Anonymous living liver donation: donor profiles and outcomes.

There are no published series of the assessment process, profiles and outcomes of anonymous, directed or nondirected live liver donation. The outcomes of 29 consecutive potential anonymous liver donors at our center were assessed. We used our standard live liver assessment process, augmented with the following additional acceptance criteria: a logical rationale for donation, a history of social altruism, strong social supports and a willingness to maintain confidentiality of patient information. Seventeen potential donors were rejected and 12 donors were ultimately accepted (six male, six female). All donors were strongly motivated by a desire and sense of responsibility to help others. Four donations were directed toward recipients who undertook media appeals. The donor operations included five left lateral segmentectomies and seven right hepatectomies. The overall donor morbidity was 40% with one patient having a transient Clavien level 3 complication (a pneumothorax). All donors are currently well. None expressed regret about their decision to donate, and all volunteered the opinion that donation had improved their lives. The standard live liver donor assessment process plus our additional requirements appears to provide a robust assessment process for the selection of anonymous live liver donors. Acceptance of anonymous donors enlarges the donor liver pool.

Intraoperative 'no go' donor hepatectomies in living donor liver transplantation.

Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT is employed worldwide, there is little data on rates and causes of 'no go' hepatectomies-patients brought to the operating room for possible donor hepatectomy whose procedure was aborted. We performed a single-center, retrospective review of all patients brought to the operating room for donor hepatectomy between October 2000 and November 2008. Of 257 right lobe donors, the donor operation was aborted in 12 cases (4.7%). The main reasons for stopping the operation were aberrant ductal or vascular anatomy (seven cases), unsuitable liver quality (three cases) or unexpected intraoperative events (two cases). Over the median period of follow-up of 23 months, there were no long-term complications of patients with aborted donor procedures. This report focuses exclusively on an important issue: the frequency and causes of no go decisions at a single large volume North American LDLT center. The rate of no go donor hepatectomies should be as low as possible without compromising donor safety--however, even with rigorous preoperative evaluation the rate of donor abortions will be significant. The default surgical position should always be to abort the donor operation if there is an unexpected finding that places the donor at increased risk.

Adult living liver donors have excellent long-term medical outcomes: the University of Toronto liver transplant experience.

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.

Adult right-lobe living liver donors: quality of life, attitudes and predictors of donor outcomes.

To refine selection criteria for adult living liver donors and improve donor quality of care, risk factors for poor postdonation health-related quality of life (HRQOL) must be identified. This cross-sectional study examined donors who underwent a right hepatectomy at the University of Toronto between 2000 and 2007 (n = 143), and investigated predictors of (1) physical and mental health postdonation, as well as (2) willingness to participate in the donor process again. Participants completed a standardized HRQOL measure (SF-36) and measures of the pre- and postdonation process. Donor scores on the SF-36 physical and mental health indices were equivalent to, or greater than, population norms. Greater predonation concerns, a psychiatric diagnosis and a graduate degree were associated with lower mental health postdonation whereas older donors reported better mental health. The majority of donors (80%) stated they would donate again but those who perceived that their recipient engaged in risky health behaviors were more hesitant. Prospective donors with risk factors for lower postdonation satisfaction and mental health may require more extensive predonation counseling and postdonation psychosocial follow-up. Risk factors identified in this study should be prospectively evaluated in future research.

Association of Ki-ras with amplified DNA sequences, detected in human ovarian carcinomas by a modified in-gel renaturation assay.

A modified in-gel DNA renaturation technique, which detects DNA sequences amplified greater than 7-fold in human DNA, was used to analyze gene amplification in surgical specimens of primary and metastatic ovarian carcinomas. Amplified DNA sequences were detected in two of eight tumors. Hybridization of these samples with different oncogene probes revealed that both tumors contained an amplified Ki-ras gene, which in one case was coamplified with c-myc. In one of the tumors, Ki-ras was found to be amplified in both the primary tumor and three different metastatic nodules. No mutations at codons 12 or 61 of Ki-ras were detected in these tumors. No additional cases of Ki-ras or c-myc amplification were detected by Southern hybridization in the tumors that were found to be amplification negative by modified in-gel renaturation assays. These results indicate that gene amplification in ovarian carcinomas is likely to involve the Ki-ras oncogene.

Aging implications on fresh muscle traits of Certified Angus Beef steaks.

