Implications of Clostridium septicum in Vascular Surgery: A Case Report and Outcomes Literature Review.

Clostridium septicum is a rare organism, accounting for approximately 1.3% of clostridial infections and is associated with synchronous colonic malignancy. This case report describes a patient successfully treated for a mycotic aortic aneurysm secondary to C. septicum bacteremia. Subsequent evaluation confirmed a colonic malignancy, prompting early intervention. A systematic literature review revealing a rate of gastrointestinal malignancy in this patient population is 71%, and hematologic malignancy is 3.9%, with the remaining cohort of patients having an unknown source. Infectious involvement of the aorta and associated vascular structures portends a poor prognosis with a 57% mortality rate. Our case and updated review demonstrates the implications of C. septicum vascular seeding and subsequent treatment outcomes.

Performance and Practice Guideline for the Use of Neoadjuvant Systemic Therapy in the Management of Breast Cancer.

PURPOSE: The American Society of Breast Surgeons (ASBrS) sought to provide an evidence-based guideline on the use of neoadjuvant systemic therapy (NST) in the management of clinical stage II and III invasive breast cancer. METHODS: A comprehensive nonsystematic review was performed of selected peer-reviewed literature published since 2000. The Education Committee of the ASBrS convened to develop guideline recommendations. RESULTS: A performance and practice guideline was prepared to outline the baseline assessment and perioperative management of patients with clinical stage II-III breast cancer under consideration for NST. RECOMMENDATIONS: Preoperative or NST is emerging as an important initial strategy for the management of invasive breast cancer. From the surgeon's perspective, the primary goal of NST is to increase the resectability of locally advanced breast cancer, increase the feasibility of breast-conserving surgery and sentinel node biopsy, and decrease surgical morbidity. To ensure optimal patient selection and efficient patient care, the guideline recommends: (1) baseline breast and axillary imaging; (2) minimally invasive biopsies of breast and axillary lesions; (3) determination of tumor biomarkers; (4) systemic staging; (5) care coordination, including referrals to medical oncology, radiation oncology, plastic surgery, social work, and genetic counseling, if indicated; (6) initiation of NST; (7) post-NST breast and axillary imaging; and (8) decision for surgery based on extent of disease at presentation, patient choice, clinical response to NST, and genetic testing results, if performed.

Genomic V exons from whole genome shotgun data in reptiles.

Reptiles and mammals diverged over 300 million years ago, creating two parallel evolutionary lineages amongst terrestrial vertebrates. In reptiles, two main evolutionary lines emerged: one gave rise to Squamata, while the other gave rise to Testudines, Crocodylia, and Aves. In this study, we determined the genomic variable (V) exons from whole genome shotgun sequencing (WGS) data in reptiles corresponding to the three main immunoglobulin (IG) loci and the four main T cell receptor (TR) loci. We show that Squamata lack the TRG and TRD genes, and snakes lack the IGKV genes. In representative species of Testudines and Crocodylia, the seven major IG and TR loci are maintained. As in mammals, genes of the IG loci can be grouped into well-defined IMGT clans through a multi-species phylogenetic analysis. We show that the reptilian IGHV and IGLV genes are distributed amongst the established mammalian clans, while their IGKV genes are found within a single clan, nearly exclusive from the mammalian sequences. The reptilian and mammalian TRAV genes cluster into six common evolutionary clades (since IMGT clans have not been defined for TR). In contrast, the reptilian TRBV genes cluster into three clades, which have few mammalian members. In this locus, the V exon sequences from mammals appear to have undergone different evolutionary diversification processes that occurred outside these shared reptilian clans. These sequences can be obtained in a freely available public repository (http://vgenerepertoire.org).

A natriuretic factor in the serum of patients with chronic uremia.

