Male breast cancer: Report of two cases with bloody nipple discharge.

We report 2 rare cases of male breast cancer with bloody nipple discharge. Patient 1, a 32-year-old male, presented with a bloody nipple discharge from the left breast. Diagnostic workup revealed papillary ductal carcinoma in situ. Patient 1 underwent bilateral mastectomy with left axillary sentinel lymph node biopsy and has been doing well ever since. Patient 2, a 70-year-old male with concomitant metastatic prostate cancer, presented with a palpable right breast mass and with initially serous, then bloody nipple discharge. Diagnostic workup revealed invasive ductal carcinoma with ductal carcinoma in situ of the right breast. Patient 2 received aromatase inhibitor therapy prior to right total mastectomy with SLN biopsy followed by adjuvant tamoxifen therapy. Patient 2 recovered without complication for 2 years until metastatic disease recurrence was detected. This case report's purpose is to increase awareness and enhance understanding of the presentation, diagnosis, treatment, and outcomes of rare malignant pathologies.

Evaluating Perioperative Complications Surrounding Supracondylar Humerus Fractures: Expanding Indications for Outpatient Surgery.

BACKGROUND: Supracondylar humerus (SCH) fractures are one of the most common pediatric orthopaedic injuries. Described using the Wilkins modification of the Gartland Classification system, current practice guidelines give moderate evidence for closed reduction and percutaneous pinning of type 2 and 3 injuries, but little evidence exists regarding the appropriate surgical setting for fixation. The goal of this study was to evaluate the perioperative complication profile of type 3 fractures with maintained metaphyseal contact and determine their suitability for outpatient surgery. METHODS: Skeletally immature patients with type 2 and 3 SCH fractures treated at a single, Level-1 trauma institution from March 2019 to January 2000 were retrospectively reviewed. A total of 1126 subjects were identified. Open, concomitant injuries, incomplete physical examination, initial neurovascular compromise, flexion-type fractures, ecchymosis, skin compromise, and those managed nonoperatively were excluded. Type 3 fractures were categorized as either "3M" versus type "3" ("M" denoting metaphyseal bony contact). Demographic data, neurovascular changes, and postoperative complications were collected. Categorical variables were evaluated using χ2 or Fisher exact tests, and continuous variables analyzed using analysis of variance, with significance defined as a P-value <0.05. RESULTS: A total of 485 patients (189 type 2, 164 type 3M, 132 type 3) met inclusion criteria. Sex and length of stay did not differ among groups. The incidence of neurovascular change between initial presentation and surgical fixation was significantly greater for type 3 fractures compared with other groups (P=0.02). No child in the 3M group had preoperative neurovascular examination changes, compared with 3 patients with type 3 injuries. When directly compared with the 3M group, type 3 fractures had a higher incidence of neurovascular examination changes that trended towards significance (P=0.08). There was no difference in postoperative complication rate between groups (P=0.61). CONCLUSIONS: Our findings demonstrate that Gartland type 3 SCH fractures lacking metaphyseal bony contact, compared with types 3M and 2, are more likely to experience neurovascular examination changes between initial presentation and definitive surgical fixation. Type 3M fractures clinically behaved like type 2 injuries and, accordingly, could be considered for treatment on an outpatient basis. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Preparation for professional self-regulation.

This article asserts that graduate study should include preparation for participation in the process of self-regulation to assure the responsible conduct of research in the scientific community. This article outlines the various ways in which doctoral study can incorporate such preparation. These suggested ways include the inculcation of general attitudes and values about professional self-regulation, various ways doctoral study can be configured so that future scientists are prepared to participate in the deterrence, detection and sanctioning of scientific wrongdoing. The stages of doctoral study in the United States and their relevance to preparation for self-regulations are also discussed. Recommendations regarding an extended role for faculty advisors, graduate assistantships, coursework and departmental policies and activities are also advanced.

Characteristics of persons with syphilis in areas of persisting syphilis in the United States: sustained transmission associated with concurrent partnerships.

