David Procedure: A 21-year Experience With 300 Patients.

BACKGROUND: Valve-sparing aortic root replacement with the David procedure is an alternative to the Bentall procedure in patients with aortic root aneurysm. The aim of this study was to describe our long-term experience with this technique and the predictive factors of late failure. METHODS: Between January 1998 and August 2019, 300 consecutive patients underwent a David procedure. Clinical and echocardiographic early- and long-term outcomes were analyzed. Median follow-up was 7.0 years (range, 4.1-11.5), with 98.3% complete. RESULTS: Early mortality was 1%. No early valve-related reoperations occurred. There were 9 cardiac-related deaths and 22 reinterventions (19 valve-related). All patients survived reoperation. In 3 patients reintervention consisted of transcatheter aortic valve implantation. Overall survival rates were 95.3% (95% confidence interval [CI], 92.0-97.2), 91.1% (95% CI, 86.5-94.2), and 82.9% (95% CI, 75.3-88.4) at 5, 10, and 15 years, respectively. Freedom from postoperative aortic insufficiency (AI) grade ≥ 2 was 84.8% (95% CI, 79.9-88.6) and 74.3% (95% CI, 67.4-79.9) at 5 and 10 years, respectively. Freedom from reintervention for aortic valve disease was 97.1% (95% CI, 94.2-98.5), 92.9% (95% CI, 88.2-95.7), and 92.5% (95% CI, 87.1-95.7) at 5, 10, and 15 years, respectively. Preoperative AI ≥ 2 (hazard ratio, 1.782; 95% CI, 1.352-2.350) and a ventriculoaortic junction ≥ 29 mm (hazard ratio, 3.379; 95% CI, 1.726-6.616) were predictive factors for postoperative AI ≥ 2 in a multivariate analysis (P < .001). CONCLUSIONS: Preoperative AI ≥ 2 and a ventriculoaortic junction ≥ 29 mm were identified as risk factors for late postoperative AI ≥ 2.

Active Aortic Endocarditis in Young Adults: Long-term Results of the Ross Procedure.

BACKGROUND: The best valvular substitute remains controversial in young adults with active aortic valve endocarditis. The Ross procedure has gained interest because of its theoretical resistance to infection. We aimed to report our long-term outcomes of the Ross procedure in this indication. METHODS: Between March 1992 and January 2019, 511 patients underwent a Ross procedure in our institution. Among them, we included 38 patients who suffered from an active aortic valve infective endocarditis. The mean age was 33.9 ± 8.1 years. Six patients had emergent procedures and 17 patients had perivalvular involvement. A pulmonary autograft was implanted using the full root technique in 78.9% of patients. Median follow-up was 12 (interquartile range, 1.75-16.25) years. RESULTS: The hospital mortality rate was 5.3%. Estimated overall survival was 84.2% ± 6.6% at 10 years. There were 2 cases of recurrent endocarditis, both requiring reoperation. Six other patients required reoperation on an autograft or homograft. Estimated freedom from recurrent endocarditis or reoperation was 89.4% ± 5.9% at 10 years. CONCLUSIONS: In experienced centers, the Ross procedure is a reliable alternative to prosthetic or homograft valve replacement in young adults experiencing active aortic valve endocarditis, with a low operative risk and good long-term results.

Plant therapy in the Peruvian Amazon (Loreto) in case of infectious diseases and its antimicrobial evaluation.

