Distinctive multicystic hemispheric lesions suggesting a novel variant of infantile astrocytoma.

Two unrelated female infants presented at 9 days and 2 months, respectively, with apneic episodes in the former and gaze preference in the latter. MRI revealed enlargement of almost the entire right hemisphere, apparently smooth cortex, simplification of the gyral pattern, and expanded white matter with abnormal signal intensity containing multiple intraparenchymal cysts. Histologic examination of both cases revealed white matter infiltration by a hypocellular lesion composed of uniform, fibrillary astrocytes in a microcystic background. Multilocular tumor cysts were prominent, but Rosenthal fibers and eosinophilic granular bodies were absent. Very rare mitoses were seen in the absence of necrosis or vascular change. There was no convincing cortical infiltration, but the subpial zone was diffusely expanded by a band of astrocytes set in a dense fibrillar feltwork which opened out into numerous cystic spaces. No desmoplastic changes or associated atypical ganglion cells were identified. There was no evidence for a BRAFKIAA1549 fusion or BRAF mutation in one case tested. In conclusion, both lesions are not desmoplastic infantile astrocytoma/ganglioglioma, fibrillary astrocytoma, or typical for pilocytic astrocytoma. Such extreme subpial spread with cysts is most unusual and may suggest a novel variant of infantile astrocytoma.

Should patients with post-resection locoregional recurrence of lung cancer receive aggressive therapy?

The outcome of thirty-seven patients with a post-resection locoregional recurrence of non-small cell lung cancer treated with radiation therapy alone between 1979 and 1989 was compared to that of 759 patients with unresected non-small cell lung cancer also treated with standard radiation during the same period. Each patient's locoregional recurrence was staged using the current American Joint Committee on Cancer staging system. Comparison of pretreatment characteristics between the two groups, including age, sex, extent of weight loss, performance status, stage, and histologic subtype revealed fewer patients with greater than 5% weight loss (35 vs. 47%, p = 0.04) and more cases with squamous histology (54 vs. 28%, p = 0.01) among the patients with locoregional recurrences than those with newly diagnosed lesions. Over 80% of both groups had clinical stage III lesions. The median radiation doses were 56 and 59 Gy for recurrent and newly diagnosed cases (p = NS). For the patients with locoregional recurrences, the median time from resection to recurrence was 13 months (range: 3-118 months), and the recurrences were predominantly nodal in 25 cases, chest wall/pleural in four and at the bronchial stump in eight. When measured from the date of documented recurrence, the median survival time and 2-year actuarial survival rate of the patients with recurrent lesions were 12 months and 22%, as compared to 12 months and 26% for the newly diagnosed patients (p = NS). Freedom from documented locoregional tumor progression at 2 years was 30% for both groups. Patients with bronchial stump lesions had superior survival to those with nodal or chest wall recurrences, with a median survival time of 36 versus 9 months. A therapeutic approach to selected patients with post-resection locoregional recurrence of non-small cell lung cancer equally aggressive to that for newly diagnosed lung cancer patients is justified by these results, especially for patients with bronchial stump recurrences.

Duplex ultrasonography to diagnose failing arterial prosthetic grafts.

BACKGROUND: Although several reports have documented the usefulness of a surveillance program with duplex ultrasonography (DU) to diagnose failing autologous vein bypasses, the effectiveness of DU to detect failing arterial prosthetic grafts has not been confirmed. We attempted to determine whether our program, which included DU and other noninvasive techniques (NonDU), was useful for this purpose. METHODS: Between July 1, 1991, and September 30, 1994, 85 prosthetic bypasses in 59 patients performed for lower extremity ischemia were entered into a graft surveillance protocol. There were 35 femoropopliteal, 16 femorotibial, 15 iliofemoral, 13 axillofemoral, and 6 femorofemoral bypasses. Both DU and NonDU were performed 1 week and every 3 months after the initial bypass or after graft revision. NonDU criteria of a failing graft included changes in symptoms or pulses, decreased ankle/brachial index greater than 0.15, or diminution of ankle pulse volume recordings greater than 50%. Normal grafts were bypasses that had less than 50% stenosis documented by arteriography or remained patent. Problem grafts were those that required revision or thrombosed before intervention. Follow-up of patient grafts ranged between 3 and 36 months (mean, 11 months). RESULTS: DU predicted 17 (81%) of 21 problem grafts versus only 5 (24%) diagnosed by NonDU (p = 0.001). Lesions associated with these 21 grafts were perianastomotic in 10 cases, in adjacent inflow or outflow arteries in 8 cases, and intrinsic to the graft in 3 cases. The likelihood of a graft thrombosing in the presence of a normal test was 7% (4 of 58) for DU compared with 21% (16 of 76) for NonDU (p = 0.04). CONCLUSIONS: DU is more sensitive than NonDU in predicting failure of prosthetic grafts. This study suggests that DU should routinely be performed as part of a surveillance program for peripheral arterial prosthetic bypasses.

