Continuous insulin infusion is associated with a reduced post-surgical length of stay, but not with the complication rate, in patients with diabetes mellitus undergoing coronary artery bypass graft.

OBJECTIVE: To establish if glucose management with continuous intravenous insulin infusion (CII) in the early post-operative period after coronary artery bypass graft (CABG) surgery is associated with complication rate and length of hospital stay (LOS) in patients with diabetes mellitus (DM). RESEARCH DESIGN AND METHODS: We reviewed the records of 587 patients with DM who underwent CABG from January 1999 until January 2008; 316 patients were placed on CII, while 271 patients were treated with subcutaneous insulin. We examined patient age, glycated hemoglobin (HgbA1c), 24- and 72-h post-operative average capillary blood glucose (CBG), length of stay (LOS), and the rate of complications. RESULTS: There was no difference in HgbA1c between the groups. Mean CBG values at both 24 h and 72 h remained the same in the CII group (167 mg/dl), while in the non-CII group they were 194 mg/dl and 189 mg/dl, respectively (p<0.001 between the groups). Post-surgical median LOS was 6 days in the CII group and 6.5 days in the non-CII group (p=0.003). Complications occurred at similar rate (in 10% and 11% of patients) in the two groups. CONCLUSIONS: CII is associated with a reduced post-surgical LOS in patients with DM who undergo CABG.

[Male infertility: definition and pathophysiology]. / Infertilité masculine: définition et physiopathologie male infertility: definition and pathophysiology.

Male infertility is present in 50% of couple infertility. Diagnosis of infertility requires methodical and rigorous approach based upon knowledge of the pathophysiology and the causes of infertility.

[Male infertility: management strategies]. / Infertilité masculine: stratégie de la prise en charge.

Although the objective of the urologist is to correct the factors of male infertility and to favour natural procreation, the strategy must consider also the couple and the female aspects of infertility. Some types of male infertility require specific treatment. In severe cases, recent advances in medical assistance to procreation have changed the prognosis of male infertility. Pregnancy can be obtained by the means of gamet manipulation and spermatozoid selection. Nevertheless, such techniques expose to genetic disorders transmission. Subsequently, genetic assessment is required during male infertility management, especially for difficult cases.

Experimental Evaluation of Faecal Escherichia coli and Hepatitis E Virus as Biological Indicators of Contacts Between Domestic Pigs and Eurasian Wild Boar.

Domestic pigs and Eurasian wild boar (Sus scrofa) share several important viral and bacterial pathogens. Therefore, direct and indirect contacts between domestic pigs and wild boar present a risk of pathogen spillover and can lead to long-term perpetuation of infection. Biological indicators could be a powerful tool to understand and characterize contacts between wild boar and domestic pigs. Here, faecal Escherichia coli and Hepatitis E virus (HEV) were explored as potential biological indicators under experimental conditions. The data gained in our pilot study suggest that faecal E. coli can be used as biological indicator of contact between wild boar and domestic pig. For HEV, faecal transmission was also confirmed. However, molecular studies on full-genome basis did not reveal markers that would allow tracing of transmission direction. Based on these promising results, future field studies will especially target the practicability of E. coli microbiome molecular typing as surrogate of contacts at the wildlife-livestock interface.

[Assessment of male infertility]. / Infertilité masculine: bilan.

The diagnosis of male infertility requires methodical approach which is primarily clinical, aimed at identifying all potential factors. Biological and radiological assessments allow diagnosis confirmation, and evaluation of both prognosis and therapeutic strategy.

The cost of steroid-free protocols in primary cadaver kidney transplantation.

Steroid-free immunosuppression regimens have been enjoying recent success in clinical transplantation. The use of antibodies required for such protocols can be an economic burden. We proposed to study their cost in our center. This retrospective study involved 147 consecutive patients subjected to 4 protocols of immunosuppression. The first received triple therapy. The second group received induction with basiliximab, whereas the third received Basiliximab plus cyclosporine (CSA) plus mycophenolate mofetil (MMF), and the fourth received Thymoglobulin plus CSA plus MMF in conjuction with only 4 days of steroid. Rejection episodes were treated with Solumedrol. Six-month charges were obtained from computerized records of the finance department, the in-house laboratories, and the transplantation service registry. All charges were expressed in 2004 dollars. Statistical analyses were obtained using chi-square, analysis of variance (ANOVA) and Kaplan-Meier tests. The 4 groups were similar with regard to donor and/or recipient gender, race, panel reactive antibodies, cold ischemia, dialysis requirements length of stay and readmission, graft survival, and function. Charges were significantly higher in the last 2 groups as compared with triple therapy.

