Ventral hernia synthetic mesh repair infected by Mycobacterium fortuitum.

We report the occurrence of a refractory infection caused by the "rapidly growing" nontuberculous mycobacterium, Mycobacterium fortuitum, after incisional hernia repair using synthetic mesh. The patient had previously undergone three herniorrhaphies incorporating polypropylene mesh. Multiple surgical debridements were required, along with complete removal of all the mesh, to eradicate the infection. Prolonged antimicrobial therapy with sulfamethoxazole, an agent active against the patient's isolate, was also used. Although this atypical mycobacterium has been reported to cause a variety of infections, including many types of periprosthetic infections, this case represents successful treatment of M. fortuitum infecting abdominal wall mesh.

Using delta/DRG diagrams and decision tree analysis to select a cost-effective surgery for cholecystitis.

BACKGROUND AND OBJECTIVES: Many studies have attempted cost analysis of laparoscopic cholecystectomy as compared to open cholecystectomy. However, these analyses have included costs, charges, expenses, etc., and at times they have been used interchangeably. This paper demonstrates how DRG diagrams containing charges and length-of-stay, preoperative prediction of conversion rates, decision-tree construction and sensitivity analysis can be used to select the most cost-efficient operation for a given patient with cholecystitis. METHODS: A Delta DRG analysis for complicated cholecystectomy (DRG 195) showed the hospital to be an extreme outlier in both charges and length of stay. Record review indicated that 55% of the cases were converted laparoscopic cholecystectomies and the remainder were aged or younger patients with advanced disease. Chart and literature review determined the causes and the probability of conversion. Data were then placed into decision-tree and sensitivity analyses. The most cost-effective operation for a given probability of conversion was demonstrated. RESULTS: Three preoperative findings and combinations of each predicted conversion rates and analysis showed that the charge of laparoscopic cholecystectomy must be held below the range of $5,361-$13,084 to make routine laparoscopic cholecystectomy cost-effective. CONCLUSIONS: This method demonstrated that using Delta/DRG, decision-tree and sensitivity analysis offers physicians, hospitals and other health-care providers a method of evaluating the treatment of DRG categories to determine the most cost-effective management.

A cost-effectiveness evaluation of preoperative type-and-screen testing for vaginal hysterectomy.

OBJECTIVE: Our purpose was to evaluate the usefulness and cost-effectiveness of routine preoperative type-and-screen testing before vaginal hysterectomy. STUDY DESIGN: A retrospective review of all vaginal hysterectomies performed at Hutzel Hospital between 1988 and 1994 with an emphasis on those that required blood transfusion was done. All vaginal hysterectomies completed at Hutzel Hospital were included in this 6-year time period for all noncancerous indications, including fibroid uterus, endometriosis, menorrhagia, uterine prolapse, pelvic pain, cervical dysplasia, and adenomyosis. RESULTS: Among 1063 patients who underwent vaginal hysterectomy, 26 needed a blood transfusion at the time of hospitalization. Medical records of the patients who needed blood transfusions were reviewed to determine the urgency and indication. Ten of the transfusions were given preoperatively because of anemia, 7 were given intraoperatively, and 9 were given postoperatively. The seven intraoperative transfusions were given because of the physician's perception of excessive blood loss; however, none of the patients received an emergency transfusion with extreme urgency. That is, the need for the intraoperative transfusion was not immediate. All patients who received a transfusion could have waited for 20 to 30 minutes for proper type and crossmatching and subsequent transfusion. CONCLUSION: In the absence of preoperative indications, routine preoperative type-and-screen testing of blood before vaginal hysterectomy is not cost-effective, does not enhance patient care, and should be eliminated.

Toward quality assurance for metaphase FISH: a multicenter experience.

