A Case Report on Brachial Plexus Anomaly, Embryological Basis, and Clinical Implications.

This study presents the routine prosection findings of a 74-year-old male anatomical donor, whose cause of death was attributed to anoxic brain injury secondary to cardiac arrest and acute exacerbation of chronic obstructive pulmonary disease (COPD). The patient exhibited a significant medical history, including severe COPD, chronic heart failure, atrial fibrillation, hypertension, stage III chronic kidney disease, heavy alcohol abuse, obesity, coronary artery disease, peripheral edema, triple bypass surgery, and right hip replacement. A detailed examination of the upper extremities revealed anomalies within the brachial plexus, with a more pronounced presence on the left side. This particular donor deviates from the expected "typical" brachial plexus anatomy, with a lack of convergence into a lateral cord and an anomalous convergence into a superior trunk. To ensure optimal patient care and procedural outcomes, a collaborative approach between surgeons and anesthesiologists that is grounded in a comprehensive understanding of these anatomical nuances is essential. Therefore, this study aims to comprehensively investigate the identified brachial plexus anomalies, elucidate their embryological origins, and explore their clinical implications. Through these objectives, this research contributes to a broader understanding of anatomical variations and their relevance in medical practice.

Megacolon as a Feature of Suspected Robinow Syndrome.

This study presents the routine prosection findings of a 73-year-old male cadaver, with the cause of death reported to be hypertension and respiratory failure. Deep thorax and abdomen dissection exposed profound external and internal anatomical abnormalities. Externally, the body exhibited the following: pectus excavatum; short-limbed dwarfism; and abnormalities of the head, face, and external genitalia. Most of these findings suggest that the donor had Robinow syndrome, a rare genetic disorder involving developmental delay and skeletal abnormalities akin to those found in this cadaver. The internal gross anatomical findings included the following: megacolon; hiatal hernia; bilateral inguinal hernias; laterally displaced right kidney with a fibrous adhesion extending from the inferior pole of the kidney to the inguinal canal; atypical branching of the abdominal aorta; superiorly displaced diaphragm; pulmonary hypoplasia; heart right of midline; and curved esophagus. Although determining the exact etiology of megacolon is difficult in a cadaveric specimen, it is important to investigate the physiological changes associated with it. Therefore, the aim of this study was to investigate the space-occupying pathology of megacolon and to discuss a potential connection between megacolon and Robinow syndrome.

Climate anomalies and competition reduce establishment success during island colonization.

Understanding the factors that facilitate or constrain establishment of populations in novel environments is crucial for conservation biology and the study of adaptive radiation. Important questions include: (1) Does the timing of colonization relative to stochastic events, such as climatic perturbations, impact the probability of successful establishment? (2) To what extent does community context (e.g., the presence of competitors) change the probability of establishment? (3) How do sources of intrapopulation variance, such as sex differences, affect success at an individual level during the process of establishment? Answers to these questions are rarely pursued in a field-experimental context or on the same time scales (months to years) as the processes of colonization and establishment. We introduced slender anole lizards (Anolis apletophallus) to eight islands in the Panama Canal and tracked them over multiple generations to investigate the factors that mediate establishment success. All islands were warmer than the mainland (ancestral) environment, and some islands had a native competitor. We transplanted half of these populations only 4 months before the onset of a severe regional drought and the other half 2 years (two generations) before the drought. We found that successful establishment depended on both the intensity of interspecific competition and the timing of colonization relative to the drought. The islands that were colonized shortly before the drought went functionally extinct by the second generation, and regardless of time before the drought, the populations on islands with interspecific competition declined continuously over the study period. Furthermore, the effect of the competitor interacted with sex, with males suffering, and females benefitting, from the presence of a native competitor. Our results reveal that community context and the timing of colonization relative to climactic events can combine to determine establishment success and that these factors can generate opposite effects on males and females.

Scale-dependent environmental effects on phenotypic distributions in Heliconius butterflies.

