Arterial Atherosclerosis: Vascular Surgery Interventions.

Atherosclerotic vascular disease is a leading cause of death worldwide. Atherosclerotic stenosis of the internal carotid or intracranial arteries causes up to 15% of strokes. Peripheral artery disease affects up to one in five people in the United States who are 60 years and older and nearly one-half of those who are 85 years and older. Renal artery stenosis may affect up to 5% of people with isolated hypertension and up to 40% of people with other atherosclerotic diseases. All patients with atherosclerotic vascular disease should receive a comprehensive program of guideline-directed medical therapy, including structured physical activity and lifestyle modification, an antiplatelet agent, a statin, antihypertensive therapy, and smoking cessation counseling. The U.S. Preventive Services Task Force recommends one-time screening for abdominal aortic aneurysm with ultrasonography in men 65 to 75 years of age who have smoked at least 100 cigarettes, but screening is not recommended for carotid, peripheral, and renal disease. Surgical revascularization decreases adverse outcomes and mortality in selected patients with advanced vascular disease. Endovascular repair has become more common for patients younger than 70 years because of decreased short-term mortality. Carotid revascularization with carotid endarterectomy or carotid artery stenting is recommended for symptomatic patients with greater than 50% internal carotid artery stenosis. Carotid artery stenting is preferred in patients with multiple comorbidities, tracheostomy, or previous neck radiation or dissection. In patients older than 70 years, carotid endarterectomy is associated with a lower risk of periprocedural stroke or death than carotid artery stenting. Revascularization is a reasonable treatment option for patients with lifestyle-limiting claudication and an inadequate response to guideline-directed therapies. Revascularization is indicated for patients with critical limb ischemia and is emergently indicated for acute limb ischemia. Renal artery revascularization offers no proven clinical benefit when added to optimal medical therapy.

Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment.

Lower extremity peripheral artery disease (PAD) affects 12% to 20% of Americans 60 years and older. The most significant risk factors for PAD are hyperlipidemia, hypertension, diabetes mellitus, chronic kidney disease, and smoking; the presence of three or more factors confers a 10-fold increase in PAD risk. Intermittent claudication is the hallmark of atherosclerotic lower extremity PAD, but only about 10% of patients with PAD experience intermittent claudication. A variety of leg symptoms that differ from classic claudication affects 50% of patients, and 40% have no leg symptoms at all. Current guidelines recommend resting ankle-brachial index (ABI) testing for patients with history or examination findings suggesting PAD. Patients with symptoms of PAD but a normal resting ABI can be further evaluated with exercise ABI testing. Routine ABI screening for those not at increased risk of PAD is not recommended. Treatment of PAD includes lifestyle modifications-including smoking cessation and supervised exercise therapy-plus secondary prevention medications, including antiplatelet therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins. Surgical revascularization should be considered for patients with lifestyle-limiting claudication who have an inadequate response to the aforementioned therapies. Patients with acute or limb-threatening limb ischemia should be referred immediately to a vascular surgeon.

An A-chain ricin immunotoxin targeted against rat class II major histocompatibility complex molecules. In vitro and in vivo effects.

Studies reported here have demonstrated that an antirat class II major histocompatibility complex molecule A-chain ricin immunotoxin could specifically remove, in a dose-dependent manner, the cells capable of stimulating the rat mixed lymphocyte reaction, an in vitro model of transplant rejection. It was further demonstrated that administration of a monoclonal antibody against class II major histocompatibility complex molecules to isolated rat pancreas grafts by hypothermic perfusion resulted in the targeting of cells bearing class II major histocompatibility complex molecules. But administration of the immunotoxin to isolated pancreases in a similar manner did not prolong their survival when allografted across a major histocompatibility barrier.

Telemedicine and endovascular aortic grafting.

Endovascular aortic grafting represents a minimally invasive approach to aortic aneurysm repair. The technique requires a variety of new skills and extensive training. Telemedicine enhances mentoring and technical support for surgeons performing the technique.

Congenital megaureter in adults: endoscopic management with holmium: YAG laser--preliminary experience.

