Renal tumors: The good, the bad, and the ugly

Renal cancers comprise a wide variety of neoplasms with quite different genetic and molecular characteristics and clinical behaviors. Several issues of significant note have arisen in association with our increased understanding of these tumors, including questions regarding early diagnosis, the evaluation of cystic lesions, the behavior of tumors occurring in young patients, and insights regarding the prognosis and best follow-up strategies for these tumors.     

Stent-graft design: the good, the bad and the ugly.

10 years of experience with endovascular AAA repair has yielded important information regarding the relationship between stent-graft design and stent-graft performance. Commercially available systems differ in important ways. General conclusions regarding endovascular AAA repair need to be qualified by reference to a specific system, or systems. Nevertheless, one can draw conclusions regarding the observed effects of certain design features, some of which are common to several devices. For example: tapered, trackable delivery systems (< or =20 French in diameter) rarely fail to traverse tortuous iliac arteries: transmural barbs provide the most secure means of proximal attachment, column strength is of little value; proximal stent migration is becoming the primary late failure mode; modular stent-grafts are more versatile than unibody stent-grafts; fully-stented graft limbs are less prone to thrombosis than unstented graft limbs, iliac implantation and low porosity are associated with lower rates of aneurysm dilatation in the absence of endoleak (endotension); any movement between the angle of a stent and the overlying fabric will lead to graft erosion; unpolished (black) Nitinol is prone to fracture; and a long trunk/short limb combination is more stable than a short trunk/long limb combination.     

Closing gastroschisis: The good,the bad,and the not-so ugly

Purpose

The diagnosis of “closing” or “closed gastroschisis” is made when bowel is incarcerated within a closed or nearly closed ring of fascia, usually with associated bowel atresia. It has been described as having a high morbidity and mortality.

Health care trends and vascular specialists: the good, the bad, and the ugly

Current health care trends include movements toward general health care reform and rapidly evolving changes affecting treatment of vascular disease. Government-sponsored programs and private coalitions increasingly influence practice management and patient care. Emerging organizational influences derive from public perceptions, policies, laws, and regulations intended to make health care safe, effective, patient centered, timely, efficient, and equitable. These trends energized methods of quality assessment, cost containment, and practice protocols over individual judgments and seek to exert increasing direction over clinical practice. Some evolving measures are good, some controversial, and some, without deliberate intent, may be harmful. This review considers evolving initiatives in the context of ethics of practice and practicalities of managing patients with vascular disease. Key issues include compliance with purely process-based measures, pay for performance, and assessment of quality outcomes. Strengths, weaknesses, opportunities, and potential threats to vascular practice are outlined.