ETHNOPHARMACOLOGICAL RELEVANCE: The plant species reported here are used in contemporary phytotherapies by native and neo-urban societies from the Iquitenian surroundings (district of Loreto, Peruvian Amazon) for ailments related to microbial infections. Inhabitants of various ethnic origins were interviewed and 81 selected extracts were evaluated for their antimicrobial properties against a panel of 36 sensitive and multi-resistant bacteria or yeast. Medicinal plant researches in the Peruvian Amazon are now significant, but none of them has focused on an exhaustive listing of identified species tested on so many microbes with standardized experiments (to obtain MIC value). AIM OF THE STUDY: The aim of the study was to inventory the plants used against infections in the Loreto, an Amazonian region of Peru. It led to the new identification of secondary metabolites in two plant species. MATERIALS AND METHODS: Ethnographic survey was carried out using "participant-observation" methodology and focus on bioprospecting of antimicrobial remedies. Selected plant extracts and antimicrobial drugs were tested in vitro with agar dilution method on 35 bacteria strains and 1 yeast to evaluate their Minimal Inhibitory Concentration (MIC). Microdilution methods using 96-well microtiter plates were used for the determination of MIC from isolated compounds, and cytotoxicity in HepG2 cells from some selected extracts were also evaluated. Activity-guided isolation and identification of compounds were performed by various chromatographic methods and structural elucidations were established using HRMS and NMR spectroscopy. RESULTS: This study outlined antimicrobial activities of 59 plant species from 33 families (72 single plant extracts and 2 fermented preparations), 7 mixtures, and one insect nest extract against 36 microorganisms. Of the 59 species analysed, 12 plants showed relevant antibacterial activity with MIC ≤0.15 mg/mL for one or several of the 36 micro-organisms (Aspidosperma excelsum, Brosimum acutifolium, Copaifera paupera, Erythrina amazonica, Hura crepitans, Myrciaria dubia, Ocotea aciphylla, Persea americana, Spondias mombin, Swartzia polyphylla, Virola pavonis, Vismia macrophylla). Examination by bioautography of E. amazonica, M. dubia and O. aciphylla extracts allowed the phytochemical characterization of antimicrobial fractions and compounds. CONCLUSION: This study suggested an a posteriori correlation of the plant extract antimicrobial activity with the chemosensory cues of the drugs and attested that those chemosensory cues may be correlated with the presence of antimicrobial compounds (alkaloids, tannins, saponosids, essential oil, oleoresin …). It also led to the first isolation and identification of three secondary metabolites from E. amazonica and M. dubia.

Physician Empathy Interacts with Breaking Bad News in Predicting Lung Cancer and Pleural Mesothelioma Patient Survival: Timing May Be Crucial.

This study is the first to examine the prognostic role of physician empathy in interaction with the type of consultation (TC) (TC, bad news versus follow-up consultations) in cancer patient survival. Between January 2015 and March 2016, 179 outpatients with thoracic cancer and a Karnofsky performance status ≥60 assessed their oncologist's empathy using the CARE questionnaire, which provides a general score and two sub-dimensions: listening/compassion and active/positive empathy. Survival was recorded until April 2018. Usual medical, social and psychological confounders were included in the Cox regression. The median follow-up time was 3.1 years. There was a statistical interaction between listening/compassion empathy and TC (p = 0.016) such that in bad news consultations, higher listening/compassion predicted a higher risk of death (hazard ratio (HR) = 1.13; 95% confidence interval (CI): 1.03⁻1.23; p = 0.008). In follow-up consultations, listening/compassion did not predict survival (HR = 0.94; 95% CI: 0.85⁻1.05; p = 0.30). The same results were found with the general score of empathy, but not with active/positive empathy. In bad news consultations, high patient-perceived physician compassion could worry patients by conveying the idea that there is no longer any hope, which could hasten death. Further studies are warranted to confirm these results and find out the determinants of patient perception of physician empathy.

Acute kidney injury after high dose etoposide phosphate: A retrospective study in children receiving an allogeneic hematopoetic stem cell transplantation.

