Oculopharyngeal muscular dystrophy complicating airway management.

Oculopharyngeal muscular dystrophy (OPMD) is an uncommon autosomal dominant disorder characterized by late onset and slow progression. Complications of OPMD include ptosis and progressive dysphagia leading to eventual malnutrition and aspiration. We report a rare case of OPMD complicating mechanical ventilator management following emergent surgery. OPMD and the resulting dysphagia contributed to multiple intubations, tracheostomy, aspiration pneumonia, and a prolonged hospital course. Awareness of the possibility of OPMD in intubated patients with a history of dysphagia is crucial for avoidance of complications.

Critical pathways and cost-effective practice.

With increasing pressure by third-party payers and federal reimbursement systems to reduce health care expenditures, cost-effective means to care for the resource intensive vascular surgical population must be explored. The challenge of meeting these cost-saving priorities while maintaining or improving quality of care can result in conflicting demands on surgeons, particularly in academic practices. The adaptation of an industrial management tool-the critical pathway method-to health care delivery is an attempt to reduce length of stay and improve efficiency. Utilization of vascular nurse practitioners, concentration of vascular patients into a dedicated unit, reduction in angiography through more aggressive use of the vascular laboratory, and optimal use of rehabilitation units and skilled nursing facilities are important adjuncts to reduce length of stay without sacrificing quality of care. This report describes the critical pathway method as implemented in a university teaching hospital, and the integration of other modalities in the care of vascular patients that has reduced length of stay by as much as 40% for some vascular surgical procedures.

Exact sampling from nonattractive distributions using summary states.

Propp and Wilson's method of coupling from the past allows one to efficiently generate exact samples from attractive statistical distributions (e.g., the ferromagnetic Ising model). This method may be generalized to nonattractive distributions by the use of summary states, as first described by Huber. Using this method, we present exact samples from a frustrated antiferromagnetic triangular Ising model and the antiferromagnetic q=3 Potts model. We discuss the advantages and limitations of the method of summary states for practical sampling, paying particular attention to the slowing down of the algorithm at low temperature. In particular, we show that such slowing down can occur in the absence of a physical phase transition.

Effects of radiofrequency glow discharge and oligopeptides on the attachment of human endothelial cells to polyurethane.

Activation of the surface of small diameter polyurethane vascular grafts using radiofrequency glow discharge (RFGD) and covalent linkage of cell attachment oligopeptides may improve graft patency. The effects of RFGD treatment were investigated on a polyurethane-polydimethylsiloxane (PU-PDMS) copolymer (Cardiothane-51; Kontron Cardiovascular, Inc., Everett, MA) membrane fabricated using the spray, phase-inversion technique. RFGD using H2O vapor was used to functionalize the membrane surface, reacted with 1',1 carbonyldiimidazole and covalently bound with oligopeptides (RGDS, RGES). Membranes not subjected to RFGD, either unmodified or with adsorbed fibronectin (Fn), vitro-nectin (Vn), RGDS, RGDV, and RGES, were used as controls. RFGD treated membrane surfaces were evaluated using electron spectroscopy for chemical analysis, which demonstrated a qualitative increase in nitrogen and silicon compared to unmodified PU-PDMS. Indirect confirmation of surface hydroxylation was provided by metallization with palladium and nickel, demonstrating uniform metallization of RFGD treated PU-PDMS surfaces. Human umbilical vein endothelial cells (HUVEC) were seeded at a density of 10(4) cells/cm2 and cell attachment assessed at 3 hr, 24 hr, and 7 days. Untreated PU-PDMS and membrane with adsorbed oligopeptides demonstrated poor HUVEC attachment at all intervals. Adsorbed Fn and Vn had significantly better early cell attachment and growth (p < 0.01). RFGD improved initial attachment and growth over non-RFGD treated controls (p < 0.01) for RGDS bound membranes, which performed as well as Fn controls (N.S.). PU-PDMS membranes can be modified using RFGD to covalently link oligopeptides. RFGD treatment alone, or with covalent linkage of cell attachment oligopeptides, improves HUVEC attachment and growth in a static environment.

Components of an optimal exercise program for the treatment of patients with claudication.

Research in vascular exercise has demonstrated remarkable improvement in symptoms of claudication without more expensive and invasive interventions. During the past 5 years, 86 patients have graduated from The Brown University Supervised Vascular Exercise Program. Patients demonstrate a threefold improvement in maximum walking distance after 12 weeks of training. Information available on 22 patients at 1-year and 2-year follow-ups show walking distance is improved or maintained with continued training. Components of the program are presented in 3 phases. Phase 1 addresses the comprehensive nursing assessment, cardiac screening, and progressive treadmill testing. Phase II includes specific method of exercise prescription and educational needs of peripheral vascular disease patients. Phase III discusses the importance of maintenance and motivating patients to continue.