PURPOSE: We report our experience with the holmium laser in the endoscopic management of primary obstructive megaureter (POM) in adults. PATIENTS AND METHODS: From February 1997 to September 1998, three women and one man 26 to 63 years old underwent ureteroscopic endoureterotomy for POM with symptomatic vesicoureteral junction obstruction. The left ureter was more commonly affected than the right (R:L 1:3). The diagnosis of POM was based on a clinical history, intravenous urography, diuretic renography (T 1/2), and micturating cystogram. Endoureterotomy of the juxtavesical and intramural part of the ureter was performed in a retrograde fashion using the holmium laser. Incision of the subepithelial part of the ureter and the ureteral orifice was avoided. A pigtail stent was left in situ for 6 weeks. Postoperatively, patients were assessed at 3 months and yearly thereafter. The mean follow-up was 30.5 months. RESULTS: All patients demonstrated symptomatic and radiologic improvement. CONCLUSIONS: Endoscopic incision of POM in adults with the holmium laser is safe, simple, and minimally invasive. This procedure should be considered as an initial approach for patients who have failed conservative treatment. However, further follow-up is necessary to determine its long-term efficacy.

Holmium:YAG laser treatment of recurrent superficial bladder carcinoma: initial clinical experience.

PURPOSE: To review our initial experience with the holmium laser in patients with recurrent superficial bladder cancer. PATIENTS AND METHODS: We treated 41 patients having 71 recurrent superficial transitional-cell tumors of the bladder between December 1994 and September 1997 using the holmium:YAG laser under local anesthesia. The laser treatment was carried out as a part of the follow-up flexible cystoscopy protocol, and topical anesthesia was used. The mean follow-up was 14 months (range 3-33 months). RESULTS: There were 13 recurrent tumors in the treated area and 38 recurrences in the untreated areas. Of interest, a subgroup of 10 patients were treated before 1994 with cystodiathermy and later on with the holmium:YAG laser at various times during their follow-up. The local recurrence rate with cystodiathermy was 32% compared with 10% after laser treatment (P = 0.39). A questionnaire study of 33 patients showed complete satisfaction with the treatment. Only 2 (6%) elected to have a further procedure under general anesthesia. In the series, 83% scored their pain as 2 or less of 10 on a visual analog scale. CONCLUSIONS: The absence of complications, high patient satisfaction, and ability to be used in the outpatient setting make the holmium:YAG laser an attractive alternative in the treatment of recurrent superficial cancer of the bladder.

A new copolymerized composite resin system: a multiphased evaluation.

Most microfilled composite resins are relatively resistant to generalized wear; however, they commonly exhibit poor resistance to localized wear because of debonding of prepolymerized particles from the resin matrix. A copolymerized new composite resin, in which the filler particle trimethylolpropane-trimethacrylate is chemically bonded to the resin matrix, is evaluated. Epic-TMPT was subjected to both generalized and localized wear tests that revealed that its wear resistance was higher than that of other composite resin systems. Epic-TMPT in posterior occlusal cavities showed less than 8 microns of wear for each restoration, 1 year after placement. Placement of Epic-TMPT into large anterior abfraction lesions without mechanical retention, with surface etching, and subject to severe traumatic occlusion resulted in 87% retention 1 year after placement. In vivo usage biocompatibility tests demonstrated no pulpal irritation or inflammation when Epic-TMPT was placed on vital dentin of crown preparations with complete enamel removal.

What's missing from multicultural competency research: review, introspection, and recommendations.

Much of the multicultural counseling research has pointed out the need for counselors to become culturally competent to appropriately address the needs of an emerging diverse community. To date, however, this body of research has largely focused on counselor competencies, with little attention being given to the client perspective of multicultural counseling competencies. This article discusses the importance of integrating the client perspective within the historical context of the multicultural literature by examining client preferences and expectations, as well as the adequacy of the current empirical data. The authors also raise the issue of politics inherent in multiculturalism and discuss how this affects the research. A number of recommendations are made as a guide for future research.

Pulpal healing and dentinal bridge formation in an acidic environment.