Venous aneurysms: surgical indications and review of the literature.

BACKGROUND: During the last 20 years we diagnosed five cases of venous aneurysm of the jugular (n = 4) and basilic (n = 1) veins. The purpose of this report was to determine the natural history and indications for surgery of venous aneurysms. METHODS: Our five cases were included in an English-language literature review performed through August 1993. RESULTS: In our series two aneurysms (one external jugular vein, one basilic vein) were excised for cosmetic reasons. Three internal jugular vein aneurysms were followed up for up to 4 years without complications with serial color duplex ultrasonography. Of 32 patients with abdominal venous aneurysms (18 portal, seven inferior vena cava, four superior mesenteric, two splenic, one internal iliac), 13 (41%) had major complications including five deaths. Of 31 patients with deep venous aneurysms of the extremity (29 popliteal, two common femoral), 22 (71%) had deep vein thrombosis or pulmonary embolism and in 17 recurrent deep vein thrombosis or pulmonary embolism developed when patients were treated with anticoagulation alone. CONCLUSIONS: Prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for most patients with lower extremity deep venous aneurysms. Other venous aneurysms should be excised only if they are symptomatic, enlarging, or disfiguring.

Five-step protocol for carotid endarterectomy in the managed health care era.

BACKGROUND: We developed a protocol combining 5 cost-effective strategies to determine whether elective carotid endarterectomy (CEA) could be performed safely without adversely affecting well-established low morbidity and mortality rates and with significant hospital cost savings. METHODS: Between April 1, 1995, and December 31, 1996, 109 of 141 patients were prospectively enrolled as candidates into a 5-step CEA protocol: (1) duplex ultrasonography (DU) performed at an accredited vascular laboratory as the sole diagnostic carotid preoperative study, (2) admission the day of operation, (3) cervical block anesthesia to eliminate intraoperative electroencephalogram monitoring, (4) transfer from the recovery room after a 4-hour observation period to the vascular ward, and (5) discharge the first postoperative morning. The other 32 patients were excluded from analysis; 16 patients were treated by vascular surgeons not participating in the protocol, 9 were treated concomitantly for other medical problems, and 7 were admitted emergently. RESULTS: One patient died of carotid hemorrhage the first postoperative morning, and one had an intraoperative embolic stroke for a combined mortality-stroke rate of 1.8% (2 of 109). Of the 109 patients, 70% (76) underwent operation using DU as the sole diagnostic study, 95% (104) were admitted the day of operation, 76% (83) had cervical block anesthesia, 59% (64) were transferred to the floor the day of operation, and 83% (90) were discharged the morning after operation. None of the 109 patients were adversely affected by these 5 cost-saving strategies except potentially the patient who bled the first postoperative morning. The predicted charges of a patient treated with a perioperative protocol that many vascular surgeons currently use (preoperative arteriography, general anesthesia with intraoperative electroencephalogram monitoring, overnight intensive care unit stay, discharge on postoperative day 2) was $16,073 compared with $10,437 for a patient who completed all 5 steps of the protocol detailed above. CONCLUSIONS: On the basis of these results documenting significant cost savings and acceptably low morbidity and mortality rates, this 5-step protocol may be considered the standard for performing CEA in this era of cost containment. These results may be compared with endovascular intervention, which has recently been proposed as a less expensive technique to treat carotid disease.

Combined hormonal and radiation therapy for lymph node-positive prostate cancer.