BACKGROUND AND GOAL: In areas with persistent syphilis, to characterize persons at higher risk for transmitting syphilis. STUDY DESIGN: Cohort study. Structured interviews of persons with early syphilis from four research centers were linked to outcomes of partner tracing. RESULTS: Of 743 persons with syphilis, 229 (31%) reported two or more partners in the previous month, and 57 (8%) received money or drugs for sex in the previous three months. Persons with at least one partner at an earlier stage of syphilis than themselves were defined as transmitters; 63 (8.5%) of persons with early syphilis met this definition. Having concurrent partners (two or more in one week in the last month) was independently associated with being a transmitter. CONCLUSION: Sexual network/behavioral characteristics of syphilis patients and their partners, such as concurrency, can help identify persons at higher risk for transmitting syphilis who should receive emphasis in disease prevention activities.

Intra-operative quality assessment of coronary artery bypass grafts.

Early coronary artery bypass graft (CABG) failure is a troubling complication that may result in a wide range of problems, including refractory angina, myocardial infarction, low cardiac output, arrhythmia, and fatal heart failure. Early graft failures are related to poor quality and size of the distal native vascular bed, coagulation abnormalities, or technical problems involving the graft conduits and anastomoses. Unfortunately, graft failure is difficult to detect during surgery by visual assessment, palpation, or conventional monitoring. We evaluated the accuracy and utility of a transit-time, ultrasonic flow measurement system for measurement of CABGs. There were no differences between transit-time measurements and volumetric-time collected samples in an in vitro circuit over a range of flows from 10 to 100ml/min (Bland and Altman Plot, 1.96 SD). Two hundred and ninety-eight CABGs were examined in 125 patients. Graft flow rate was proportional to the target vessel diameter. Nine technical errors were detected and corrected. Flow waveform morphology provided valuable information related to the quality of the anastamosis, which led to the immediate correction of technical problems at the time of surgery.

Mediastinitis and long-term survival after coronary artery bypass graft surgery.

BACKGROUND: Mediastinitis is a dreaded complication of coronary artery bypass surgery (CABG). The long-term effect of mediastinitis on mortality after CABG has not been well studied. METHODS: We examined the survival of 15,406 consecutive patients undergoing isolated CABG surgery from 1992 through 1996. Patient records were linked to the National Death Index. Mediastinitis was defined as occurring during the index admission and requiring reoperation. RESULTS: Mediastinitis occurred in 193 patients (1.25%). Patients with mediastinitis were older and more likely to have had emergency surgery, diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, and preoperative dialysis-dependent renal failure. Patients with mediastinitis were also more likely to be severely obese and had somewhat lower preoperative ejection fraction. After multivariate adjustment for these factors, the first year post-CABG survival rate was 78% with mediastinitis and 95% without, and the hazard ratio for mortality during the entire follow-up period was 3.09 (CI 95% 2.28, 4.19; p < 0.0001). CONCLUSIONS: Mediastinitis is associated with a marked increase in mortality during the first year post-CABG and a threefold increase during a 4-year follow-up period.

Experimental confirmation of effectiveness of fenestration in acute aortic dissection.

BACKGROUND: Aortic fenestration is used clinically to treat organ ischemia in acute descending aortic dissection. However, fenestration has not been studied experimentally. This study does so using an animal model. METHODS: Descending aortic dissection was created in six dogs, with subsequent fenestration of the infrarenal aorta. Blood flow (femoral, cephalic, and renal), blood pressure (femoral and carotid), and aortic distensibility were measured at baseline, after dissection, and after fenestration. Values were compared using paired t tests. RESULTS: Baseline femoral, cephalic, and renal arterial flows were 53+/-37, 78+/-65, and 83+/-52 mL/min, respectively. Baseline femoral and carotid pressures were 82+/-13 and 81+/-11 mm Hg, respectively. After dissection, femoral, cephalic, and renal arterial flow decreased to 20+/-21 (p < 0.05), 38+/-26, and 56+/-36 mL/min, respectively. Femoral blood pressure decreased to 28+/-17 mm Hg (p < 0.05). With fenestration, femoral, cephalic, and renal flows increased to 60+/-37 (p < 0.05), 78+/-51, and 80+/-48 mL/min, respectively. Femoral blood pressure increased to 85+/-28 mm Hg (p < 0.05). Carotid pressure remained unchanged with dissection and fenestration (77+/-17 mm Hg, 82+/-17 mm Hg, respectively). Baseline aortic distensibility (21%) decreased significantly after dissection (to 1.4%, p < 0.05) and increased after fenestration (to 12%, p < 0.05). CONCLUSIONS: Experimental aortic fenestration restored blood pressure and flow to hypoperfused organs in acute descending aortic dissection. The continued clinical application of fenestration is supported.