Vacuum-packaged Certified Angus Beef (CAB) subprimals ( = 72) that included the longissimus thoracis (LT), longissimus lumborum (LL), gluteus medius (GM), and infraspinatus (IF) muscles were purchased from a major beef packing facility. Subprimals were allocated to 1 of 3 aging periods (14, 28, or 42 d) and aged at 2°C. After aging, 5 steaks were cut from each subprimal and assigned to pH, water-holding capacity, Warner-Bratzler shear force (WBSF), cooked color, cooking yield, cooking loss, and sensory panel analysis. Infraspinatus steaks were more tender ( < 0.05) than all other steaks, and subprimals aged 14 d had greater ( < 0.05) WBSF values than the other 2 aging periods, regardless of muscle. Water-holding capacity and cook yield were greater ( < 0.05) for LL and LT than IF and GM steaks, whereas purge loss was greater ( < 0.05) for IF and GM than LL and LT steaks. Throughout the aging periods, pH declined for all muscle groups, with IF steaks having the greatest ( < 0.05) pH values among all muscles. Among IF steaks, sensory evaluations of all attributes did not ( ≥ 0.26) differ across aging periods; yet among LT steaks, consumers rated those aged 14 d greater ( < 0.05) in overall impression than LT steaks aged 28 and 42 d. Among LT steaks, those aged 14 d received greater ( < 0.05) flavor ratings than LT steaks subjected to longer aging periods, and LT steaks aged 14 d received the greatest ( < 0.05) overall impression, with consumers giving greater ( < 0.05) overall impression scores to LT steaks aged 42 d over those aged 28 d. Aging period had no effect ( ≥ 0.017) on consumer ratings for flavor, tenderness, juiciness, or overall impression of LL steaks. Among GM steaks, consumers rated steaks aged 14 and 28 d more ( < 0.05) flavorful than those aged 42 d, and consumer ratings for overall impression were greater ( < 0.05) for GM steaks aged 28 d than for GM steaks aged 42 d; however, consumers failed ( = 0.035) to note differences in tenderness scores of GM steaks in response to aging period. Furthermore, consumers indicated a greater ( < 0.05) likelihood to purchase LT steaks aged 14 d over LT steaks aged 28 d, LL steaks aged 42 d over LL steaks aged 14 d, and GM steaks aged 14 and 28 d over GM steaks aged 42 d. These results indicate that consumers struggled to identify steak flavor attributes and suggest that the benefit of aging for premium beef products does not offer a tremendous sensory advantage to the consumer.

The role of surgical debulking in cancer of the uterine cervix.

From 1978 to 1985, 159 women with advanced cervical cancer received definitive radiation therapy following extraperitoneal surgical staging including pelvic lymph node dissection and periaortic lymph node sampling. Relapse-free survival was a strong function of peritoneal and nodal metastases but was independent of clinical stage. The 5-year relapse-free rate fell from 86% in women without pelvic node metastases to 0% in those with unresectable pelvic node metastases. Women with microscopically positive pelvic node metastases had virtually the same (56%) relapse-free rate as those with grossly positive but completely resected metastases (57%). The overall pelvic failure rate was 16.4% and was significantly higher in women with unresectable pelvic node metastases. Periaortic and peritoneal metastases substantially increased the probability of recurrence. Although histologic grade was prognostically significant, histopathologic category was not. Severe enteric morbidity occurred in 3.6% of patients treated solely to the pelvis and in 7.9% of patients treated to the pelvis and periaortics. Therapeutic implications of debulking pelvic node metastases are discussed.

Radical vulvectomy with postoperative irradiation for vulvar cancer: therapeutic implications of a central block.