BACKGROUND: Etoposide phosphate (EP; single injection, 60 mg/kg) followed by total body irradiation (TBI) at 12 Gy has been used as an allogeneic stem cell transplantation (allo-SCT) conditioning regimen for children since 2010. In our institution, EP has been suspected of leading to acute nephrotoxicity. The aim of this study was to assess the potential renal toxicity of EP in this context. MATERIALS AND METHODS: A retrospective study was carried out on children hospitalized between 2007 and 2015 for allo-SCT with TBI-based myeloablative conditioning associated with cyclophosphamide (CY, 60 mg/kg/day × 2 days) or EP. The primary endpoint of the study was the occurrence of acute kidney injury (AKI). Additional endpoints were time to recovery for children with AKI, survival, and treatment-related mortality. RESULTS: Thirty-five patients were analyzed (CY: 22 vs. EP: 13). AKI occurred more frequently in the EP group than in the CY one (69% vs. 27%, adjusted odds ratio 6.0, 95% confidence interval [CI] [1.145; 31.445], P = 0.03). The median time to recovery was estimated at 3 days, 95% CI (2; 17), with CY and 11 days 95% CI (5; 18) with EP (adjusted hazard ratio of recovery for EP vs. CY 0.262, 95% CI [0.071; 0.969], P = 0.04). No significant difference was highlighted between the two treatments for survival or for treatment-related mortality. DISCUSSION: This study shows that EP at high dosage or one of its excipients is probably responsible for AKI, as compared to CY. Further studies are required to explore the origin of this adverse effect.

Comparison of three molecular assays for detection of enteric viruses in stool samples.

Three molecular assays (FTD® Viral GE from Fast-track diagnostics, RIDA®GENE VSP1 from R-Biopharm, and Xpert Norovirus from Cepheid) were compared for virus detection in acute diarrhea samples. RIDA®GENE and FTD® Viral GE showed perfect/almost perfect agreement for Rotavirus, Sapovirus and Norovirus, substantial agreement for Adenovirus, and moderate agreement for Astrovirus.

Quantified analysis of histological components and architectural patterns of gleason grades in apparent diffusion coefficient restricted areas upon diffusion weighted MRI for peripheral or transition zone cancer locations.

PURPOSE: To quantify and compare the histological components and architectural patterns of Gleason grades in cancerous areas with restriction on apparent diffusion coefficient (ADC) maps. MATERIALS AND METHODS: Twelve consecutive cases with 14 separate ADC restriction areas, positive for cancer in the peripheral zone (PZ) and transition zone (TZ) were included. All had 3 Tesla MRI and radical prostatectomy. Ten regions of interest (ROIs) within and outside the 14 ADC restriction areas positive for cancer were selected. For each ROI, we performed quantitative analysis of (a) prostate benign and malignant histological component surface ratios, including stroma, glands, epithelium, lumen, cellular nuclei; (b) percent of Gleason grades and measures of ADC values. Means of histological components according to ADC restriction for cancerous area were compared with analyses of variance with repeated measures. RESULTS: Independent predictors of the probability of cancer were median epithelium/ROI ratio (P = 0.001) and nuclei/ROI ratio (P = 0.03). Independent predictors of the probability of ADC restriction were malignant glands/ROI and luminal space/ROI (P < 0.0001). Effect of malignant glands/ROI area was different according to the localization of the ROI (P = 0.03). We observed an overall difference between the means for all of the histological components for the comparison of true positive and false negative (P < 0.0001), except for the percent of Gleason grade 4 (P = 0.18). In TZ cancers, a predominant grade 3 pattern was associated with low ADC values. In PZ cancers, a predominant grade 4 pattern was associated with low ADC values. CONCLUSION: Determinants of low ADC were high ratio of malignant glands/ROI area which may be seen in Gleason grades 3 or 4 cancers. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1786-1796.

Renal outcomes analysis after endovascular and open aortic aneurysm repair.