Sera from chronically uremic and normal individuals were subjected to gel filtration with Sephadex G-25 and the same fraction of both was infused into rats with a decreased nephron population to determine the effects on sodium excretion. Sodium excretion rate and fractional sodium excretion increased slightly with the normal fractions; but the increase in both functional parameters produced by the uremic fractions was substantially and significantly greater. The natriuresis could not be explained by associated changes in glomerular filtration rate (GFR), para-aminohippurate (PAH) clearance, filtration fraction, hematocrit, or blood pressure. The possibility thus exists that the inhibitor affected some component part of the transepithelial sodium transport system. The elution characteristics of the fraction plus certain of its physicochemical properties suggest that the inhibitor of sodium reabsorption by the rat nephron may be identical with the inhibitor of PAH uptake by kidney slices and the inhibitor of transepithelial sodium transport by the frog skin and toad bladder previously found in the serum of chronically uremic patients.

Enalapril and lisinopril in the treatment of mild to moderate essential hypertension.

Hypertensive patients were randomly assigned to receive 5 mg of enalapril (n = 50) or 10 mg of lisinopril (n = 47) daily. During a four-week titration period, the doses were increased weekly to a maximum of 40 mg once daily until the treatment goal of diastolic blood pressure (BP) of less than 90 mmHg was reached; treatment was then continued for four weeks. Systolic and diastolic BP declined significantly in the two treatment groups, from 147/98 mmHg in both the enalapril and lisinopril groups to 126/82 and 122/81 mmHg, respectively, at the end of treatment. During the first week of treatment, the goal of diastolic BP of less than 90 mmHg was reached by 40% of the enalapril group and 62% of the lisinopril group; by the end of the titration period, 98% and 96%, respectively, had achieved the BP goal. Few side effects were reported and there were no abnormal laboratory findings during treatment. It is concluded that once-daily administration of enalapril or lisinopril was generally effective and well-tolerated in the management of mild to moderate uncomplicated essential hypertension.

Enalapril and verapamil in the treatment of isolated systolic hypertension in the elderly.

A prospective, investigator-blinded, randomized study was conducted to compare the efficacy and tolerability of enalapril and verapamil in the treatment of isolated systolic hypertension in elderly patients. Of the 115 patients who completed the study, 58 received enalapril and 57 verapamil. The goal of treatment was a systolic blood pressure < 160 mmHg and a reduction of at least 20 mmHg below baseline. The initial daily dose of enalapril was 5 mg, and of verapamil 240 mg. The dosage was titrated upward until the goal blood pressure was achieved. At the end of the titration period, systolic and diastolic blood pressures were significantly decreased (P < 0.001) in both patient groups. Blood pressure remained significantly decreased (P < 0.001) in both groups during the 8-week maintenance treatment period. There were no significant differences between groups. Two patients in the enalapril group and nine patients in the verapamil group were withdrawn from the study because of adverse effects. The results of this study demonstrate that enalapril and verapamil are well tolerated and effective in the treatment of isolated systolic hypertension in the elderly.

Diagnosis of acute and chronic renal failure.

This article presents a systematic approach--through history, physical examination, and laboratory findings--for the pursuit of the diagnosis of acute and chronic renal failure. These guidelines are based on the pathophysiology of the syndromes. In management, they serve the goal of staying the failure and regaining renal function.

Differential diagnosis of acute renal failure.

This prospective study compares the fractional excretion of sodium, FENa, urinary sodium concentration, UNa, urine osmolality, Uosm, and the U/P creatinine ratio in their diagnostic effectiveness in 87 patients with acute renal failure: 22 acute tubular necrosis, 18 non-oliguric acute tubular necrosis, 12 acute urinary tract obstruction, 14 acute glomerulonephritis, and 21 pre-renal azotemia. Discriminant analysis demonstrated a correct diagnostic classification in 86 of 87 patients using FENa, and only 46, 60 and 65 correct using Uosm, UNa, and U/P Cr, respectively. FENa is identified as the most effective non-invasive test for the differential diagnosis of acute renal failure. An FENa of 1 classifies all entities into two groups: FENa more than 1; acute tubular necrosis, non-oliguric acute tubular necrosis and urinary tract obstruction and less than 1; pre-renal azotemia and acute glomerulonephritis (P less than 0.001).

[Comparative study of propofol with thiopental and etomidate in anesthetic induction]. / Estudio comparativo del propofol con tiopental y etomidato en la inducción anestésica.