Unexplained excess of electronlike events from a 1-GeV neutrino beam.

The MiniBooNE Collaboration observes unexplained electronlike events in the reconstructed neutrino energy range from 200 to 475 MeV. With 6.46x10;{20} protons on target, 544 electronlike events are observed in this energy range, compared to an expectation of 415.2+/-43.4 events, corresponding to an excess of 128.8+/-20.4+/-38.3 events. The shape of the excess in several kinematic variables is consistent with being due to either nu_{e} and nu[over ]_{e} charged-current scattering or nu_{mu} neutral-current scattering with a photon in the final state. No significant excess of events is observed in the reconstructed neutrino energy range from 475 to 1250 MeV, where 408 events are observed compared to an expectation of 385.9+/-35.7 events.

Measurement of muon neutrino quasielastic scattering on carbon.

The observation of neutrino oscillations is clear evidence for physics beyond the standard model. To make precise measurements of this phenomenon, neutrino oscillation experiments, including MiniBooNE, require an accurate description of neutrino charged current quasielastic (CCQE) cross sections to predict signal samples. Using a high-statistics sample of nu_(mu) CCQE events, MiniBooNE finds that a simple Fermi gas model, with appropriate adjustments, accurately characterizes the CCQE events observed in a carbon-based detector. The extracted parameters include an effective axial mass, M_(A)(eff)=1.23+/-0.20 GeV, that describes the four-momentum dependence of the axial-vector form factor of the nucleon, and a Pauli-suppression parameter, kappa=1.019+/-0.011. Such a modified Fermi gas model may also be used by future accelerator-based experiments measuring neutrino oscillations on nuclear targets.

Search for electron neutrino appearance at the Delta m2 approximately 1 eV2 scale.

The MiniBooNE Collaboration reports first results of a search for nu e appearance in a nu mu beam. With two largely independent analyses, we observe no significant excess of events above the background for reconstructed neutrino energies above 475 MeV. The data are consistent with no oscillations within a two-neutrino appearance-only oscillation model.

A simple method for preventing blood-borne contamination to operating room personnel during vascular reconstructive operations.

Although the risk of infection with hepatitis or HIV remains low, and the effectiveness of steps to reduce even this small risk is difficult to assess, the sequelae of the infection with either virus are often devastating. We described herein the use of a sterile Petri dish to inspect vascular anastomoses during arterial reconstructive operations. This simple, inexpensive precaution has been in use at the University of Cincinnati for two years and has proved so effective in preventing the contamination of operating room personnel with blood from a patient that it has recently become a routine part of all vascular reconstructive operations.

Insertion of peritoneal dialysis catheters: the lateral approach.

Potential complications of peritoneal dialysis catheters include ventral herniation, dialysate leakage, and catheter dysfunction. Using local anesthesia and a paramedian, muscle-splitting approach, we have significantly reduced the morbidity of the procedure. Security of fascial closure and identification of the peritoneum, even in obese patients, has been facilitated through this technique.

Midaortic pseudoaneurysm complicating extensive endovascular stenting of aortic disease.

We report a case of successful surgical management of a potentially life-threatening complication of aortoiliac stent placement. A 59-year-old man who had Leriche syndrome underwent bilateral iliac artery and infrarenal aortic stent placement at another institution. His history was significant for retroperitoneal lymph node dissection at 19 years of age for testicular cancer. One week after stent placement, the patient was readmitted with abdominal pain, poor oral intake, and diffuse intermittent tenderness. Evaluation with computed tomographic scanning and endoscopy was unremarkable, and the patient was discharged. He was admitted to our institution 1 week later with persistent abdominal pain. A computed tomographic scan of the abdomen revealed a large pseudoaneurysm of the abdominal aorta. The patient underwent urgent exploration, and exclusion of his infrarenal aorta was achieved with aortobifemoral bypass grafting. After the operation, the patient's course was complicated by a large paraduodenal hematoma, which resulted in a gastric outlet obstruction, which was managed without operation. This case illustrates a potential life-threatening complication of extensive stent placement for aortoiliac occlusive disease. Injury to the abdominal aorta must be considered in a symptomatic patient after the placement of stents in the aortoiliac region, beyond the immediate periprocedural period.