OBJECTIVES: To evaluate the efficacy of combined radiation and hormonal therapy in patients with prostate cancer metastatic to the pelvic lymph nodes. METHODS: Fifty consecutive patients with node-positive prostate cancer were evaluated by the Departments of Urology and Radiation Oncology at the University of Pennsylvania and offered combined hormonal and radiation therapy. All patients received pelvic radiation to 45 Gy, with a boost dose to the prostate to 65 to 71 gy. Forty-five of the patients were treated with concurrent hormonal therapy consisting of diethylstilbestrol (2 patients), orchiectomy (18 patients), leuprolide (5 patients), or combined androgen blockade (20 patients); the other 5 patients declined hormonal therapy. Patients represented a group with locally advanced disease with a high incidence of T3 tumors (66%), high grade (74%; Gleason score more than 7), high prostate-specific antigen (PSA) (40%; more than 30.0 ng/mL), and a high incidence of gross (36%) or bilateral (30%) adenopathy and a high incidence of multiply involved lymph nodes (62%). RESULTS: Median follow-up of patients is 42 months (range, 10 to 102). All 5 patients declining hormonal therapy relapsed within 18 months and only 1 patient survived longer than 3 years. Among patients treated with combined hormonal and radiation therapy, the 6-year survival rate is 82%, the clinical disease-free survival at 6 years is 71%, and the probability of survival free of recurrence, with a PSA less than 0.2 ng/mL, is 62%. Only two PSA recurrences occurred, both in patients who elected to discontinue hormone therapy. There was no synergistic toxicity observed as a result of combined therapy. CONCLUSIONS: Combined hormonal and radiation therapy offers the potential for extended disease-free survival and may represent an effective treatment option for patients with locally advanced prostate cancer.

Orbital recurrence of choroidal melanoma 20 years after enucleation.

A 54-year-old woman developed an orbital mass 20 years after enucleation of the left eye for a choroidal melanoma, which proved to be of spindle-A type. Computed tomography of the orbit suggested the diagnosis of a cavernous hemangioma, but orbital biopsy confirmed the diagnosis of recurrent malignant melanoma and the patient was managed by orbital exenteration followed by radiotherapy. The orbital recurrence was of the mixed cell type, suggesting a gradual 20-year transition of the spindle-A cells to spindle-B and epithelioid cells. We recommend that the selected surgical management of extrascleral extension of uveal melanomas be determined by the degree of extrascleral involvement and by whether the extrascleral extension is discovered clinically, at surgery, or in the pathology laboratory. We recommend that orbital computed tomography be performed periodically after enucleation in all patients who have orbital extension of uveal melanomas.

Revision of failing lower extremity bypass grafts.

BACKGROUND: Color-duplex ultrasound (CDU) surveillance of arterial bypass grafts has been validated, but the natural history of "failing" grafts remains poorly defined. Our purpose was to compare failing grafts having prophylactic revision with those that did not. METHODS: Postoperative duplex surveillance was performed in an accredited vascular laboratory for all lower extremity bypass grafts performed at a single institution. Eighty-five infrainguinal grafts (57 vein, 21 polytetrafluoroethylene (PTFE), and 7 composite grafts) in 83 patients were identified as failing by accepted criteria. Twenty-five grafts were revised early (early), 20 grafts revised more than 2 months after the initial CDU-abnormality (late), and 40 grafts were not prophylactically revised (no revision) at any time. RESULTS: The three groups were not different (P > 0.10) with regard to gender, age, level of bypass, type of conduit, location of stenoses, or timing of abnormality after surgery. No revision patients more frequently had diffuse low peak systolic flow velocity (PSV) as the CDU abnormality (P = 0.013). Cumulative primary patency was significantly better at 12 months (P = 0.028) in the no revision group (78.9%) compared with early grafts (43.1%) or late grafts (63.8%), and this difference remained significant when low PSV grafts were excluded from analysis. However, assisted primary patency, secondary patency, and limb salvage rates did not differ between the three groups (P > 0.10). CONCLUSIONS: Our experience in this retrospective study contradicts other reports supporting the efficacy of prophylactic graft revision for grafts identified as failing by currently accepted CDU criteria. Refinement of CDU criteria to more accurately predict graft thrombosis is needed.

Management and outcome of infrapopliteal arterial graft infections with distal graft involvement.

PURPOSE: The purpose of this study was to determine the outcome of patients with infrapopliteal artery graft infections (InfraPopGIs) who presented with graft infection distal to the popliteal artery. PATIENTS AND METHODS: Between July 1, 1979 and June 30, 1994, 27 patients presented with infrapopliteal artery graft infections (18 polytetrafluoroethylene [PTFE], 9 autologous vein). The infection involved the anastomosis in 22 cases (8 anterior tibial, 8 posterior tibial, 4 peroneal, 2 dorsalis pedis arteries) and was localized to the body of the graft in 5 cases (4 calf, 1 ankle). All bypasses were originally performed for limb salvage. Twelve patients with patent grafts and intact anastomoses were managed by complete graft preservation. Fifteen patients presented with occluded grafts (10), anastomotic hemorrhage (4), or systemic sepsis (1) and were treated by total or subtotal graft excision. RESULTS: The hospital mortality rate was 19% (5 of 27) and the amputation rate in survivors was 27% (6 of 22). These results were compared with a mortality rate of 13% (15 of 114; P > 0.05) and a limb loss rate of 10% (10 of 99)(P = 0.05) in 114 patients during this period who presented with infection proximal to the tibial arteries. Of 6 survivors with graft infections who required amputations, 5 lacked a suitable outflow artery for a secondary bypass and 1 developed progressive gangrene despite a patent secondary bypass. Among the other 16 survivors, 7 (44%) limbs remained viable without requiring a secondary bypass, 6 (37%) limbs were salvaged with successful preservation of patent grafts, and 3 (19%) required secondary bypasses to prevent limb loss. CONCLUSIONS: Patients presenting with infrapopliteal artery graft infections have higher amputation rates than patients with more proximal infected peripheral grafts. Selective graft preservation and selective revascularization when outflow arteries are available are essential adjuncts to minimize high rates of limb loss associated in patients with graft infections.