Skeletal muscle ventricles in continuity with the bloodstream.

BACKGROUND AND AIM OF STUDY: The prevalence of end-stage congestive heart failure and limitation of clinical alternative treatments present the need for creative new solutions. Formation of a ventricle from skeletal muscle (SMV) has shown promise in the animal laboratory. Two modes of the SMV for cardiac assistance, the counterpulsation (CP-SMV) and the ventricular assist (VA-SMV), using the latissimus dorsi muscle were applied in a canine model. Ability to augment arterial pressure was assessed. The effect of stimulation delay on the degree of augmentation was also evaluated. METHODS AND RESULTS: Thirty-five SMVs were connected in continuity with the bloodstream in the two modes: (1) CP-SMV (aorta-to-aorta) (n = 12); and (2) VA-SMV (left ventricular [LV] apex-to-aorta) (n = 23). In the CP-SMV mode, designed to simulate the intra-aortic balloon pump, the SMV was simply interposed into the path of the descending aorta (DAo) without prosthetic valves in either the inflow or the outflow conduit. In order to obligate blood flow through the SMV, the DAo was ligated between the two grafts. In the VA-SMV mode, the connection was made with valved conduits from the LV apex (inflow) to the ascending aorta (outflow) (n = 11) or to the DAo (n = 12). The ascending aorta (AAo) was also ligated proximal to the outflow conduit for the same reason of obligating blood flow through the SMV. The SMV was timed to contract in diastole in both the CP-SMV mode and the VA-SMV mode. In the VA-SMV mode, the average systolic pressure without stimulation was 101.6 +/- 2.2 mmHg and with stimulation 118.21 +/- 4.78 mmHg (mean augmentation, 14.5 +/- 2.6 mmHg) (p < 0.01). In the CP-SMV mode, the average systolic pressure without stimulation was 97 +/- 32 mmHg and with stimulation, 122 +/- 26 mmHg (mean augmentation, 25 +/- 8.6 mmHg) (p < 0.001). We also extended earlier work on timing of stimulation of isolated SMV by evaluating the effect of stimulation delay on the degree of augmentation in continuity with the bloodstream with the SMV in the VA-SMV configuration. Delays of 50 msec to 225 msec were evaluated. SMV stimulation was via the thoracodorsal nerve at an amplitude of 1.5 V and a frequency of 25 Hz. The greatest augmentation occurred at a stimulation delay of 150 msec (p < 0.001). CONCLUSION: Both counterpulsation and assist configurations produced effective diastolic augmentation. Although diastolic augmentation occurred with all timing delays, the optimal delay was 150 msec. Complications in the survival animals include AAo problems, SMV rupture, respiratory insufficiency, intraoperative instability, and thrombosis (which occurred in 51% [18/35] of the animals). This high frequency of thrombosis in the canine model suggests the use of a less thrombogenic SMV lining, more aggressive or prolonged anticoagulation, or an alternative animal model.

Reoperative mitral valve surgery via right thoracotomy: decreased blood loss and improved hemodynamics.