[Prevention of female genital mutilation in The Netherlands]. / Preventie van vrouwelijke genitale verminking in Nederland.

Political attention was drawn to the item of female genital mutilation in The Netherlands in 2004. A task force has been installed to investigate the incidence of and evaluate the attitude towards female genital mutilation. The incidence is estimated to be 50 girls a year, especially girls from Africa. The government has decided to draw up rules for physicians and nurses in paediatric public health in order to influence the attitude of women and help them to abandon this tradition.

Gastric antisecretory 9H-xanthen-9-amines.

A series of 9H-xanthen-9-amines possessing a wide variety of nitrogen substituents at C-9 was prepared for evaluation of gastric antisecretory activity. These substituents included the acetamidine, imidate, pyrimidine, thiazoline, quinuclidine, 2-hydrazinopyridine, aminopiperidine, aminoalkylimidazole, and aminoalkylpyridine moieties. The majority of compounds in this series inhibited gastric acid secretion when tested orally in the pylorus-ligated rat. Potency was increased by intraduodenal administration and diminished by incubation with gastric juice, suggesting partial degradation of the compounds in the gastric environment. A representative example, 3-(9H-xanthen-9-ylamino)-1-ethylpiperidine, exhibited similar activity in dogs, although no free compound could be detected in the blood. It is therefore hypothesized that this compound is either rapidly bound to tissue and/or metabolized to an active species.

En bloc transplantation of infant kidneys: ten-year experience.

BACKGROUND: Recent data have shown that en bloc infant kidneys transplanted to adult recipients functioned well. Longterm graft survival and function are not available, however. This study analyzes the 10-year experience with transplantation of en bloc infant kidneys from 1987-1997. STUDY DESIGN: This is a chart review of adult recipients of en bloc infant kidneys with respect to donors' and recipients' age, weight, creatinine, HLA antigen matching, panel reactive antibodies, cold ischemia time, surgical complications, original disease, and longterm graft function and survival. RESULTS: Five en bloc kidneys thrombosed (6.4%). Two ureteral fistulas were repaired successfully. Five patients underwent dialysis (6.4%). Two patients died of infection, six of heart attack and stroke, and one of cancer. All had excellent graft function at patients' death. Renal artery stenosis was dilated in seven patients. Six grafts were lost to rejection (one from noncompliance at 20 months). The original disease recurred in three patients with massive proteinuria despite excellent function. Graft survival at 43 months (range, 6-123 months) was 79%, with serum creatinine levels at 1, 3, 9 and 10 years of 1.2, 1.0, 0.8 and 0.8 mg/dl, respectively. Creatinine clearance averaged 88 mL/min (range, 34-188 mL) and 24-hour proteinuria was 146 mg (normal range, 10-150). CONCLUSIONS: In conclusion, en bloc infant kidneys can be transplanted successfully with excellent longterm function, hyperfiltration injury was not observed, and infant kidneys should be used more frequently.

Rapid capillary gel electrophoresis of proteins.

The rapid separation of sodium dodecyl sulphate-protein complexes according to their molecular masses (M(r)) by capillary gel electrophoresis is described. Using commercial equipment, standard proteins with M(r) in the range 29,000-97,400 were resolved to the baseline in less than 2 min by utilizing a separation distance of 7 cm. A linear relationship between migration time and log M(r) was found and rapid determination of the molecular mass of light and heavy chains of human immunoglobulin G is reported. The results are compared with applications using longer separation distances, showing that rapid and efficient analysis and adequate resolution can be obtained by using short separation distances.

Laser surgery and immunotherapy in the management of laryngeal papilloma.

Twenty-three cases of laryngeal papilloma have been treated and followed for four years utilizing laser excision and laser excision/immunotherapy. Fourteen cases responded well to laser excision alone, nine did not and immunotherapy was instituted as adjunctive treatment. To date, immunotherapy has contributed little to the relief in this group of refractory cases.

Size of pancreatic islets of Langerhans: a key parameter for viability after cryopreservation.