Although fluorescent in situ hybridization (FISH) is rapidly becoming a part of clinical cytogenetics, no organization sponsors multicenter determinations of the efficacy of probes. We report on 23 laboratories that volunteered to provide slides and to use a probe for small nuclear ribonucleoprotein polypeptide N (SNRPN) and a control locus. Experiences with FISH for these laboratories during 1994 ranged from 0 to 645 utilizations (median = 84) involving blood, amniotic fluid, and bone marrow. In an initial study of hybridization efficiency, the median percentage of metaphases from normal individuals showing two SNRPN and two control signals for slides prepared at each site was 97.0 (range = 74-100); for slides prepared by a central laboratory, it was 97.8 (range = 81.6-100). In a subsequent blind study, each laboratory attempted to score 5 metaphases from each of 23 specimens [8 with del(15)(q11.2-->q12) and 15 with normal #15 chromosomes]. Of 529 challenges, the correct SNRPN pattern was found in 5 of 5 metaphases in 457 (86%) and in 4 of 5 in 33 (6%). Ambiguous, incomplete, or no results were reported for 32 (6%) challenges. Seven (1%) diagnostic errors were made, including 6 false positives and 1 false negative: 1 laboratory made 3 errors, 1 made 2, and 2 made 1 each. Most errors and inconsistencies seemed due to inexperience with FISH. The working time to process and analyze slides singly averaged 49.5 min; slides processed in batches of 4 and analyzed singly required 36.9 min. We conclude that proficiency testing for FISH by using an extensive array of challenges is possible and that multiple centers can collaborate to test probes and to evaluate costs.

Experience with the P.A.S.-PORT venous access device in patients with gynecologic malignancies.

Experience with the P.A.S.-PORT, a peripherally implanted central venous access device, is evaluated in a retrospective review of 154 patients from July 1991 to June 1994. Blood could not be aspirated from six patients. Complications included temporary minor thrombophlebitis in seven patients (4.5%), symptomatic axillary or subclavian vein thrombosis in five patients (3.2%), clotted port in two patients (1.2%), port pocket cellulitis in two patients (1.2%), and fungal sepsis in two patients (1.2%). In six patients (3.8%) the P.A.S.-PORT had to be removed because of complications. The P.A.S.-PORT facilitated delivery of chemotherapy, parenteral nutrition, blood products, antibiotics, hydration, and blood sampling. It was demonstrated that the P.A.S.-PORT may be inserted and used with a low incidence of complications in gynecologic cancer patients.

Toward quality assurance for metaphase FISH: a multi-center experience.

Although fluorescent in situ hybridization (FISH) is rapidly becoming a part of clinical cytogenetics, no organization sponsors multi-center determinations of the efficacy of probes. We report on 23 laboratories that volunteered to provide slides and to use a probe for SNRPN and a control locus. Experiences with FISH for these laboratories during 1994 ranged from 0 to 645 utilizations (median = 84) involving blood, amniotic fluid and bone marrow. In an initial study of hybridization efficiency, the median percentage of metaphases from normal individuals showing two SNRPN and 2 control signals for slides prepared at each site was 97.0 (range = 74-100); for slides prepared by a central laboratory, it was 97.8 (range = 81.6-100). In a subsequent blind study, each laboratory attempted to score 5 metaphases from each of 23 specimens [8 with del(15) (q11.2-->q12) and 15 with normal 15 chromosomes]. Of 529 challenges, the correct SNRPN pattern was found in 5 of 5 metaphases in 457 (86%) and in 4 of 5 in 33 (6%). Ambiguous, incomplete or no results were reported for 32 (6%) challenges. Seven (1%) diagnostic errors were made including 6 false positives and 1 false negative: 1 laboratory made 3 errors, 1 made 2, and 2 made 1 each. Most errors and inconsistencies seemed due to inexperience with FISH. The working time to process and analyze slides singly averaged 49.5 minutes; slides processed in batches of 4 and analyzed singly required 36.9 minutes. We conclude that proficiency testing for FISH using an extensive array of challenges is possible and that multiple centers can collaborate to test probes and to evaluate costs.

Flare-up of endometriosis induced by gonadotropin-releasing hormone agonist leading to bowel obstruction.

OBJECTIVE: To report a case of intestinal obstruction that developed shortly after preoperative administration of a GnRH analogue (GnRH-a) that caused flare-up and rapid progression of enteric endometriosis. DESIGN: Case report. SETTING: University tertiary reproductive endocrinology practice. PATIENT: A 34-year-old nulligravid female with progressive severe symptomatic endometriosis. INTERVENTIONS: Planned preoperative administration of GnRH-a for 3 months followed by extirpative surgery and hormone replacement therapy. Instead, total abdominal hysterectomy, bilateral salpingoophorectomy, resection of the obstructed ileocecal junction, and side-to-side ileo-ascending enterocolostomy was performed. RESULTS: Preoperative GnRH-a administered in the midfollicular phase resulted in flare-up of preexisting ileocecal endometriosis that rapidly progressed, resulting in partial small bowel obstruction. CONCLUSION: Gonadotropin-releasing hormone agonist should be used with caution when there is known or suspected enteric endometriosis. Consideration should be given to blocking the agonistic effect of GnRH-a in this setting by the prior or concomitant use of progestins or danazol.