OBJECTIVE: The purpose of this study was to compare renal outcomes (glomerular filtration rate [GFR] and renal volume) after endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysm (AAA). METHODS: All AAA repairs performed between November 2009 and July 2011 were included in this retrospective study. Patients requiring suprarenal clamping and renal bypass or reimplantation and patients requiring fenestrated endografting were excluded from the OR and EVAR groups, respectively. All EVARs were performed with transrenal proximal fixation. Renal volume (calculated with a three-dimensional workstation) and GFR (estimated with the Modification of Diet in Renal Disease formula) were evaluated before the procedure, at 12 months after the procedure, and yearly thereafter. RESULTS: The study included 90 patients (41 ORs and 49 EVARs). Both groups were comparable except for age at intervention, body mass index, smoking, peripheral arterial disease, arrhythmia, and vitamin K antagonist treatment. Median follow-up was 2.8 years for OR (2.5-2.9 years) and 3.2 years for EVAR (3.0-3.4 years). In both groups, we found a significant decrease when comparing postoperative estimated GFR with 1-year (14.4% decrease [3.8%-23.8%]; P = .002) and 3-year (12.8% decrease [3.8%-20.9%]; P = .0007) levels. In both groups, total renal volumes significantly diminished. Median preoperative total renal volume (372 cm(3) [311-349]) significantly decreased (6.7% [2.8%-10.5%]; P = .008) between 1 year and 2 years of follow-up. CONCLUSIONS: Renal function impairment is similar after open and endovascular AAA repair. It is associated with a decrease in total renal volume, which seems to be an early and constant marker of postoperative renal impairment.

Influence of infusion method on gemcitabine pharmacokinetics: a controlled randomized multicenter trial.

PURPOSE: Ensuring the correct administration of antineoplastic drugs is a constantly challenging task. Nowadays, several specific infusion devices have been marketed to decrease occupational exposure to these drugs through a post-administration rinsing step. As their impact on drug pharmacokinetics has never been evaluated, the objective of this study was to assess how the infusion process may alter the pharmacokinetics of antineoplastic drugs. METHODS: We developed a prospective randomized multicenter pharmacokinetic study (ONCOPERF01) to compare the influence of three infusion techniques (gravity-fed infusion-GFI, infusion pump-IP, and gravity-fed infusion with post-administration rinsing-PAR) to assess the impact of both flow rate and post-administration rinsing on gemcitabine pharmacokinetics during three consecutive administrations. Gemcitabine pharmacokinetics was determined with a two-compartment model after plasma dosing with an HPLC-UV method. Statistical comparisons of the three groups were made using repeated-measure analysis of variance (PROC MIXED). RESULTS: Patients received gemcitabine by gravity-fed infusion (GFI, n = 9; IP, n = 9; PAR, n = 7). Significant differences were noted between infusion duration (GFI = 30.0 ± 2.6 min, IP = 29.1 ± 1.2 min, PAR = 33.7 ± 3.5 min; p = 0.003) and AUCt (GFI = 23.5 ± 8.2 µM h, IP = 25.4 ± 9.1 µM h, PAR = 28.5 ± 6.3 µM h; p = 0.0009), which was significantly higher in the infusion group with post-administration rinsing than in the other groups. CONCLUSIONS: The ONCOPERF01 study indicates that post-administration rinsing leads to a significant increase in patient exposure to gemcitabine, whereas controlling flow rate has no significance. Further surveys are required to assess the impact of such infusion techniques on other antineoplastic drugs.

Aortic root surgery improves long-term survival after acute type A aortic dissection.

OBJECTIVE: Our objective was to analyze the long term survival of patient operated on for acute type A aortic dissection. METHODS: Between 1990 and 2010, 226 patients underwent emergency surgical operation for acute type A aortic dissection. We have followed the long-term outcomes. RESULTS: 144 patients were operated on with a supracommissural replacement of the ascending aorta (SCR) and 82 with an aortic root surgery (ARS, including 77 Bentall procedures and 5 Tirone David operations). Aortic cross-clamp was longer in ARS group (150.8 vs. 103.6 min, p<0.0001). Overall in-hospital mortality was lower in ARS group (20% vs. 34%, p 0.03). Median follow-up was 11.6 years. 10-year survival was higher in ARS group (85.7% vs. 65.9%, p 0.03) and 10-year freedom from aortic root reoperation was significantly lower in ARS group (93.4% vs. 82.9%, p 0.02). In a multivariate analysis aortic root surgery was an independent protective factor for proximal reoperations OR 0.393, CI 95% [0.206-0.748], p=0.005. CONCLUSIONS: Our study suggests that complete aortic root replacement in type A aortic dissection does not burden short-term outcomes, improves long-term survivals and decreases the rate of late reoperation. Whether this approach has to be preferred in younger patient has to be demonstrated in further studies.