Large amounts and excellent viabilities of pancreatic islets are prerequisites for recent advances in islet transplantation. Cryopreservation has been shown to enlarge transplanted cell mass, but has been accompanied by reduced viability. In this study rat pancreatic islets were differentiated into small (<200 micro m), medium (200-400 micrometers) and large (>400 micrometers) categories and their susceptibilities to different freezing conditions were evaluated: concentration of cryoprotectant (0.7-3.1 M), equilibration (15 vs. 45 min, 22 degrees C vs. on ice) and post-thaw removal of cryoprotectant (15 vs. 30 min, stepwise vs. one-step). The most prominent finding was a negative correlation between islet size and viability observed in non-frozen islets to a minor degree (r=-0.44) and significantly enhanced after cryopreservation (r<-0.8). The concentration of cryoprotectant showed the most significant influence on viability affecting small, medium and large islets. Different techniques of equilibration with the cryoprotectant resulted in significant changes of islet viability of medium islets, whereas small and large islets were unaffected. For different techniques of removal of the cryoprotectant, no significant influence on viabilities was found. We conclude that large islets represented a highly susceptible population concerning damage due to cryopreservation.

Nonreamed nailing of tibial diaphyseal fractures in blunt polytrauma patients.

The efficacy of nonreamed nailing as the treatment of choice of unstable blunt tibial diaphyseal fractures was studied. From March 1, 1990, through August 31, 1991, 72 patients with 74 fractures that required fixation were treated. One patient died and six were lost to follow-up, leaving 65 patients with 67 fractures. Follow-up averaged 21 months (range 5-43). Fisher's exact and logistic regression analyses were used to compare grades of open fractures, comminution as classified by Winquist, and dynamic and static nailings. The failure rates of 51 titanium and 16 stainless steel nails were compared. Times to union were compared by the log rank statistic method. The average time to union was 32 weeks with 26 (39%) additional operations required to achieve union; 13 dynamizations (12 successful), 12 exchange nailings (11 successful), and one plate and bone graft. The rate of reconstructive procedures to achieve union was a more sensitive indicator of difficulties achieving union than was time to union. Reoperation rates were 33% for closed or grade I and II fractures compared with 46% for grade III fractures (NS). Among closed grade I and II static versus dynamic nailing, times to union were 36 versus 25 weeks (p < 0.01), and the reoperation rates were 44% versus 13% (p < 0.04). Winquist I and II fractures required a 24% reoperation rate versus 53% for grade III and IV and segmental fractures (p < 0.01). Static locked fractures required a 48% reoperation rate versus 12% for dynamic locked fractures (p < 0.01). A logistic regression analysis demonstrated that locking mode was the most important factor in determining reoperation rates. Fifteen additional reoperations for infection, broken or painful implants, or to remodel bones that united with an incomplete circumference of cortex were performed. With an additional 12 elective nail removals, the total reoperations numbered 53 (79%). Titanium alloy nails had a 2% failure rate versus 25% for stainless steel nails (p < 0.01). Two of 28 (7%) grade III fractures became infected. All fractures united within 10 degrees of normal alignment and 1 cm of length. Nine (13%) united with an incomplete cortical circumference, refractory to dynamization and full weight bearing. Thirteen of the 58 (22%) fractures available for an evaluation of ankle motion were symptomatic, with < 10 degrees of dorsiflexion.(ABSTRACT TRUNCATED AT 400 WORDS)

Who will lead?

A recent survey conducted by the UCLA Center for Health Services Management and the Physician Executive Practice of Heidrick & Struggles, an executive search firm, sheds light on the emerging physician executive's role. The goal of the research was to identify success factors as a means of evaluating and developing effective industry leaders. Respondents were asked to look at specific skills in relation to nine categories: Communication, leadership, interpersonal skills, self-motivation/management, organizational knowledge, organizational strategy, administrative skills, and thinking. Communication, leadership, and self-motivation/management emerged, in that order, as the three most important success factors for physician executives. An individual's general competencies, work styles, and ability to lead others through organizational restructuring defines his or her appropriateness for managerial positions in the health care industry.

Strategies for achieving sustained competitive advantage.

Sound strategic planning, even in the midst of unprecedented uncertainty and turmoil, is a critical element of every successful health care organization's action plan. The author examines how one organization has responded to the changing demands of the marketplace and a dramatically changed reimbursement system through appropriate strategic planning, selective downsizing on certain fronts and new product development expansion on others. The result is an organization molded to the new environment. It is no longer based on an illness-model hospital but rather focuses on a vertically integrated multi-health cluster intent on capturing market share by providing a single source continuum of health care.

[Conservative surgery and iridium 192 in stage pT2 bladder tumor. A 5-year follow up]. / Chirurgie conservatrice et iridium 192 pour tumeur vésicale de stade pT2. Résultats à 5 ans.