Is academic managed care an oxymoron?

BACKGROUND: A review of 1993 data on length of stay (LOS) and charges for diagnosis-related group (DRG) 195 (complicated cholecystectomies) showed that Maricopa Medical Center charged more and had longer LOS than all other area hospitals. METHODS: Twenty DRG 195 charts were analyzed for the causes of the inefficiencies. The remaining cholecystectomy DRGs were similarly analyzed. RESULTS: Analysis of the charts for DRG 195 showed that 55% of the patients had laparoscopic conversions. Charges and LOS varied significantly because of the conversions, increased preoperative hospital days and increased operative times. Moreover, 30% of patients were more than 70 years old. Comparisons of other cholecystectomy DRGs showed similar inefficiencies, indicating a hospital system's problem. CONCLUSIONS: Diagnosis-related group delta analysis is a powerful performance improvement tool. Once problem areas are identified and corrected, monitoring prospective data produces rapid analysis of quality of care and cost improvements. The models can serve as a means for teaching hospitals to become more competitive and satisfy the Joint Commission on Accreditation of Healthcare Organizations requirements for patient-care improvements.

Autologous saphenous vein popliteal-tibial artery bypass for limb-threatening ischemia: a reassessment.

BACKGROUND: The purpose of this review was to ascertain the cumulative primary and secondary graft patency rates, the cumulative limb salvage rate, and the frequency of atherosclerotic disease progression proximal to the graft origin, in patients with autologous saphenous vein popliteal-tibial artery bypass grafts whose operative indication was limb-threatening ischemia. PATIENTS AND METHODS: Forty-three short autologous saphenous vein grafts originating from the popliteal artery were retrospectively reviewed. The life-table method was used to determine primary and secondary graft patency and limb salvage rates. Atherosclerotic disease progression proximal to the graft origin was assessed via follow-up arteriography, segmental limb pressures, or pulse-volume recordings. All other data were compared by chi-square analysis. RESULTS: The cumulative primary graft patency rate at 1, 3, and 5 years (86%, 66%, 58%) was similar to the cumulative secondary patency rate (90%, 70%, 62%) and the cumulative limb salvage rate (80%, 55%, 55%). No patient developed hemo-dynamically significant atherosclerotic disease proximal to the graft origin during the follow-up period. CONCLUSIONS: The similarity of the life-table data suggests graft-dependent, poorly collateralized limbs; it is therefore not uncommon for these patients to require major amputations shortly after bypass failure. There was no evidence of critical proximal disease progression that might warrant a more proximal graft origin. Poplitealtibial artery bypass grafts are durable, with acceptable graft patency and limb salvage rates.

Inhibition of breast and ovarian carcinoma cell growth by 1,25-dihydroxyvitamin D3 combined with retinoic acid or dexamethasone.

This study examined the growth inhibitory effects of combining 1,25-dihydroxyvitamin D3 (calcitriol) with retinoic acid or dexamethasone against cultured breast and ovarian carcinoma cells. Retinoic acid (12.5-50 nM) increased the effectiveness of calcitriol (12.5-50 nM) against MCF-7 and NIH:OVCAR3 cells, with synergistic interactions at two of the three ratios tested. Dexamethasone augmented calcitriol effects, with synergism at 0.05 and 0.1 nM dexamethasone in MCF-7 cells and 5 nM in Caov-4 ovarian cells. This study showed favorable interactions for calcitriol-retinoic acid and calcitriol-dexamethasone combinations in breast and ovarian cancer cell lines.

Chromosomal abnormalities in 47 pediatric brain tumors.

The karyotypes of 47 pediatric brain tumors (14 cerebellar pilocytic astrocytomas, six cerebral pilocytic astrocytomas, seven anaplastic astrocytomas and glioblastomas, nine medulloblastomas [PNETs], one cerebral neuroblastoma, four ependymomas, and seven miscellaneous other neoplasms) are presented. Most of the pilocytic astrocytomas and ependymomas had normal karyotypes. In contrast, the majority of the anaplastic astrocytomas-glioblastomas were abnormal. The abnormalities included losses and structural abnormalities of chromosomes 9, 13, and 17, and double minutes. There were no losses of chromosomes 10 and 19q or gains of chromosome 7, which are among the most common abnormalities of adult glioblastomas. The chromosomal abnormalities in the medulloblastomas were similar to those reported in the literature but less frequent. Four tumors (choroid plexus papilloma, meningioma, cerebral malignant rhabdoid tumor, and immature teratoma) had losses of chromosome 22.