PURPOSE/OBJECTIVE: To report the long-term results of vulvectomy, node dissection, and postoperative nodal irradiation using a midline vulvar block in patients with node positive vulvar cancer. METHODS AND MATERIALS: From 1971 through 1992, 27 patients with carcinoma of the vulva and histologically involved inguinal lymph nodes were treated postoperatively with radiation therapy after radical vulvectomy and bilateral lymphadenectomy (n = 25), radical vulvectomy and unilateral lymphadenectomy (n = 1), or hemivulvectomy and bilateral lymphadenectomy (n = 1). Federation Internationale de Gynecologic et d'Obstetrique stages were III (n = 14), IVA (n = 8), and IVB (n = 5) squamous cell carcinoma. Inguinal lymph nodes were involved with tumor in all patients (average number positive = 4, range 1-15). Postoperative irradiation was directed at the bilateral groin and pelvic nodes (n = 19), unilateral groin and pelvic nodes (n = 6), or unilateral groin only (n = 1). These 26 patients had the midline blocked. In addition, one patient received irradiation to the entire pelvis and perineum. Doses ranged from 10.8 to 50.7 Gy (median 45.5) with all patients except 1 receiving > or = 42.0 Gy. RESULTS: Actuarial 5-year overall survival and disease-free survival estimates were 40% and 35%, respectively. Recurrences developed in 63% (17/27) of the patients at a median of 9 months from surgery (range 3 months to 6 years) and 15 of these have died; two patients with recurrences are surviving at 24 and 96 months after further surgery and radiation therapy. Central recurrences (under the midline block) were present in 13 of these 17 patients (76%), either as central only (n = 8), central and regional (n = 4), or central and distant (n = 1). Additionally, three patients developed regional recurrences and one patient developed a concurrent regional and distant relapse. One patient developed a squamous cell cancer of the anus under the midline block 54 months after the initial vulvar cancer and an additional patient developed transitional cell carcinoma of the ureter (outside the radiation field) 12 months after diagnosis. Factors associated with a decreased relapse-free survival included increasing Federation Internationale de Gynecologic et d'Obstetrique stage (p = 0.01) and invasion of the tumor into the subcutaneous (SC) fat or deep soft tissue (p = 0.05). Chronic lower extremity edema developed in four patients, but there have been no other complications. CONCLUSIONS: Radical vulvectomy has often been considered sufficient central treatment for vulvar carcinoma, with postoperative irradiation directed only to the nodes. Although designed to protect the radiosensitive vulva, use of a midline block in this series resulted in a 48% (13/27) central recurrence rate, much higher than the 8.5% rate previously reported with this technique. Routine use of the midline block should be abandoned and, instead, postoperative irradiation volumes should be tailored to the individual patient.

Radiation therapy versus pelvic node resection for carcinoma of the vulva with positive groin nodes.

From 1977 to 1984, 114 eligible patients with invasive squamous cell carcinoma of the vulva and positive groin nodes after radical vulvectomy and bilateral groin lymphadenectomy were randomized to receive either radiation therapy or pelvic node resection. Fifty-three of the 59 patients randomized to radiation therapy received a 4500- to 5000-rad tumor dose in five to 6.5 weeks bilaterally to the groins and to the midplane of the pelvis even if only unilateral positive groin nodes had been detected; no radiation was given to the central vulvar area. Fifty-three of the 55 patients randomized to further surgery had pelvic node resection performed on the side containing positive groin nodes either unilaterally or bilaterally. Acute and chronic morbidity was similar for both regimens. The two major poor prognostic factors were clinically suspicious or fixed ulcerated groin nodes and two or more positive groin nodes. The difference in survival for the 114 evaluable patients was significant, favoring the adjunctive radiation therapy group (P = .03). The estimated two-year survival rates were 68% for the radiation therapy group and 54% for pelvic node resection group. The most dramatic survival advantage for radiation therapy was in patients who had either of the two major poor prognostic factors present; at this time, the benefit of radiation therapy for the remaining patients is uncertain. In this randomized prospective study, the addition of adjunctive groin and pelvic irradiation therapy after radical vulvectomy and inguinal lymphadenectomy proved superior to pelvic node resection.

The Brenner tumor: a clinicopathologic review.

The Brenner tumor of the ovary has been the topic of voluminous clinical and pathologic literature since its original description by Macnaughton-Jones in 1898. One of the major problems confronting most investigators of this uncommon neoplasm has been the question of histogenesis. There is general agreement that the tumor is derived from surface (coelomic) epithelium, as are the serous and mucinous cystadenomas. Most Brenner tumors are asymptomatic except for some which have features suggestive of estrogen production. The major pathologic variants are the proliferating and the malignant Brenner tumors; a poor prognosis is associated with the latter neoplasm. Approximately 30% of all benign Brenner tumors have a second histologic type of tumor in the ipsilateral or contralateral ovary, a serous or mucinous cystadenoma in most cases. Brenner tumors have also been reported in the broad ligament and in the testis on rare occasions.

Paraaortic lymph node radiotherapy in cancer of the uterine corpus.