Carotid stump pressure, stump pulse, and retrograde flow.

In order to obtain a more comprehensive intraoperative hemodynamic profile and to predict hypoperfusion during carotid endarterectomy, stump pressure, stump pulse, and retrograde internal carotid flow were measured in 261 patients. Our results show a significant correlation between stump pressure and retrograde flow (p < 0.001), stump pressure and the presence of a stump pulse (p < 0.001), and retrograde flow and the presence of a stump pulse (p < 0.001). We also demonstrated a significant correlation between stump pressure (lower), retrograde flow (less), and the absence of a stump pulse in patients with contralateral carotid artery occlusion. There was no correlation between the indication for carotid endarterectomy and any hemodynamic measurement. The triad of stump pulse, stump pressure, and retrograde flow accurately reflects collateral blood flow when the carotid is cross-clamped. These determinations can be obtained at low cost and are easily and rapidly performed. A protocol for selective shunting in patients undergoing carotid endarterectomy with general anesthesia is suggested.

Recommendations for initial antibiotic treatment of extracavitary arterial graft infections.

BACKGROUND: Initial antibiotic treatment of extracavitary arterial graft infections is usually empiric or based on Gram's stain findings. Increasing virulence of bacteria causing extracavitary arterial graft infections may render previous choices of antibiotics obsolete. The purposes of this study were to correlate Gram's stain findings of gram-positive bacteria and gram-negative bacteria with wound cultures and provide a microbiologic basis for appropriate initial antibiotic therapy. METHODS: Between July 1, 1979 and June 30, 1994, specimens obtained on the day of admission from purulent wounds involving 113 extracavitary arterial graft infections were retrospectively reviewed for Gram's stain and culture and sensitivity results. RESULTS: Gram's stain findings correlated with final cultures on only 28 of 113 cases (25%), including 20 of 48 pure gram-positive, 2 of 24 pure gram-negative, and 6 of 41 mixed bacterial cultures. Staphylococcus aureus was the most common gram-positive bacteria cultured (43 isolates) and Pseudomonas species was the most common gram-negative bacteria (25 isolates). Bacteria were sensitive to a first-generation cephalosporin in only 32% (36 of 113) of infections. A combination of vancomycin and either ticarcillin-clavulanic acid or ceftazidime, which have minimal toxicity and provide excellent coverage against staphylococci, Pseudomonas, and other gram-negative bacteria, would have covered 96% (109) and 95% (107) of cultured organisms, respectively. CONCLUSIONS: Regardless of Gram's stain findings, current recommendations for initial treatment of extracavitary arterial graft infections should include vancomycin and ceftazidime or ticarcillin-clavulanic acid until final culture and sensitivity results dictate the use of more selective antibiotics.

Cost-effectiveness and cost-efficiency in vascular surgery.

Medical costs have been an increasing focus of attention in medicine in general, particularly in the United States health care environment. Because vascular disease is most prevalent in the elderly, the forecasted growth of this population over the next several decades will put increasing strains on health care financing. Costs will undoubtedly be a major component of any system of outcomes measurement, and it is important for vascular surgeons and others who specialize in vascular disease to be familiar with the definitions and methodology and cost-effectiveness analysis. Similarly, improving cost efficiency within the practice of vascular surgery will be mandated. The purpose of this article is to review systems of cost-effectiveness analysis as they pertain to vascular surgery, as well as to define critical pathway models that have been used to improve cost-efficiency in vascular surgery.

How to avoid and manage nerve injuries associated with aortic surgery: ischemic neuropathy, traction injuries, and sexual derangements.