OBJECTIVE: Study of the 5-year oncological results of a series of 24 patients treated by conservative surgery and Iridium 192 for stage pT2 bladder transitional cell carcinoma. MATERIAL AND METHODS: Retrospective study of 24 patients (mean age: 60 years) treated between March 1979 and June 1988, for a solitary bladder tumour, with a diameter less than 5 cm, without lymphadenopathy or detectable metastases at the time of treatment. Treatment successively consisted of TUR of the lesion for histological diagnosis, preoperative pelvic irradiation of 10.5 Gy, lymph node dissection in 3 patients, insertion of brachytherapy tubes at the resection site (5 cases), associated with lumpectomy (9 cases) or partial cystectomy (10 cases). 18 patients underwent a brachytherapy with doses of 45 to 60 Gy, while 6 patients received a half-dose protocol: brachytherapy 30 Gy + postoperative external beam irradiation (20 to 30 Gy to the tumour site, 30 to 40 Gy to pelvic lymph node chains). RESULTS: At 5 years, 2 out of 6 deaths were attributable to bladder cancer. 4 other patients died without recurrence, 4 patients relapsed at the site of brachytherapy and/or away from this site, requiring salvage cystectomy in one patient, and repeated TUR +/- BCG therapy in the other three patients. Overall, 18 out of 24 patients were alive at 5 years, 17 had a functional bladder, and 14 were free of recurrence. CONCLUSION: Conservative surgery associated with Iridium 192 brachytherapy can be an oncologically reasonable alternative to total cystectomy for selected pT2 bladder tumours: unifocal tumours, less than 5 cm in diameter.

[Role of multiarray scanner in the choice of therapeutic strategy in kidney cancer. Report of a case of kidney tumor with double thrombus in inferior vena cava]. / Intérêt du scanner multibarrette dans le choix de la stratégie thérapeutique du cancer du rein. A propos d'un cas de tumeur du rein avec double thrombus de la veine cave inférieure.

Renal cancer with caval thrombus is a disease which requires precise preoperative assessment, in order to adapt the surgical technique to the stage and extent of the disease. Recent developments in CT imaging, spiral acquisition and, more recently, the multiarray technique, allow a high quality evaluation. In the light of a case of right renal tumour with bifocal caval extension, the authors discuss the valuable contribution of this imaging modality in the staging assessment and evaluation of arterial (single or multiple artery, anatomical situation in relation to the left renal vein, presence of early bifurcations, etc.), and venous structures (renal vein, genital vein, extension of the thrombus, lumbar vein and hepatic vein). Improvements in CT imaging constitute a major progress in the staging of renal cancers with caval thrombus and make a considerable contribution to the choice of treatment strategy.

SU-D-213CD-01: 4D Ultrasound Calibration for Radiotherapy Guidance Using Automatic Intramodality Image Registration.

PURPOSE: In prior work we developed a robotic system providing real-time soft-tissue ultrasound (US) volumes during radiotherapy beam delivery. for image guidance, the US volumes must be transformed to the linear accelerator reference frame. In this work we propose and characterize a new method of calibrating 4D US volumes based on automatic intramodality image registration. METHODS: A dynamic navigation link was used to port 3D US volumes from a Philips iU22 xMatrix machine to a PC in real-time. Sixty volumetric (3D) US images of a pelvic phantom were collected from various probe positions while the transducer's pose was monitored by an optical tracking system. US volumes were automatically registered to the first US volume using normalized mutual information. A system of equations was formulated and solved for the US probe-to-image transformation using the registration transformations and the optical tracking information. Accuracy of the US calibration was assessed on eight additional US volumes with two separate methods. In the first method, a set of three fiducial markers implanted in the phantom was manually selected in each volume by three individual readers. Selected marker locations were reconstructed in the stationary camera frame, and for each marker, mean distance to the reconstructed centroid was measured. In the second method, a bladder structure was semi-automatically segmented in each image volume. Mean distance between bladders segmented in a reference volume and the other seven volumes was computed. Calibration accuracy was also investigated as a function of the number of calibration images used. RESULTS: Mean error for the fiducial marker reconstruction was 2.3 mm. Mean distance error between segmented structures was 1.1 mm. The proposed calibration method typically converged with less than 20 images. CONCLUSION: Automatic image registration facilitates fast and simple US spatial calibration with accuracy under 2.3 mm using any US phantom. This work is supported in part by the Stanford University BioX program and by Philips Medical. Two of the authors of the abstract are employed by Philips Medical.