Stentless porcine bioprosthesis in pulmonary position after ross procedure: midterm results.

BACKGROUND: Stentless porcine roots (SPV) have been proposed for right ventricular outflow tract reconstruction in the Ross procedure due to the relative availability of pulmonary homografts in large diameters. We report here our experience with SPV used in the Ross procedure. METHODS: Between March 1992 and February 2011, 360 patients had a Ross procedure; 61 patients received a SPV in pulmonary position and they represent the study population. Mean age was 38 ± 7.6 years. Indication for surgery was an infective endocarditis in 15 cases, there were 3 redo operations. Median SPV diameter was 29 mm (range, 25 to 29 mm). Pulmonary stenosis was defined as a peak transvalvular gradient of more than 50 mm Hg. RESULTS: Perioperative mortality was 4.9% (3 patients) and late mortality was 3.3% (2 patients). Median follow-up was 4 years (range, 7 days to 14.9 years). There was no reoperation on the right ventricle outflow tract, and freedom from pulmonary stenosis was 100% at 5 years. Mean transpulmonary gradients were 7.1 ± 3.1 mm Hg and 13.5 ± 6.8 mm Hg postoperatively and at 5 years, respectively. Mean transpulmonary gradient increased faster over time when the SPV diameter was less than 29 mm (p = 0.03). CONCLUSIONS: The SPV could represent an alternative to cryopreserved pulmonary homografts during the Ross procedure in adult patients. Hemodynamic results were improved by using large diameter SPV, but longer follow-up is mandatory to confirm those results.

Results of elective cardiac surgery in patients with severe obesity (body mass index≥35 kg/m2).

BACKGROUND: The increasing number of obese patients eligible for cardiac surgery requires risks and benefits to be balanced in this population. AIMS: To study the results of cardiac surgery in severely obese patients (body mass index [BMI]≥35 kg/m2). METHODS: In this retrospective study of 3564 patients undergoing elective cardiac surgery between 2004 and 2012, the population was divided into two groups: BMI 20-34.9 kg/m2 (n=3282) and BMI≥35 kg/m2 (n=282). Patients with BMI<20 kg/m2 were excluded due to the well-known increased mortality risk. The primary endpoint was 90-day mortality. A multivariable analysis was performed to identify prognostic factors. RESULTS: Among our patients, 58.2% and 27.7% underwent isolated coronary or valvular surgery, respectively; 9.7% had combined valvular and coronary surgery and 4.4% had other procedures. Severely obese patients were younger: 62.5±9.3 years vs 67.8±10.7 years (P=0.0001). Overall 90-day mortality was 4.0%. Severe obesity did not influence postoperative mortality. In the multivariable analysis, the interaction between preoperative renal failure and severe obesity was an important mortality prognostic factor (hazard ratio: 11.17; P=0.03). Mediastinitis rates were similar between groups in non-diabetic patients; in diabetic patients, severe obesity was associated with higher mediastinitis rates (P=0.002). Superficial wound infections were higher in severely obese patients (P=0.003). CONCLUSION: Elective cardiac surgery in severely obese patients was not associated with increased perioperative morbimortality, but had a higher superficial wound infection risk. Nevertheless, severe obesity itself should not be a contraindication to elective surgery.

Reoperation after the Ross procedure: incidence, management, and survival.