Giant mucinous ovarian tumor with low malignant potential with foci of well-differentiated mucinous adenocarcinoma masked by massive obesity. A case report.

A giant (64-kg) mucinous tumor with low malignant potential and foci of well-differentiated mucinous adenocarcinoma was removed from a massively obese (250 kg) woman. This case represents the largest tumor of this type reported to date.

Amputation or revascularization in the > 70 year old.

An aggressive posture toward limb salvage in the elderly was assessed by retrospective review of a 5 year experience. A total of 302 primary lower extremity revascularizations and 465 primary major amputations were performed; of these, 62 per cent (472/767) were performed in patients 70 years or older (range 70-104, mean 78). Psychosocial status was utilized to indicate primary amputation; revascularization was attempted in all patients capable of ambulation or transfer. Revascularization was performed in 119 patients > 70 years old (44 femoropopliteal, femorotibial, or sequential, 24 extra-anatomic, and 11 miscellaneous) with a 30-day mortality of 8 per cent, thrombosis 12 per cent, and early amputation 7 per cent. There were five additional mortalities and three amputations, for a 77 per cent life and limb salvage at one year. This contrasted with a 2.2 per cent mortality (P < 0.05), 5.4 per cent thrombosis, and 3.3 per cent amputation rate in 183 revascularizations in < 70 year old patients. Primary amputation was performed with an 8 per cent (23/253) mortality in 253 patients > 70 years old undergoing 192 above and 61 below-knee procedures. There were two mortalities in 154 elective cases, but a 22 per cent rate in urgent situations (P < 0.01) ranging from 66 per cent (12/18) for emergency and 25 per cent (3/12) guillotine to 8 per cent (6/69) for physiologic amputation (P < 0.001). Fifty per cent of all amputation survivors died within 1 year. The comparative mortality for 212 amputations in < 70 year old patients was 1.5 per cent (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective randomized trial of LLETZ versus laser ablation in patients with cervical intraepithelial neoplasia.

Three hundred seventy-five patients with CIN on referral Pap and with a distinct cervical lesion on colposcopy were prospectively randomized to treatment with LLETZ or to standard colposcopic evaluation with directed cervical biopsies, endocervical curettage, and laser ablation of the transformation zone for biopsy proven CIN. Of the 195 patients that randomized to treatment with LLETZ, 32.5% had no evidence of dysplasia, 26.5% had CIN 1, 17.3% had CIN 2, 22.7% had CIN 3, and 0.5% had microinvasive carcinoma on final histologic evaluation. Of the 180 patients randomized to laser ablation, initial cervical biopsies demonstrated no evidence of dysplasia in 52.8% of patients, CIN 1 in 22.0%, CIN 2 in 18.3%, and CIN 3 in 5.7%. Only 114 (63.3%) of the women in the laser group required therapy. Complications were comparable for each treatment arm. Only 6.7% of patients randomized to LLETZ and 4.4% with laser ablation had persistent CIN on follow-up Pap. LLETZ appears to be effective, well tolerated, and less expensive, but the cost savings advantage of LLETZ over laser ablation may not apply to patients with CIN 1 on referral Pap smear since many do not require treatment.

Mucinous adenocarcinoma arising in a neovagina.

The development of carcinoma in a neovagina is a rare occurrence. A case of mucinous adenocarcinoma of a neovagina is presented. A neovagina was formed in 1945 to correct a congenital anomaly. Subsequently the patient developed a chronic rectovaginal fistula. It is thought that the mucinous adenocarcinoma developed as a result of chronic inflammation secondary to the fistula. Although rare, development of a malignancy in ectopic tissue can occur. Clinicians need to be aware of this as they follow these patients.

Treatment of recurrent and metastatic endometrial carcinoma with cisplatin and doxorubicin.

Between April 1985 and February 1989, 19 patients with advanced or recurrent endometrial carcinoma were treated with the combination of cisplatin (50 mg/m2) and doxorubicin (50 mg/m2) administered intravenously every 21 days. Eight patients had Stage III disease, two had Stage IV and nine had recurrent cancer. Eleven patients had measurable disease at the start of therapy. There were 7 partial responses among the 19 patients, for an overall response rate of 36%. The median survival for the whole group was 17 months with a median progression free interval of 5 months. Patients without measurable disease at the onset of therapy had median survivals and progression free intervals which were significantly better than those patients with measurable disease, p < 0.011 and p < 0.025 respectively. Granulocytopenia (< 1000 microliters) occurred in 7 patients. No important thrombocytopenia, cardiotoxicity nephrotoxicity or neurotoxicity was observed. Emesis and alopecia occurred in all patients. No treatment related deaths were encountered.