From 1973 through 1982, 48 women received 4500 to 5075 rads to the paraaortic lymph nodes as part of their primary management for cancer of the uterine corpus. One patient developed severe enteric morbidity. Five-year survival rates were 52% in the total group, 57% in clinically staged patients, and 47% in surgically staged patients. Patients with surgically confirmed pelvic lymphatic spread had a five-year survival rate of 67%. Patients with surgically confirmed paraaortic spread alone or pelvic and paraaortic spread had five-year survival rates of 47 and 43%, respectively. Eighty-eight percent of recurrences were outside of the radiation portals. In contradistinction to much of the last decade's literature, radiation therapy has salvaged a substantial fraction of patients with nodal metastases, and morbidity rates have been acceptable.

A new look at measles.

Since the measles vaccine was licensed in the United States in 1963, the number of measles cases has declined by 98%. Nevertheless, measles has not been eliminated as had been hoped, and, in fact, has started to increase in incidence. The increase in the number of cases has been accompanied by a change in measles epidemiology; the highest attack rate now occurs in preschool-age children and in older school-age and college students. The latter is the basis for the adoption of a two-dose measles immunization schedule by the ACIP and AAP. In preschool-age children, however, the problem is more disturbing and reflects low rates of immunization, particularly among inner-city populations. A major public health effort must be directed to achieve and maintain high vaccination rates if measles elimination is to be accomplished. Otherwise, measles outbreaks, with their accompanying morbidity and mortality, will continue to occur.

Hypomyelinated mutant mice IV: peripheral myelin in jp msd.

This study compares peripheral myelination in a specific subdivision of the sciatic nerve of jp msd and unaffected littermate mice. No significant differences are found in numbers of myelinated and unmyelinated axons, diameters of axons, thickness of myelin sheaths relative to axon diameter, extent of unmyelinated axons segregation by Schwann cell processes, or in the ultrastructure of myelin and Schwann cells. By contrast, jp msd mutant mice show severe CNS hypomyelination. This evidence, that the jp msd mutation affects only oligodendrocytes, distinguishes mutations at this locus from others producing CNS hypomyelination in which PNS myelin is also affected.

Hypomyelinated mutant mice: description of jpmsd and comparison with jp and qk on their present genetic backgrounds.

Hypomyelinated mutant mice are valuable natural animal systems for analysis of CNS myelin development, chemistry and diseases. One mutant, jpmsd, has never received thorough morphological description. We here describe the detailed morphology of jpmsd, compare it with well-studied jp and qk on their present genetic backgrounds, and discuss the genetic histories of all 3 mutants. Region for region, jpmsd has twice as much myelin as jp, but 1/2--1/5 as much as qk. Both jp and jpmsd have scarce oligodendrocytes, rare nodes of Ranvier, clustering of myelin segments, abnormal lipid-filled cells, frequent degenerating cells, and rare distorted myelin profiles. In contrast, qk has abnormally numerous oligodendrocytes, frequent nodes of Ranvier, no obvious myelin clustering, no lipid-filled cells, rare degenerating cells, and frequent abnormal or distorted myelin profiles. jp and jpmsd are quantitatively different, but qualitatively similar. Since its origin, the jpmsd disease has inadvertently been ameliorated by transferring the mutation to a different background. Persistent differences in the remainder of the genome might account for all remaining apparent differences between jp and jpmsd. In contrast, qk is totally dissimilar in morphology and presumably in pathophysiology.

Myelination of jp,jpmsd, and qk axons by normal glia in vitro: ultrastructural and autoradiographic evidence.

Normal optic nerve glia were 'injected' into hypomyelinated mutant jp,jpmsd, and qk cerebellum by co-culturing explants in direct physical contact. Quantitative light microscopic studies demonstrated that such glial injection significantly increased the number of myelin profiles counted in cultures, suggesting that axons in all 3 mutants can accept myelination from competent glia when they are made available. In each mutant, the observed increase in myelination was independent of the ages of donor optic nerves and recipient cultures, but absolutely required positioning of the optic nerve so that direct contact occurred with the mutant cerebellar explants. The additional myelin found near the zone of fusion with the optic nerve morphologically resembled normal, not mutant myelin. Autoradiographs made after [3H]thymidine-labeled normal optic nerve was injected into jpmsd cultures showed that labeled cells had colonized the nearby mutant tissue. Labeled cells identified as oligodendrocytes by ultrastructural criteria were found adjacent to myelin segments near the fusion zone, but direct continuity between processes of these oligodendrocytes and myelin sheaths was not demonstrated. The astrocytes and phagocytic cells which were also labeled had no obvious relationship to myelinated axons. These results provide experimental evidence that the primary abnormalities produced by the three mutations jp,jpmsd, and qk are inherent in their glial cells, probably although not definitely in the oligodendrocytes.