Anesthetic characteristics were studied in three homogeneous groups of twenty patients ASA I who underwent intravenous anesthetic induction with propofol 2 mg/kg; thiopental 5 mg/kg; or etomidate 0.3 mg/kg. The unconsciousness time was similar in the three groups, whereas awaking time and time of response and orientation were longer after thiopental and etomidate than after propofol. Intravenous injection of the three anesthetic agents was followed by a decrease in systolic and diastolic arterial pressure. Heart rate increased after thiopental and etomidate and had only slight fluctuations after propofol. After tracheal intubation there was a significant increase in systolic and diastolic arterial pressure and heart rate in thiopental and etomidate group. These changes were minimal after propofol. The highest number of complications occurred after etomidate.

[Comparative study between propofol and isoflurane as a maintenance anesthetic in ambulatory surgery]. / Estudio comparativo entre propofol e isoflurano como mantenimiento anestésico en cirugía ambulatoria.

OBJECTIVES: To evaluate postanesthetic recovery and complications in outpatient surgery for which anesthetic maintenance was achieved with either isoflurane or propofol. PATIENTS AND METHODS: Eighty patients were randomly divided into two groups for prospective study according to anesthetic used: isoflurane (group A) or propofol (group B). The patients were undergoing short surgery and in both groups induction was with 2-2.5 mg/kg propofol, 0.4-0.5 mg/kg atracurium, 20 microgram/kg alfentanil and 20 microgram/kg droperidol. In 40 patients maintenance was with 0.5-1% isoflurane (group A) and in the remaining 40 0.1-1.15 mg/kg/min propofol (group B) was used; in both groups 50% N2O-O2 was used. RESULTS: We found no statistically significant differences in time until eye opening after a verbal command (3.8 +/- 2 in group A and 4.1 +/- 2.8 min in group B), in time until the patient was able to answer five questions (6.5 +/- 3 in group A and 6 +/- 2.9 min in group B) or in Aldrete test scores upon awakening (9 +/- 1 in group A and 8.7 +/- 0.9 in group B). Nor were there differences in frequency of nausea reported (2 in each group) or in level of pain after surgery. CONCLUSIONS: Recovery and incidence of complications after out-patient anesthesia were similar when anesthetic maintenance was achieved with propofol or isoflurane.

MammaPrint Feasibility in a Large Tertiary Urban Medical Center: An Initial Experience.

Background. The MammaPrint (MP) diagnostic assay stratifies breast cancer patients into high- and low-risk groups using mRNA analysis of a 70-gene profile. The assay is validated for assessment of patients with estrogen receptor positive or negative tumors less than 5 cm with 3 or fewer malignant lymph nodes. TargetPrint (TP) is an assay for assessing estrogen, progesterone, and HER2-neu receptor status based on mRNA expression. A potential limitation of these assays is that they require an evaluation of fresh tissue samples. There is limited published experience describing MP or TP implementation. Methods. Over 10 months, 4 breast surgeons obtained samples from 54 patients for MP/TP analysis. The samples were analyzed by Agendia Labs. The tumors were independently evaluated for receptor status using immunohistochemistry (IHC). Retrospectively, we identified patients who were assessed by MP/TP during this period. Patients who underwent OncotypeDx evaluation were also identified. Results. Of the 54 patients receiving MP, 4 were found ineligible for MP risk assessment because >3 lymph nodes were found to be malignant. Out of all eligible patients, 14/50 (28%) had samples whose quantity of tumor was not sufficient for analysis (QNS). Out of eligible patients with tumors <1 cm, 7/8 (88%) had QNS samples. 7/42 with tumors ≥1 cm (17%) had QNS samples. Nine patients had discordant receptor results when evaluated by IHC versus. TP. Of patients who also underwent OncotypeDx testing, 6/14 (43%) had discordant results with MP. Conclusions. This study indicates that using MP/TP assay is feasible in a tertiary care center but there may be utility in limiting MP testing to patients with tumors between 1 and 5 cm due to high likelihood of uninformative results in subcentimeter tumors. Further study is needed to explore the discordance between oncotype and MP results.

The immunoglobulin heavy chain locus in the platypus (Ornithorhynchus anatinus).