BACKGROUND: The risk of reoperation on the autograft and homograft is the major long-term drawback of the Ross procedure. The incidence and clinical implications of reoperations after the Ross procedure are reported. METHODS: Between March 1992 and February 2010, 336 consecutive patients had a Ross procedure (mean follow-up, 6.2±4.9 years). Autograft implant technique was freestanding root replacement in 269 patients, subcoronary implantation in 52 patients and a modified root replacement with the autograft included in a Valsalva tube graft in 15. RESULTS: Subsequently, 38 patients (11.3%) underwent reoperations, for autograft dilatation in 23 and a significant autograft insufficiency in 9, at 9.6±3.7 years and 2.6±3.9 years, respectively. Aortic and pulmonary infective endocarditis occurred in 3 patients. Three patients underwent a non valve-related cardiac reoperation. Three patients received a transcatheter pulmonary valve implantation after 12.2±1.7 years. At 15 years, freedoms for autograft and homograft explantation (with 95% confidence interval) were 83.3% (77.4%- to 9.2%) and 92.8% (87.6% to 97.9%), respectively. Native aortic valve regurgitation, indexed aortic annulus diameter exceeding 1.35 cm/m2 and autograft diameter were risk factors for dilated autograft reoperation (hazard ratio, 3.23 [95% confidence interval, 1.19 to 8.81], p=0.02; 3.83 [0.9 to 16.33], p=0.07 and 1.2 per mm [1.01 to 1.41], p=0.03), respectively. CONCLUSIONS: Autograft dilatation was the leading cause of reoperation in patients who underwent root replacement. Long-term follow-up is mandatory to determine whether modifications of the operative technique could limit autograft dilatation.

Open window thoracostomy and thoracoplasty to manage 90 postpneumonectomy empyemas.

BACKGROUND: Postpneumonectomy empyema (PPE) is a serious complication. The treatment options are similar to the management of any abscess, with drainage, ideally open, often of critical importance. After infection control, many techniques for space obliteration have been described. This study summarizes a 10-year experience in the management of PPE in our center. METHODS: From 2000 to 2010, 90 patients (83 men) with PPE were treated. Median follow-up was 5.3 years. Once the diagnosis of empyema was confirmed, chest drainage was performed through open window thoracostomy (OWT), with ensuing extramusculoperiosteal thoracoplasties if healthy tissue was present. RESULTS: Pneumonectomy was performed in 72 patients with lung cancer. Mortality after PPE was 2.2%. OWT achieved infection control in 89 patients. Seven OWT spontaneously healed, and 24 were never closed. The remaining 59 patients with OWT underwent thoracoplasty. Mortality after thoracoplasty was 5%. Empyema recurred in 3 patients. Overall success rate of PPE control after pleural obliteration was 91.5%. CONCLUSIONS: Thoracoplasty is a reliable filling procedure. It has a significantly higher success rate and a lower mortality rate than the other techniques. We believe that this procedure has a part to play in the future management of PPE.

Ploidy of cell-sorted trophic and cystic forms of Pneumocystis carinii.

Once regarded as an AIDS-defining illness, Pneumocystis pneumonia (PcP) is nowadays prevailing in immunocompromised HIV-negative individuals such as patients receiving immunosuppressive therapies or affected by primary immunodeficiency. Moreover, Pneumocystis clinical spectrum is broadening to non-severely-immunocompromised subjects who could be colonized by the fungus while remaining asymptomatic for PcP, thus being able to transmit the infection by airborne route to susceptible hosts. Although the taxonomical position of the Pneumocystis genus has been clarified, several aspects of its life cycle remain elusive such as its mode of proliferation within the alveolus or its ploidy level. As no long-term culture model exists to grow Pneumocystis organisms in vitro, an option was to use a model of immunosuppressed rat infected with Pneumocystis carinii and sort life cycle stage fractions using a high-through-put cytometer. Subsequently, ploidy levels of the P. carinii trophic and cystic form fractions were measured by flow cytometry. In the cystic form, eight contents of DNA were measured thus strengthening the fact that each mature cyst contains eight haploid spores. Following release, each spore evolves into a trophic form. The majority of the trophic form fraction was haploid in our study. Some less abundant trophic forms displayed two contents of DNA indicating that they could undergo (i) mating/fusion leading to a diploid status or (ii) asexual mitotic division or (iii) both. Even less abundant trophic forms with four contents of DNA were suggestive of mitotic divisions occurring following mating in diploid trophic forms. Of interest, was the presence of trophic forms with three contents of DNA, an unusual finding that could be related to asymmetrical mitotic divisions occurring in other fungal species to create genetic diversity at lower energetic expenses than mating. Overall, ploidy data of P. carinii life cycle stages shed new light on the complexity of its modes of proliferation.