This study was designed to observe the healing and bridging capacity of mechanically exposed pulps that were capped with silicate or zinc phosphate cements and biologically sealed with zinc oxide-eugenol cement to exclude bacteria. In six monkeys, Class V facial cavities with pulpal exposures were randomly distributed throughout 105 teeth, of which 80 were directly capped, 40 with silicate cement and 40 with zinc phosphate cement. Twenty of each group were filled to the cavosurface margin with the respective cement and 20 were surface sealed to the cavosurface margin with zinc oxide-eugenol cement. The remaining 25 exposures were capped with calcium hydroxide and amalgam as controls. Tissues were obtained by perfusion fixation after intervals of 21, 14, 10, 5 and 3 days. The 25 pulps capped with calcium hydroxide showed cell migration and organization at 5 days and dentinal matrix deposition at 10 days. At 3 and 5 days, all exposures in the experimental groups showed clot resolution. At 10 days, fibroblasts had stratified against the cement interface. At 14 days, pulps in both experimental groups showed new dentinal bridge formation directly adjacent to the acidic cements. The 21-day experimentally capped and sealed pulps presented healing similar to the controls. This study indicates that acidic components of silicate and Zinc phosphate cements are not directly responsible for pulpal inflammation or necrosis. The exposed dental pulp possesses an inherent healing capacity for cell reorganization and dentinal bridge formation when a bacterial seal is provided.

Guidewire fragmentation during holmium:YAG laser endopyelotomy.

A guidewire fracture is a rare complication of laser surgery. We report that this rare complication occurred during a retrograde endoureteropyelotomy with the holmium:YAG laser. No data are available about the safety of commonly used guidewires. A comparative in vitro study was performed with two types of guidewires to assess their resistance. At all energy levels tested, a Teflon-coated guidewire performed best in the present safety test.

Comparison of seven commercial kits for detection of antibodies to Borrelia burgdorferi.

Five enzyme immunoassay (EIA) and two Western blot (WB) commercial kits were compared for their ability to detect antibodies to Borrelia burgdorferi. The panel of 53 test sera consisted of 25 sera positive for antibodies to Borrelia burgdorferi, 15 sera negative for such antibodies, 5 sera reactive in serologic tests for syphilis, and 8 sera containing antinuclear antibodies and/or rheumatoid factor. The rate of agreement with reference results was 93%, 90%, 90% and 88% for EIA kits from Diamedix, Cambridge Biotech, Mardx and Sigma respectively. The sensitivity and specificity was 84% and 100% respectively for Cambridge Biotech, 76% and 94% for Diamedix, 68% and 83% for Mardx, and 68% and 83% for Sigma. The three confirmatory tests, Cambridge Biotech WB, General Biometrics P39 EIA and Mardx WB, demonstrated 75%, 60% and 63% agreement respectively. The sensitivity and specificity was 52% and 100% respectively for Cambridge Biotech WB, 24% and 100% for General Biometrics P39 EIA, and 44% and 100% for Mardx WB. The results demonstrate the variable performance of commercial serologic kits for detection of antibodies to Borrelia burgdorferi. WB appears to be a better confirmatory test than the single protein EIA.

Retrograde endoureteropyelotomy with the holmium:YAG laser. Initial experience.

OBJECTIVE: To evaluate the safety and efficacy of the holmium:YAG laser in the management of pelviureteric junction (PUJ) obstruction. PATIENTS AND METHODS: Between November 1994 and February 1996, 8 patients with 5 primary and 3 secondary PUJ obstructions underwent retrograde ureteroscopic holmium:YAG laser endopyelotomy. A 320- to 365-micron (Slimline, Coherent) fibre was used to deliver the laser energy. A posterolateral endopyelotomy was performed under visual monitoring. All patients had a ureteral stent left in place postoperatively for 6 weeks and a renogram was performed after 3 months. The mean follow-up was 12.4 months (3-24 months). RESULTS: Almost bloodless, accurate and layered division of the PUJ was easily performed. The average procedure time was 37.5 min. Our overall success rate was 87.5%. CONCLUSION: The holmium:YAG laser is a safe, reliable laser with adequate coagulative properties and precise cutting abilities. This allows a 'bloodless' operative field for controlled, accurate and safe endoscopic division of the PUJ.