Immunoglobulins loci in mammals are well known to be organized within a translocon, however their origin remains unresolved. Four of the five classes of immunoglobulins described in humans and rodents (immunoglobulins M, G, E and A-IgM, IgG, IgE and IgA) were found in marsupials and monotremes (immunoglobulin D-IgD was not found) thus showing that the genomic structure of antibodies in mammals has remained constant since its origin. We have recently described the genomic organization of the immunoglobulin heavy chain locus in reptiles (IGHM, IGHD and IGHY). These data and the characterization of the IGH locus in platypus (Ornithorhynchus anatinus), allow us to elucidate the changes that took place in this genomic region during evolution from reptile to mammal. Thus, by using available genome data, we were able to detect that platypus IGH locus contains reptilian and mammalian genes. Besides having an IGHD that is very similar to the one in reptiles and an IGHY, they also present the mammal specific antibody genes IGHG and IGHE, in addition to IGHA. We also detected a pseudogene that originated by recombination between the IGHD and the IGHM (similar to the IGHD2 found in Eublepharis macularius). The analysis of the IGH locus in platypus shows that IGHY was duplicated, firstly by evolving into IGHE and then into IGHG. The IGHA of the platypus has a complex origin, and probably arose by a process of recombination between the IGHM and the IGHY. We detected about 44 VH genes (25 were already described), most of which comprise a single group. When we compared these VH genes with those described in Anolis carolinensis, we find that there is an evolutionary relationship between the VH genes of platypus and the reptilian Group III genes. These results suggest that a fast VH turnover took place in platypus and this gave rise to a family with a high VH gene number and the disappearance of the earlier VH families.

Percutaneous balloon occlusion of the inferior vena cava as an adjunct for treating ruptured type IV thoracoabdominal aneurysm and aortocaval fistula.

Spontaneous aortocaval fistulas are rare and thoracoabdominal aneurysms eroding into the inferior vena cava are rarer still. We describe a patient who presented to our hospital with a fistula between a Type IV thoracoabdominal aneurysm and the inferior vena cava. Expanding endovascular capabilities of vascular surgeons enabled us to insert proximal and distal occluding balloon catheters into the vena cava which greatly minimized blood loss.

The Salt Step Test: its usage in the diagnosis of salt-sensitive hypertension and in the detection of the salt hypertension threshold.

The Salt Step Test was devised to characterize the response of the hypertensive patient to dietary salt. The test has three phases: unrestricted salt, to document hypertension and customary salt intake; restricted salt (2 g/day), to identify the salt-sensitive patient; and stepwise increased salt (each step = 1 g/day), to find the level that precipitates hypertension. The Salt Step Test identified that out of 30 well-established adult hypertensives, 13 were salt-sensitive. It also revealed that in each salt-sensitive patient, a distinct level of salt (range 3-16 g/day) precipitated hypertension, i.e., a Salt Hypertension Threshold. Definition of the Salt Hypertension Threshold should be useful in providing specific, individualized guidelines for dietary salt restriction.

The FENa test. Use in the differential diagnosis of acute renal failure.

The FENa test, a determination of the excreted fraction of the filtered sodium, was performed in patients in the oliguric phase of acute renal failure. Patients with prerenal azotemia had an FENa of less than 1, and patients with acute tubular necrosis had an FENa of more than 3 (P less than .001). This simple test clearly differentiates between these two conditions and, thus, is of considerable clinical value.

Effect of proportional reduction of sodium intake on the adaptive increase in glomerular filtration rate/nephron and potassium and phosphate excretion in chronic renal failure in the rat.

1. The influence of dietary sodium intake on the glomerular filtration rate (GFR/nephron) and potassium and phosphate excretion was examined at three stages of progressive chronic renal failure produced in rats by sequential partial nephrectomies. 2. The adaptive increased sodium excretion per nephron in the control group receiving a constant sodium intake did not occur in the experimental group that had a gradual reduction of dietary sodium in direct proportion to the fall in GFR. 3. Despite the difference in sodium excretion, the increase in GFR/nephron, the daily variation in the amount of potassium and phosphate excreted, the increase in potassium and phosphate excretion per unit nephron, and the plasma potassium and phosphate concentrations were the same in the two groups. 4. The concept of 'autonomous adaptation' in chronic renal failure is presented.