Both open and endovascular surgery of the infrarenal aorta are attended by risks of neurologic complications. Injury to the periaortic autonomic plexi frequently results in ejaculatory and erectile dysfunction. Traction injuries to lumbosacral nerve roots can cause peripheral nerve injury, most commonly exhibited as a femoral nerve deficit. The least common but most feared neurologic complication that can occur with infrarenal aortic surgery is ischemic injury to the spinal cord, or conus medullaris. The risk of this complication is increased with emergent or complicated aortic reconstructions. The importance of internal iliac artery perfusion to the development of ischemic cord and nerve root injury has been recognized. Although some neurologic complications may be avoidable by technical modifications, there is a small and probably irreducible neurologic risk to aortic surgery that should be considered when weighing options for treatment of aortic pathology.

Hepatic artery aneurysms: evaluation and current management.

Twelve patients underwent surgical treatment for hepatic artery aneurysm (HAA) at Mayo Clinic between 1979 and 1991. Six patients presented with symptoms, while in six the HAA was asymptomatic. Two HAAs presented with rupture: one ruptured into the portal vein and one iatrogenic rupture occurred during cholecystectomy. Ultrasonography and computed tomography were important for diagnosis, while arteriography was used for planning of the operation. All HAAs were true aneurysms, with atherosclerosis being the etiology in 10 of 12 patients. The common hepatic artery was involved in 11 patients. Nine of 12 patients had aneurysms in other locations and half had major concomitant operations in addition to HAA repair. One patient had hepatic artery ligation, while in eleven the artery was reconstructed. Graft patency was poor (25%) when the gastroduodenal artery was excluded from the repair. No hepatic morbidity occurred. Mortality was 100% (1/1) for emergent operation, and 9.1% (1/11) in the elective setting. Because of the prevalence of other aneurysms, complete vascular evaluation and close follow-up are recommended.

Methods of reducing Ascogregarina chagasi parasitaemia in laboratory colonies of Lutzomyia longipalpis.

Ascogregarina chagasi is an aseptate gregarine parasite found naturally in populations of Lutzomyia longipalpis. Under intensive rearing conditions in the laboratory, the parasite is known to reduce longevity and egg production, therefore, it is thought to be a major contributing factor to the phenomenon of colony crashes. A study is described to test egg cleansing techniques, with a view to controlling this parasite in laboratory colonies. Methods used include washing eggs with formol, benzalkonium chloride and irradiating with ultraviolet light. It was concluded that cleansing with 0.1% formol solution was the most efficient method of controlling A. chagasi.

Role of nursing personnel in implementing clinical pathways and decreasing hospital costs for major vascular surgery.

Collaboration with key nursing personnel is essential to successfully implement clinical pathways, establish a dedicated vascular wing, and achieve significant hospital cost savings while still maintaining quality care with low morbidity and mortality rates. Key nursing personnel met once a month during a 1-year period with vascular surgeons, hospital administrators, and health care advisors to plan strategies to develop clinical pathways and establish a dedicated vascular ward. The pathways were then implemented. We compared morbidity, mortality, readmission rates, adn hospital costs among two groups of patients admitted for major vascular surgery. Nursing personnel, attending staff, and surgical residents found that treating patients who had undergone major vascular surgery was more straightforward and efficient after clinical pathways and a dedicated vascular wing were established. In addition, there were no significant differences between the groups in terms of overall mortality or pulmonary, neurologic, or cardiac complications despite shorter hospital stay and decreased hospital costs. Also there were no significant differences in readmission rates within 30 days.

A comprehensive analysis of high school genetics standards: are states keeping pace with modern genetics?

Science education in the United States will increasingly be driven by testing and accountability requirements, such as those mandated by the No Child Left Behind Act, which rely heavily on learning outcomes, or "standards," that are currently developed on a state-by-state basis. Those standards, in turn, drive curriculum and instruction. Given the importance of standards to teaching and learning, we investigated the quality of life sciences/biology standards with respect to genetics for all 50 states and the District of Columbia, using core concepts developed by the American Society of Human Genetics as normative benchmarks. Our results indicate that the states' genetics standards, in general, are poor, with more than 85% of the states receiving overall scores of Inadequate. In particular, the standards in virtually every state have failed to keep pace with changes in the discipline as it has become genomic in scope, omitting concepts related to genetic complexity, the importance of environment to phenotypic variation, differential gene expression, and the differences between inherited and somatic genetic disease. Clearer, more comprehensive genetics standards are likely to benefit genetics instruction and learning, help prepare future genetics researchers, and contribute to the genetic literacy of the U.S. citizenry.