 had postmortem examination. Platelet-fibrin thrombi were present in multiple organs including the coronary arteries of 4 patients with myocardial infarction or failure, the pulmonary arteries of 2 patients, 1 of whom died of acute right ventricular failure, the brains of 2 patients who sustained a stroke, and the kidneys of 4 patients, 3 of whom had development of renal dysfunction. Renal dysfunction occurred in 13 patients (65%), and all were 65 years of age or older. Five of these patients required hemodialysis. Among 20 age-matched patients who had similar operations without aprotinin, there was one hospital death (5%) from myocardial infarction, and renal dysfunction developed in 1 patient (5%), who did not require dialysis. None of these 20 patients required reoperation for bleeding. Although aprotinin has been shown to reduce blood loss in patients having cardiac operations employing cardiopulmonary bypass, this benefit was not attained in this group of patients with thoracic aortic disease in whom hypothermic circulatory arrest was used. Use of aprotinin in elderly patients undergoing these procedures was associated with an increased risk of renal dysfunction and failure, and of myocardial infarction and death.

A clinicopathologic study of the eyes in familial adenomatous polyposis with extracolonic manifestations (Gardner's syndrome).

The eyes of a 51-year-old woman with familial adenomatous polyposis and extracolonic manifestations (Gardner's syndrome) were obtained postmortem and studied by light microscopy and by transmission and scanning electron microscopy. We found a generalized abnormality in melanogenesis of the retinal pigment epithelium and at least three types of pigmented lesions. The histologic findings in one type of lesion were consistent with congenital hypertrophy of the retinal pigment epithelium or benign pigmented nevus of the retinal pigment epithelium. The other two types of lesion were most consistent with hamartomatous malformations of the retinal pigment epithelium featuring cellular hypertrophy, hyperplasia, and rarely retinal invasion and formation of a minute mushroom-shaped tumor. These histopathologic findings indicate a generalized effect of the familial adenomatous polyposis gene on the retinal pigment epithelium. This oncogene, which is responsible for tumor formation in the gastrointestinal tract, soft tissues, bone, and other locations in patients with familial adenomatous polyposis, also leads to a generalized defect in melanogenesis and focal lesions of the retinal pigment epithelium.

Endogenous Listeria monocytogenes endophthalmitis presenting as keratouveitis.

We report a case of Listeria monocytogenes endophthalmitis that presented as a recalcitrant keratouveitis in a nonimmunocompromized patient. L. monocytogenes was recovered from the patient's aqueous, vitreous, and two of three blood cultures. He was treated with topical, subconjunctival, and systemic antibiotics, but the visual outcome was poor, possibly because of late diagnosis. A review of previous cases of L. monocytogenes endophthalmitis demonstrates unique features of this infection: (a) presentation as an anterior uveitis or keratouveitis with elevated intraocular pressure, (b) endogenous origin, and (c) frequent occurrence in nonimmunocompromized patients.