Identifying the relative importance of different mechanisms responsible for the emergence and maintenance of phenotypic diversity can be challenging, as multiple selective pressures and stochastic events are involved in these processes. Therefore, testing how environmental conditions shape the distribution of phenotypes can offer important insights on local adaptation, divergence, and speciation. The red-yellow Müllerian mimicry ring of Heliconius butterflies exhibits a wide diversity of color patterns across the Neotropics and is involved in multiple hybrid zones, making it a powerful system to investigate environmental drivers of phenotypic distributions. Using the distantly related Heliconius erato and Heliconius melpomene co-mimics and a multiscale distribution approach, we investigated whether distinct phenotypes of these species are associated with different environmental conditions. We show that Heliconius red-yellow phenotypic distribution is strongly driven by environmental gradients (especially thermal and precipitation variables), but that phenotype and environment associations vary with spatial scale. While co-mimics are usually predicted to occur in similar environments at large spatial scales, patterns at local scales are not always consistent (i.e., different variables are best predictors of phenotypic occurrence in different locations) or congruent (i.e., co-mimics show distinct associations with environment). We suggest that large-scale analyses are important for identifying how environmental factors shape broad mimetic phenotypic distributions, but that local studies are essential to understand the context-dependent biotic, abiotic, and historical mechanisms driving finer-scale phenotypic transitions.

Disruption of the odorant coreceptor Orco impairs foraging and host finding behaviors in the New World screwworm fly.

The evolution of obligate ectoparasitism in blowflies (Diptera: Calliphoridae) has intrigued scientists for over a century, and surprisingly, the genetics underlying this lifestyle remain largely unknown. Blowflies use odors to locate food and oviposition sites; therefore, olfaction might have played a central role in niche specialization within the group. In insects, the coreceptor Orco is a required partner for all odorant receptors (ORs), a major gene family involved in olfactory-evoked behaviors. Hence, we characterized the Orco gene in the New World screwworm, Cochliomyia hominivorax, a blowfly that is an obligate ectoparasite of warm-blooded animals. In contrast, most of the closely related blowflies are scavengers that lay their eggs on dead animals. We show that the screwworm Orco orthologue (ChomOrco) is highly conserved within Diptera, showing signals of strong purifying selection. Expression of ChomOrco is broadly detectable in chemosensory appendages, and is related to morphological, developmental, and behavioral aspects of the screwworm biology. We used CRISPR/Cas9 to disrupt ChomOrco and evaluate the consequences of losing the OR function on screwworm behavior. In two-choice assays, Orco mutants displayed an impaired response to floral-like and animal host-associated odors, suggesting that OR-mediated olfaction is involved in foraging and host-seeking behaviors in C. hominivorax. These results broaden our understanding of the chemoreception basis of niche occupancy by blowflies.

High-risk Meningioma: Initial Outcomes From NRG Oncology/RTOG 0539.

BACKGROUND: Phase 2 cooperative group meningioma trial assessing the safety and efficacy of risk-adaptive management strategies. This is the initial analysis of the high-risk cohort. METHODS AND MATERIALS: High-risk patients were those with a new or recurrent World Health Organization (WHO) grade III meningioma of any resection extent, recurrent WHO grade II of any resection extent, or new WHO grade II after subtotal resection. Patients received intensity-modulated radiotherapy (IMRT) using a simultaneous integrated boost technique (60 Gy high dose and 54 Gy low dose in 30 fractions). Three-year progression-free survival (PFS) was the primary endpoint. Adverse events (AEs) were scored per NCI Common Terminology Criteria for Adverse Events version 3. RESULTS: Of 57 enrolled patients, 53 received protocol treatment. Median follow-up was 4.0 years (4.8 years for living patients). Two patients withdrew without progression before year 3; for the remaining 51 patients, 3-year PFS was 58.8%. Among all 53 protocol-treated patients, 3-year PFS was 59.2%. Three-year local control was 68.9%, and overall survival was 78.6%. Of 51 patients, 1 patient (1.9%) experienced a late grade-5 necrosis-related AE. All other acute (23 of 53 patients) and late (21 of 51 patients) AEs were grades 1 to 3. CONCLUSIONS: Patients with high-risk meningioma treated with IMRT (60 Gy/30) experienced 3-year PFS of 58.8%. Combined acute and late AEs were limited to grades 1 to 3, except for a single necrosis-related grade 5 event. These results support postoperative IMRT for high-risk meningioma and invite ongoing investigations to improve outcomes further.