BACKGROUND AND AIMS OF THE STUDY: Reoperative mitral surgery via sternotomy can be associated with significant complications, including excessive blood loss and injuries to the heart, great vessels and patent coronary artery grafts. The right antero-lateral thoracotomy offers excellent exposure with less risk from re-entry. MATERIALS AND METHODS: Between 1982 and 1992, 221 patients had repeat mitral valve procedures at our institution. Fifteen of these 221 underwent mitral valve replacement via right thoracotomy. Indications for surgery in each group included bioprosthetic valve failure, paravalvular leak and bacterial endocarditis. Fifteen patients having reoperative mitral valve surgery via right thoracotomy approach were compared with a control group of 33 patient who underwent surgery via repeat sternotomy. All thoracotomy patients underwent mitral replacement or repair with ventricular fibrillation without aortic cross-clamping. Operative time, cardiopulmonary bypass time, requirement for inotropic support, blood loss within the first six postoperative hours, number of blood units transfused, length of ICU stay, days to discharge, and 30-day survival were compared between the two groups. In addition, the preoperative PaO2/FiO2 (P/F) ratio was evaluated as a prognostic indicator. RESULTS: Bypass time (162 +/- 43 min thoracotomy group vs. 131 +/- 34 min sternotomy group), operative time (389 +/- 100 min thoracotomy group vs. 450 +/- 25 min sternotomy group), ICU stay (6 +/- 8 days thoracotomy group vs. 5 +/- 6 days sternotomy group), P/F ratio (352 +/- 142 thoracotomy group vs. 423 +/- 108 sternotomy group), and 30-day survival (93% thoracotomy group vs. 91% sternotomy group) were not found to be significantly different between groups. Of great significance was the reduction in blood loss (277 +/- 152 ml thoracotomy vs. 651 +/- 504 ml sternotomy, p < 0.05) and blood transfused (2.0 +/- 1.7 units thoracotomy vs. 6.5 +/- 3.3 units sternotomy, p < 0.01) with the thoracotomy approach. Also of significance was a reduction in frequency with which significant inotropic support was needed to separate from cardiopulmonary bypass (26% vs. 63%, p < 0.05). Despite decreased access to the heart for de-airing maneuvers, no cerebrovascular events whatsoever were noted with the thoracotomy approach. CONCLUSION: The right thoracotomy approach is recommended for redo mitral valve surgery. Despite these advantages, severe pulmonary dysfunction (as indicated by a P/F ratio less than 300) correlated with a prolonged hospital course in four thoracotomy patients; such patients should have repeat sternotomy.

Optimal timing of coronary artery bypass graft surgery after acute myocardial infarction.

BACKGROUND: To assess optimal timing for coronary artery bypass graft surgery (CABG) after an acute myocardial infarction (AMI), all patients undergoing CABG without associated procedures at our institution from January 1, 1991, to July 30, 1992, were reviewed. Patients were divided into three groups based on time from infarct to revascularization. The control group consisted of patients operated on for angina refractory to medical management. Relative risks (incident infarction group divided by incident control group) were established for need of vasopressors, new balloon to separate from bypass, perioperative myocardial infarction, and hospital mortality. METHODS AND RESULTS: One hundred sixteen patients underwent CABG within 6 weeks of infarction. In the experimental group, 58 patients underwent CABG for non-Q-wave infarction, and 58 patients underwent CABG for Q-wave infarction. In the control group, 255 patients underwent surgery for angina without infarction. Patients were analyzed by group relative to the time between infarction and CABG. Patients were analyzed between infarction and CABG and assigned to one of three groups. Group 1 patients were revascularized within 48 hours; group 2, between 3 and 5 days; and group 3, after 5 days. Significance was determined by Fisher's exact or Mantel-Haenszel chi 2 test where appropriate. Multivariate analysis was performed on statistics that were significant. All patients within all groups after Q-wave or non-Q-wave myocardial infarction had a significantly higher risk of needing an intra-aortic balloon pump and vasopressors to be weaned from bypass and a greater incidence of perioperative MI compared with control patients. Surgical mortality is highest immediately after Q-wave infarctions. CONCLUSIONS: Patients with non-Q-wave infarction may undergo CABG relatively safely at any time. Acceptable timing for CABG after Q-wave infarction is after 48 hours.

The effects of supercooling chemicals on myocardial ultrastructure: a transmission electron microscopy case study.

Extended ischemia results in organ infarction which limits the availability of donor hearts. Hypothermic storage extends heart preservation by effectively stopping cellular metabolism, thereby preventing toxic accumulations of metabolic wastes and depletion of energy stores. However, cell swelling as a result of ion concentration changes and cell laceration due to ice crystal growth are consequences of hypothermic ischemia. Supercooling successfully preserves hearts for an extended time without associated myocardial necrosis. The efficacies of four supercooling preservative solutions, containing hypertonic glucose, polyethylene glycol, and or winter flounder antifreeze protein, are assessed using the Langendorff isolated organ perfusion apparatus and transmission electron microscopy. Polyethylene glycol seems the most effective in preventing myocardial necrosis possibly by dehydrating, minimizing cellular ice formation, protecting against cell swelling, and functioning as an antioxidant. Hypertonic glucose seems the most effective in reducing cell swelling; it may also depress solution freezing points, bind water, adjust both intra- and extracellular osmolarities, stabilize proteins, and assist in adenosine triphosphate (ATP) production. Antifreeze protein seems to bind effectively to ice and inhibit its growth; it may also reduce membrane permeabilities to Ca2+ and K+ ions.