Indications and results of anterior mediastinal tracheostomy for malignancies.

BACKGROUND: This study was designed to assess the early and long-term results, and determine suitable indications of anterior mediastinal tracheostomy, after radical resection for cervicothoracic malignancies. METHODS: From 1985 to 2009, 13 patients ranging in age from 40 to 75 years underwent an anterior mediastinal tracheostomy for malignancy, 2 as an isolated procedure, 5 with concomitant laryngectomy, and 6 with concomitant laryngopharyngoesophagectomy. The patients had subglottic carcinoma, proximal tracheal carcinoma invading the subglottic larynx (n = 6), stomal recurrence following laryngectomy (n = 4), esophageal carcinoma invading the proximal trachea (n = 2), or tracheal recurrence after conventional resection (n = 1). The postoperative course and outcome were assessed in all patients. RESULTS: In 5 patients, the postoperative course was uneventful. There were 2 in-hospital deaths, and 6 patients experienced nonfatal complications including three pharyngocutaneous fistulas, two pharyngogastric or pharyngocolic anastomotic leaks, and one pulmonary embolism. Satisfactory airway was achieved in 7 patients presenting with proximal obstruction, and ability to tolerate oral feeding, in 2 patients with esophageal carcinoma. The mean follow-up time for survivors was 89 months (range, 9 to 201 months). Patients with esophageal carcinoma or recurrence of tracheal carcinoma showed a poor outcome. In contrast, in the subgroup of patients with head and neck malignancy, 3-year and 5-year survival rates were 57% and 43%, respectively. CONCLUSIONS: Our results and survival analysis from the literature suggest that suitable indications for anterior mediastinal tracheostomy are (1) carcinoma of the subglottic region or proximal trachea invading the subglottic larynx, (2) stomal recurrence after laryngectomy, and (3) well-differentiated thyroid carcinoma invading the trachea or recurrence.

Modified Ross operation with reinforcement of the pulmonary autograft: Six-year results.

OBJECTIVE: The Ross procedure is widely used for aortic valve disease in patients who are still growing and young adults with active lifestyles or the desire for pregnancy. The need for autograft reoperation remains the principal limitation of the procedure. Autograft inclusion in a polyester tube prosthesis has been proposed with good postoperative results, but the durability of these technical modifications has not been assessed. We report the midterm results of pulmonary autograft reinforcement with a Valsalva Gelweave Dacron tube (Terumo Cardiovascular Systems Inc, Ann Arbor, Mich). METHODS: Since 1992, we have performed 322 Ross operations; 12 patients underwent a modified Ross procedure with the autograft included in a Valsalva Gelweave Dacron tube. The mean age of these patients was 29.7 +/- 10.8 years (range, 15.3-46.5 years). The mean aortic crossclamp time was 126 +/- 11 minutes (range, 110-142 minutes). The mean follow-up was 4 +/- 1.4 years (range 1.7-5.8 years). RESULTS: No perioperative deaths were observed, and all patients are alive and doing well. No significant autograft regurgitation was recorded during follow-up. The mean diameters of the autograft annulus and the neosinus of Valsalva were 23.3 +/- 2.6 mm and 32.6 +/- 3.3 mm, respectively, at discharge, and 24.0 +/- 1.9 mm and 33.6 +/- 3.3 mm, respectively, at the last control (P = .32 and P = .08, respectively). CONCLUSION: These results support that this technical modification of the Ross operation might be proposed for patients at risk of autograft dilatation when an inclusion technique is not feasible.

High-speed cell sorting of infectious trophic and cystic forms of Pneumocystis carinii.

The separation of Pneumocystis carinii life-cycle stages while preserving infectivity is a hitherto unresolved challenge. We describe an original, reproducible, and efficient method for separating trophic from cystic forms of P. carinii using a high-speed cell sorter. The large amounts of highly purified (99.6+/-0.3%) infectious trophic and cystic forms can now be used to elucidate the poorly understood P. carinii life cycle.