Discovering Pathologies in the Anatomy Lab: The Case of Brachial Plexopathy Mimicking Neurological Thoracic Outlet Syndrome.

CONTEXT: Well-established human anatomy labs with access to expert faculty are exceedingly valuable tools to medical student education. In this manuscript, we detail an infero-lateral subclavicular lipoma which was discovered as a result of the utilization of both those labs and expert faculty. This lipoma may have caused brachial plexopathy or may serve as an unusual cause of neurologic thoracic outlet syndrome (NTOS) due to the location of the mass. EDUCATIONAL CASE PRESENTATION: During prosection of a donor in the human anatomy lab, a mass was discovered by a medical student. This medical student utilized the human anatomy lab faculty members and resources to identify the mass as a lipoma. The lipoma compressed the lateral cord of the brachial plexus and the suprascapular nerve, but no diagnosis of NTOS or brachial plexopathy was made during the life of the donor, nor was any surgical intervention indicated. Removal of the lipoma immediately relieved stress upon the nerves. Histochemical analysis confirmed the diagnosis of a lipoma and demonstrated almost only mature adipocytes. CONCLUSION: The authors concluded that the lipoma of this patient was not identifiable with computerized tomography imaging modalities, despite ultrasound demonstrating a hyperechoic outline of the mass in the cadaver of the patient. It is very likely that this lipoma had not been diagnosed previously due to the atypical location of the tumor. Equally, typical surgical methods associated with brachial plexopathy or NTOS treatment would be difficult or more complicated, due to the lateral and inferior location of the lipoma. Physicians treating thoracic outlet syndrome-type symptoms without resolution should consider potential non-malignant obstruction located outside the thoracic outlet, toward the extremity. Deep palpatory methods and physical therapy should be considered until diagnosis is certain, as ultrasound would be difficult and typical transaxillary surgical methods would be nonhelpful. Medical students and early-career residents and physicians should be aware of the resources provided to them via campus human anatomy laboratories which they may utilize to further their understanding and knowledge of specific pathologies.

The evolution of microendemism in a reef fish (Hypoplectrus maya).

Marine species tend to have extensive distributions, which are commonly attributed to the dispersal potential provided by planktonic larvae and the rarity of absolute barriers to dispersal in the ocean. Under this paradigm, the occurrence of marine microendemism without geographic isolation in species with planktonic larvae poses a dilemma. The recently described Maya hamlet (Hypoplectrus maya, Serranidae) is exactly such a case, being endemic to a 50-km segment of the Mesoamerican Barrier Reef System (MBRS). We use whole-genome analysis to infer the demographic history of the Maya hamlet and contrast it with the sympatric and pan-Caribbean black (H. nigricans), barred (H. puella) and butter (H. unicolor) hamlets, as well as the allopatric but phenotypically similar blue hamlet (H. gemma). We show that H. maya is indeed a distinct evolutionary lineage, with genomic signatures of inbreeding and a unique demographic history of continuous decrease in effective population size since it diverged from congeners just ~3,000 generations ago. We suggest that this case of microendemism may be driven by the combination of a narrow ecological niche and restrictive oceanographic conditions in the southern MBRS, which is consistent with the occurrence of an unusually high number of marine microendemics in this region. The restricted distribution of the Maya hamlet, its decline in both census and effective population sizes, and the degradation of its habitat place it at risk of extinction. We conclude that the evolution of marine microendemism can be a fast and dynamic process, with extinction possibly occurring before speciation is complete.

Facultative pupal mating in Heliconius erato: Implications for mate choice, female preference, and speciation.