Hypomyelinated mutant mice. V. Relationship between jp and jpmsd re-examined on identical genetic backgrounds.

jp and jpmsd, two allelic mutations in the mouse that sharply reduce the amount of CNS myelin, produce diseases that can be distinguished morphologically only by their severity. This has raised the question of whether the two mutations are truly distinguishable. Since the two mutations have never been maintained on the same genetic background, correct quantitative and morphological comparison have not been possible. We have prepared a B6C3H stock of jp on the same genetic background as the available stock of jpmsd. In this jp stock, behavioral abnormalities, relative proportion of myelinated axons, and major morphological characteristics of the disease in situ are unchanged from the previous jp stock. The jp disease continues to be more severe than that of jpmsd. However, tissue from the new B6C3H stock myelinates better in organotypic culture than previous jp stocks. The increase in myelination is advantageous, not only for accurate comparison of the two alleles but for all culture studies of jp. Strictly comparable strains or stocks should be utilized in any comparative studies of closely related mutations such as jp and jpmsd.

Hypomyelinated mutant mice. II. Myelination in vitro.

Organotypic cultures of cerebellum from hypomyelinated mutant mice provide a powerful experimental system for studying the cell biology of the mutant diseases. We have examined the extent to which the culture system reproduces the diseases of three well-known mutants, qk, jpmsd, and jp. Quantitation of myelin profiles per sq. mm of section demonstrates that in vitro, as in situ, qk produces the most myelin jpmsd an intermediate amount, and jp the least. Myelin in qk cultures is unique in being invisible by light microscopy of the living culture. Hypomyelination of jp may be more severe in vitro than in situ. Cultures of jpmsd exhibit many of the ultrastructural features of cerebellar abnormalities that occur in situ: degree of hypomyelination, clustering of myelin segments, scarcity of oligodendrocytes, absence of nodes of Ranvier but presence of heminodes, and apparent structural integrity of the myelin sheaths. Correspondence between in vitro and in situ ultrastructure is more difficult to assess for jp, because the available sample of jp myelin in vitro is too small, and for qk, because the abnormalities observed in situ resemble nonspecific abnormalities of normal myelin in vitro.

Pelvic coccidioidomycosis.

Pelvic inflammatory disease due to Coccidioides immitis is rare. However, female patients with disseminated coccidioidomycosis may have unrecognized pelvic involvement as pelvic examinations are frequently not performed. Inappropriate and inadequate therapy of pelvic coccidioidomycosis may very well contribute to the demise of such patients. The diagnosis must also be suspected in patients with pelvic abscesses which do not respond to antibiotic therapy and conventional surgery. Extirpative surgery, in addition to amphotericin B, is frequently necessary to eradicate the disease. A patient is reported whose course illustrates these conclusions.

Fibromatosis of the female pelvis.

Fibromatosis is a benign, infiltrating, nonmetastasizing neoplasm which is rarely completely resected. Therefore, the incidence of recurrence is high. Fibromatosis is more common in females and is frequently diagnosed during pregnancy. Inasmuch as fibromatosis of the female pelvis appears to be a discrete entity, management poses significant problems for the gynecologist. Radiation therapy, frequently used following incomplete resection or for recurrence, is undesirable due to the loss of ovarian function and fertility. Hormonal manipulation and combination chemotherapy are alternatives which have been effective in some reports. Three patients with pelvic fibromatosis, referred within 1 year, are reported. The various aspects of this neoplasm and the diagnostic procedures are discussed. Treatment modalities whose effects are reversible are recommended for recurrent fibromatosis. Radiation therapy can be reserved for patients in the older age groups or for those with progressive disease not responding to other therapy.

Prediction of malignancy using transvaginal color flow Doppler in patients with gynecologic tumors.

Eighty-five patients referred to the Women's Cancer Center, University of Minnesota had transvaginal color flow Doppler performed to determine if pelvic malignancy could be predicted by blood flow assessment. Their mean age was 49 years (range 21-86 years). Thirty-five patients were subsequently found to have malignant tumors of the cervix, uterus or ovary. The presence of increased intratumoral blood flow as depicted by color flow Doppler had a sensitivity of 83%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 89% for malignancy. The mean intratumoral Pulsatility Index (PI) of the patients with malignant tumors was 0.81 (SD 0.24; range 0.3-1.2), which was significantly lower than for the benign group (P = 0.001). A PI of