Additive inhibition of RL95-2 endometrial carcinoma cell growth by carboplatin and 1,25 dihydroxyvitamin D3.

Responses of stage III/IV endometrial adenocarcinomas to cytotoxic agents have been partial and of short duration, results which indicate a need for new agents and therapeutic strategies. This study was undertaken to determine the effects of carboplatin and the active metabolite of vitamin D, 1,25 dihydroxyvitamin D3 (calcitriol), on the growth of RL95-2 endometrial carcinoma cells. Carboplatin is a second-generation platinum-based cytotoxic agent. Calcitriol is a biologic agent that has activity against multiple solid tumors, including ovarian carcinomas. Carboplatin inhibited the growth of RL95-2 cells in a concentration-dependent manner with maximal inhibition (78%) at 200 micrograms/ml. Calcitriol also inhibited RL95-2 growth in a concentration-dependent manner. Maximal inhibition (29%) was elicited by 80 nM calcitriol. Addition of 10-50 nM calcitriol to 5-20 micrograms/ml carboplatin resulted in improved growth inhibition. The degree of interaction between carboplatin and calcitriol was assessed using isobolographic analysis and was found to be additive at all drug concentrations and ratios examined. These results suggest that carboplatin and calcitriol each inhibit the growth of RL95-2 endometrial carcinoma cells and that the combination of these two agents acts additively to inhibit the growth of RL95-2 cells. These agents merit further investigation for their utility against endometrial carcinomas.

Inhibition of c-myc in breast and ovarian carcinoma cells by 1,25-dihydroxyvitamin D3, retinoic acid and dexamethasone.

The role and regulation of the c-myc protooncogene in breast and ovarian neoplasms is receiving increased attention. The downregulation of the c-myc protooncogene by 1,25-dihydroxyvitamin D3 (calcitriol), retinoic acid (RA) and dexamethasone (Dex) is closely associated with growth inhibition in leukemic cells. Calcitriol, RA and Dex have anti-proliferative activity in breast and gynecologic carcinoma cells; however, the regulation of c-myc by these agents in breast and ovarian cancers is mostly unknown. We have addressed the regulation of c-myc in these cancers using an adaptation of a novel method which employs an immunohistochemical procedure to detect c-myc protein followed by quantification of c-myc staining with computerized image analysis. This system represents an alternative to protein product assay by Western blotting and is straightforward, rapid (1 day), can be carried out on a small scale and provides a sample size that readily facilitates statistical analysis of assay data. In MCF-7 human breast cancer cells, c-myc was suppressed 29% by 0.5 nM Dex, 45% by 0.01 nM RA and 54% by 100 nM calcitriol after 24 h of drug treatment. At the same hormone concentrations, growth was inhibited 18% by Dex, 18% by RA and 39% by calcitriol after 3 days of treatment (p < 0.05 for all hormones). Similar patterns of growth and c-myc inhibition were seen in T47D human breast cancer cells and NIH:OVCAR3 human ovarian cancer cells, with the exception of Dex in T47D cells, which caused no inhibition of c-myc or growth.(ABSTRACT TRUNCATED AT 250 WORDS)

[Electrosurgical loop excision as diagnostic and simultaneously therapeutic intervention in cervical intraepithelial neoplasia]. / Elektrochirurgische Schlingenexzision als diagnostischer und gleichzeitig therapeutischer Eingriff bei der zervikalen intraepithelialen Neoplasie.

109 women referred to our center for colposcopy because of suspicious cervical cytology and in whom an abnormal epithelial pattern was diagnosed on colposcopy, or in whom a discrepancy between cytology and colposcopy was encountered, concomitantly underwent loop electrosurgical excision procedure as an outpatient procedure. All removed specimens were examined and no invasive cancer was found in any of them. No serious complications occurred. Ambulatory loop electrosurgical excision procedure appears to be a cost-effective and well tolerated treatment modality for the management of women with cervical intraepithelial neoplasia, with the advantage that this conservative procedure allows histologic examination of the removed tissue.