Mating systems have broad impacts on how sexual selection and mate choice operate within a species, but studies of mating behavior in the laboratory may not reflect how these processes occur in the wild. Here, we examined the mating behavior of the neotropical butterfly Heliconius erato in the field by releasing larvae and virgin females and observing how they mated. H. erato is considered a pupal-mating species (i.e., males mate with females as they emerge from the pupal case). However, we observed only two teneral mating events, and experimentally released virgins were almost all mated upon recapture. Our study confirms the presence of some pupal-mating behavior in H. erato, but suggests that adult mating is likely the prevalent mating strategy in this species. These findings have important implications for the role of color pattern and female mate choice in the generation of reproductive isolation in this diverse genus.

Comparative Genomics Reveals Accelerated Evolution in Conserved Pathways during the Diversification of Anole Lizards.

Squamates include all lizards and snakes, and display some of the most diverse and extreme morphological adaptations among vertebrates. However, compared with birds and mammals, relatively few resources exist for comparative genomic analyses of squamates, hampering efforts to understand the molecular bases of phenotypic diversification in such a speciose clade. In particular, the ∼400 species of anole lizard represent an extensive squamate radiation. Here, we sequence and assemble the draft genomes of three anole species-Anolis frenatus, Anolis auratus, and Anolis apletophallus-for comparison with the available reference genome of Anolis carolinensis. Comparative analyses reveal a rapid background rate of molecular evolution consistent with a model of punctuated equilibrium, and strong purifying selection on functional genomic elements in anoles. We find evidence for accelerated evolution in genes involved in behavior, sensory perception, and reproduction, as well as in genes regulating limb bud development and hindlimb specification. Morphometric analyses of anole fore and hindlimbs corroborated these findings. We detect signatures of positive selection across several genes related to the development and regulation of the forebrain, hormones, and the iguanian lizard dewlap, suggesting molecular changes underlying behavioral adaptations known to reinforce species boundaries were a key component in the diversification of anole lizards.

Evolution of novel mimicry rings facilitated by adaptive introgression in tropical butterflies.

Understanding the genetic basis of phenotypic variation and the mechanisms involved in the evolution of adaptive novelty, especially in adaptive radiations, is a major goal in evolutionary biology. Here, we used whole-genome sequence data to investigate the origin of the yellow hindwing bar in the Heliconius cydno radiation. We found modular variation associated with hindwing phenotype in two narrow noncoding regions upstream and downstream of the cortex gene, which was recently identified as a pigmentation pattern controller in multiple species of Heliconius. Genetic variation at each of these modules suggests an independent control of the dorsal and ventral hindwing patterning, with the upstream module associated with the ventral phenotype and the downstream module with the dorsal one. Furthermore, we detected introgression between H. cydno and its closely related species Heliconius melpomene in these modules, likely allowing both species to participate in novel mimicry rings. In sum, our findings support the role of regulatory modularity coupled with adaptive introgression as an elegant mechanism by which novel phenotypic combinations can evolve and fuel an adaptive radiation.

Dual-modality optical biopsy of glioblastomas multiforme with diffuse reflectance and fluorescence: ex vivo retrieval of optical properties.

Glioma itself accounts for 80% of all malignant primary brain tumors, and glioblastoma multiforme (GBM) accounts for 55% of such tumors. Diffuse reflectance and fluorescence spectroscopy have the potential to discriminate healthy tissues from abnormal tissues and therefore are promising noninvasive methods for improving the accuracy of brain tissue resection. Optical properties were retrieved using an experimentally evaluated inverse solution. On average, the scattering coefficient is 2.4 times higher in GBM than in low grade glioma (LGG), and the absorption coefficient is 48% higher. In addition, the ratio of fluorescence to diffuse reflectance at the emission peak of 460 nm is 2.6 times higher for LGG while reflectance at 650 nm is 2.7 times higher for GBM. The results reported also show that the combination of diffuse reflectance and fluorescence spectroscopy could achieve sensitivity of 100% and specificity of 90% in discriminating GBM from LGG during ex vivo measurements of 22 sites from seven glioma specimens. Therefore, the current technique might be a promising tool for aiding neurosurgeons in determining the extent of surgical resection of glioma and, thus, improving intraoperative tumor identification for guiding surgical intervention.