Dynamic cardiomyoplasty.

Dynamic cardiomyoplasty is a promising new technique that appears to effect symptomatic improvement in patients with NYHA class III heart failure. Objective improvement in systolic performance of the left ventricle appears small but remains to be further defined. No survival advantage has yet been realized, although this may be seen as the technique is further refined and operative risk curtailed. Mechanism of action may include a girdling effect that prevents progressive left ventricular dilatation. This effect may be independent of any role in augmenting systolic performance. Randomized clinical trials currently in progress will provide definitive answers within the next few years to these important questions.

Skeletal muscle for cardiac assist.

Although current efforts at cardiomyoplasty have not produced the anticipated clear-cut benefits in cardiac function, replicable improvements in subjective function have resulted. Efforts at optimizing conditioning protocols, skeletal muscle strength, and timing of skeletal muscle assist devices should provide further improvements in cardiomyoplasty. Further work with alternative ways of configuring skeletal muscle for cardiac assist is extremely promising. SMVs, in particular, offer potential to augment cardiac function directly or indirectly powering pumps. Work in all these areas is in early stages, but the future is bright.

5'-Nucleotidase inhibition enhances postischemic myocardial performance.

Adenosine methylene diphosphate (AMPCP), a 5'-nucleotidase inhibitor, was evaluated as an adjunct to cold crystalloid cardioplegic myocardial protection. Cardiopulmonary bypass (CPB) was instituted at 28 degrees C in two groups of mongrel dogs (each, n = 6). Myocardial ischemia was induced for 150 min by aortic cross clamping. Crystalloid cardioplegia (4 degrees C) was infused into the aortic root at 15 ml/kg/20 min in the control group (CP). The experimental group (CP + AMPCP) received identical doses of cardioplegia supplemented with 250 microM AMPCP. While on CPB, the mean arterial pressure was 70 mm Hg and the myocardial temperature ranged from 16 to 22 degrees C. Hemodynamic parameters were recorded prior to institution of CPB and at 15 and 45 min following the termination of CPB. Starling curves were constructed for cardiac index (CI), mean arterial pressure (MAP), mean left ventricular pressure (LVP), +dP/dt and -dP/dt at each time point for left atrial pressures between 5 and 12.5 mm Hg. The area under each curve was calculated and expressed as a percentage of prebypass values. Statistical analysis was performed with Student's two-tailed t test. The data demonstrate that although recovery of CI, MAP, heart rate, and LVP was similar in both groups, statistically significant improvement in recovery of myocardial compliance (-dP/dt) and systolic function (+dP/dt) was seen with AMPCP. The addition of the 5'-nucleotidase inhibitor, AMPCP, to cold crystalloid cardioplegia enhances postischemic myocardial performance in vivo and may be useful during prolonged periods of global myocardial ischemia.

Inflammatory abdominal aortic aneurysm masquerading as occlusion of the inferior vena cava.

Inflammatory aneurysms are an uncommon disorder that represent between 5% and 10% of abdominal aortic aneurysms. Their presentation is often variable and may include pain and obstruction of adjacent anatomic structures. This report describes a 68-year-old man who sought treatment after insidious onset of progressive bilateral lower extremity edema over a 6-month period. Noninvasive studies were suggestive of bilateral iliac vein occlusion, and a venogram showed a nearly obstructed vena cava from external compression. A CT scan showed a thick-walled infrarenal abdominal aneurysm. At exploration an inflammatory abdominal aortic aneurysm was found. Because of the presence of dense inflammatory changes surrounding the aneurysm and extending into the pelvis, the surgical procedure of choice was an aortobifemoral bypass graft done with Dacron. The aneurysmal wall was debrided from the vena cava. His postoperative course was uneventful, his edema resolved, and follow-up noninvasive studies were normal. Postoperative venography showed resolution of the extrinsic compression of the vena cava.

Suture granuloma masquerading as malignancy of the biliary tract.

Eighteen years after having a duodenal leiomyosarcoma resected, a patient presented with weight loss, pruritus, and abdominal pain. ERCP was consistent with a cholangiocarcinoma with proximal hepatic duct stricture and nonfilling of the cystic duct. CAT scan revealed no extrinsic masses compressing the gallbladder or biliary tract. At surgical exploration, the patient was found to have a suture granuloma with surrounding fibrosis within the common bile duct. There was no evidence of malignancy.