Pathology concordance levels for meningioma classification and grading in NRG Oncology RTOG Trial 0539.

BACKGROUND: With advances in the understanding of histopathology on outcome, accurate meningioma grading becomes critical and drives treatment selection. The 2000 and 2007 WHO schema greatly increased the proportion of grade II meningiomas. Although associations with progression-free survival (PFS) and overall survival (OS) have been independently validated, interobserver concordance has not been formally assessed. METHODS: Once mature, NRG Oncology RTOG-0539 will report PFS and OS in variably treated low-, intermediate-, and high-risk cohorts. We address concordance of histopathologic assessment between enrolling institutions and central review, performed by a single pathologist (AP), who is also involved in developing current WHO criteria. RESULTS: The trial included 170 evaluable patients, 2 of whom had 2 eligible pathology reviews from different surgeries, resulting in 172 cases for analysis. Upon central review, 76 cases were categorized as WHO grade I, 71 as grade II, and 25 as grade III. Concordance for tumor grade was 87.2%. Among patients with WHO grades I, II, and III meningioma, respective concordance rates were 93.0%, 87.8%, and 93.6% (P values < .0001). Moderate to substantial agreement was encountered for individual grading criteria and were highest for brain invasion, ≥20 mitoses/10 high-powered field [HPF], and spontaneous necrosis, and lowest for small cells, sheeting, and ≥4 mitoses/10 HPF. In comparison, published concordance for gliomas in clinical trials have ranged from 8%-74%. CONCLUSION: Our data suggest that current meningioma classification and grading are at least as objective and reproducible as for gliomas. Nevertheless, reproducibility remains suboptimal. Further improvements may be anticipated with education and clarification of subjective criteria, although development of biomarkers may be the most promising strategy.

Results of a prospective multicenter trial of CTAG thoracic endograft.

OBJECTIVE: As thoracic aortic aneurysms (TAAs) are more frequently being treated with endografts, the anatomic challenges of the thoracic aorta have led to design modifications of endografts. The Conformable GORE TAG (CTAG) device (W. L. Gore & Associates, Flagstaff, Ariz) was specifically designed to be more conformable in tortuous anatomy, more resistant to compression, and more accommodating to various aortic diameters compared with the original GORE TAG device. This prospective, multicenter study evaluated the safety and effectiveness of the CTAG endograft in the repair of descending TAA. METHODS: This was a prospective, multicenter regulatory study with a primary end point of freedom from major device event through 1 month after treatment. Two-year outcomes included aneurysm-related morbidity (endoleaks and morphology changes), aneurysm-related mortality, and all-cause mortality. RESULTS: Fifty-one patients were enrolled between October 2009 and October 2010, with at least one endograft implanted in 50 patients. After the regulatory study successfully completed its primary end point and expanded to a continued-access phase, 15 additional patients were enrolled in the continued-access arm of the study from February 2011 until September 2011, for a total treatment group of 66 patients for the early results and 65 patients for the long-term clinical results with imaging evaluation. There was one 30-day death (1.5%), two patients (3%) with spinal cord ischemia, and two central strokes (3%) ≤30 days. Five patients (7.6%) died ≤1 year; 1 of ascending aortic aneurysm rupture, 2 of cardiac disease, and 2 of respiratory failure. The core laboratory adjudicated 1-month imaging in 60 patients (92.3%), where nine endoleaks (15.0%) were identified (1 type Ia, 4 type II, and 4 indeterminate). Forty-five patients (69.2%) had 2-year imaging with five endoleaks (11.1%; two type II and three indeterminate), and one patient had a distal aortic dilatation that required a secondary intervention. At 2 years, 20 of 38 imaged patients (52.6%) had aneurysm shrinkage ≥5 mm, 15 (39.5%) had no change in diameter, and three patients (7.9%) had an increase in aneurysm diameter of ≥5 mm. There were no conversions, fractures, compressions, or aneurysm ruptures of the treated segment through 2 years. CONCLUSIONS: This next-generation thoracic endograft has a low rate of major device events through 2 years, with no graft compressions or device failures. The data for this new endograft demonstrate favorable outcomes and confirm low risks for treatment for patients with TAA. Follow-up will be continued for 5 years.

Comparative genetic structure of two mangrove species in Caribbean and Pacific estuaries of Panama.

BACKGROUND: Mangroves are ecologically important and highly threatened forest communities. Observational and genetic evidence has confirmed the long distance dispersal capacity of water-dispersed mangrove seeds, but less is known about the relative importance of pollen vs. seed gene flow in connecting populations. We analyzed 980 Avicennia germinans for 11 microsatellite loci and 940 Rhizophora mangle for six microsatellite loci and subsampled two non-coding cpDNA regions in order to understand population structure, and gene flow within and among four major estuaries on the Caribbean and Pacific coasts of Panama. RESULTS: Both species showed similar rates of outcrossing (t= 0.7 in A. germinans and 0.8 in R. mangle) and strong patterns of spatial genetic structure within estuaries, although A. germinans had greater genetic structure in nuclear and cpDNA markers (7 demes > 4 demes and Sp= 0.02 > 0.002), and much greater cpDNA diversity (H(d)= 0.8 > 0.2) than R. mangle. The Central American Isthmus serves as an exceptionally strong barrier to gene flow, with high levels nuclear (F(ST)= 0.3-0.5) and plastid (F(ST)= 0.5-0.8) genetic differentiation observed within each species between coasts and no shared cpDNA haplotypes between species on each coast. Finally, evidence of low ratios of pollen to seed dispersal (r = -0.6 in A. germinans and 7.7 in R. mangle), coupled with the strong observed structure in nuclear and plastid DNA among most estuaries, suggests low levels of gene flow in these mangrove species. CONCLUSIONS: We conclude that gene dispersal in mangroves is usually limited within estuaries and that coastal geomorphology and rare long distance dispersal events could also influence levels of structure.

Bovine pericardial patch repair in infected fields.

OBJECTIVE: Bovine pericardial patches (BPP) are frequently used for arterial reconstruction, but little data exist regarding their ability to resist infection. We hypothesize that BPP would provide a reasonable alternative to autologous vein patches in infected fields. METHODS: We used BPP to repair 51 arteriotomies (25 brachial, 23 femoral, three popliteal) in 48 consecutive patients (mean age, 68 years; 65% men, 75% diabetic, 67% dialysis dependent) undergoing removal of infected (33 gram-positive, three gram-negative, eight mixed flora, and four culture-negative) polytetrafluoroethylene grafts (35 arteriovenous grafts, nine femoral-distal bypasses, and four femoral patch angioplasties) between January 2007 and January 2011. Patient records were retrospectively reviewed and outcomes, including death, rupture, secondary reconstruction, and infection, were recorded. RESULTS: Over a mean follow-up of 2.1 years (range, 3-48 months), 50 of 51 patches remained in place without evidence of recurrent infection, rupture, or revision. One patient had acute rupture of a popliteal arteriotomy 1 week postrepair and had subsequent ligation and above-knee amputation. Eight of the 48 patients died from unrelated causes during follow-up (three withdrew from dialysis, three myocardial infarction, and two unknown). CONCLUSIONS: BPP provide a durable alternative to saphenous vein for arterial reconstruction following removal of infected arterial grafts.

Cerebral hemorrhage due to internal jugular vein stenosis in a hemodialysis patient.

A 53 year old female with ESRD on hemodialysis presented with headache, vomiting, and lethargy that had started 2 h prior to presentation. Magnetic resonance imaging revealed parenchymal hemorrhage in the temporal, occipital, and cerebellar white matter. Magnetic resonance venography disclosed hypoplastic transverse sinus. On cerebral angiogram there was no evidence of cerebral aneurysm, vasculitis or vascular malformation. Angiogram demonstrated a high-grade stenosis was present in the left internal jugular vein (IJV) just below the anastomosis of the graft. There was retrograde high flow in the left IJV above the anastomosis of the graft, which fills a small left transverse venous sinus. There was also filling of the multiple abnormally enlarged leptomeningeal veins over the surface of the left cerebral and left cerebellar hemispheres. Retrograde blood flow was due to IJV stenosis which led to cerebral venous hypertension and intraparenchymal brain hemorrhage. She then underwent occlusion of her left brachiojugular dialysis graft. Thereafter, her mental status markedly improved and her headache resolved. Since IJV stenosis and hypoplastic transverse sinuses are not rare, patients with jugular grafts should probably be closely watched for symptoms of increased intracranial pressure. As awareness of vein preservation in CKD patients grows, the prevalence of CVS would probably decline in future.

Quality assurance parameters and predictors of outcome for ilioinguinal and inguinal dissection in a contemporary melanoma patient population.

BACKGROUND: Regional lymph node dissection (RLND) is currently the most effective therapy for metastatic melanoma in groin lymph nodes. With thorough surgery, RLND lymph node (LN) retrieval numbers have a predictable distribution. Whether patients have inguinal or ilioinguinal dissection varies between institutions. This study was designed to provide LN retrieval parameters for inguinal and ilioinguinal LN dissections, and secondarily, to analyze known predictors for survival outcomes, including LN ratio, i.e., involved/total number LN removed. METHODS: A prospective database was used to identify 189 patients who had 200 groin dissections between July 2002 and February 2008 to derive parameters of LN retrieval. A subgroup of 177 patients who had one RLND was assessed for predictors of survival outcome. RESULTS: Inguinal dissection had median LN retrieval of 11 (interquartile range, 10-14); 8 LN or more were retrieved in 90% of cases, and 38% of cases had 10 LN or less. Ilioinguinal dissection had median LN retrieval of 21.5 (interquartile range, 17-25); 14 LN or more were retrieved in 90% of cases, and 0 cases had 10 LN or less. The strongest predictors of survival on multivariate analysis were LN ratio, macroscopic LN disease, and ulceration of the primary melanoma. Overall 39% of ilioinguinal dissections had positive pelvic LNs, but only 9.3% of those completed after positive sentinel node biopsy. CONCLUSIONS: Thorough groin RLNDs have a predictable LN yield. LN ratio is the strongest predictor of outcome. Because pelvic LNs are frequently positive ilioinguinal dissection should be considered for all patients, especially those with macroscopic metastases to groin LNs.

Drug-eluting tibial stents: objective patency determination.

PURPOSE: Endovascular management of limb-threatening ischemia often requires treatment of tibial occlusive disease. This study was preformed to examine the patency of drug-eluting tibial stents. MATERIALS AND METHODS: The medical records of all patients undergoing drug-eluting tibial stent placement for limb-threatening ischemia from June 2004 to June 2008 were retrospectively reviewed. Postprocedural antiplatelet therapy included clopidogrel and aspirin. Patients were followed with serial arterial duplex ultrasonography and had selective subsequent angiographic evaluation based on noninvasive findings. Primary patency of the target lesion, limb salvage, and survival rates were reported. RESULTS: A total of 240 patients underwent 283 tibial angioplasty procedures to treat limb-threatening ischemia during the 4-year period. Fifty-two patients (22%) had a suboptimal balloon result and were treated with a drug-eluting tibial stent. Balloon-expandable paclitaxel-eluting stents were used in all patients (1.2 stents per patient; range, 1-3; median diameter, 2.75 mm; range, 2.5-3.5 mm; median length, 24 mm; range, 20-32 mm). Forty-eight of those 52 patients (92%) had simultaneous endovascular treatment of proximal lesions. Mean follow-up was 14.3 months (range, 1-48 months). Target lesion patency of the drug-eluting tibial stent was 73% at 24 months (SE < 10%). Limb salvage rate in patients treated with drug-eluting tibial stents was 86% at 26 months (SE < 10%), and the survival rate was 65% at 24 months (SE < 10%). CONCLUSIONS: Drug-eluting tibial stents are a viable option for the endovascular management of limb-threatening ischemia and have acceptable patency rates. The majority of patients require multilevel endovascular treatment, and close surveillance is required for limb salvage.