Clinical and economic evaluation of the trellis thrombectomy device for arterial occlusions: preliminary analysis

OBJECTIVES: This preliminary study examined the technical efficacy, safety, and cost of treating arterial occlusions with a single device that combines pharmacologic and mechanical thrombolysis. METHODS: The technical success, bleeding complications, and costs for the first 26 consecutive patients in whom lower extremity ischemia was treated with the Trellis infusion catheter (TIC) were analyzed. Procedure time, thrombolytic infusion time, technical success, bleeding complications (major and intracranial hemorrhage), interventional suite time, and 30-day amputation-free survival were evaluated. RESULTS: 15 of 26 patients (58%) who received treatment with the TIC had acute arterial occlusions, and 11 of 26 patients (42%) had nonacute arterial occlusions. Nineteen of 26 patients (73.1%) received treatment of an infrainguinal occlusion, and 7 of 26 patients (26.9%) received treatment of a suprainguinal occlusion. Lower extremity native arteries were treated in 18 of 26 patients (69%), and lower extremity bypass grafts in 8 of 26 patients (31%). The technical success rate with TIC treatment was 92%, and the 30-day amputation-free survival rate was 96%. There was no difference in technical success or amputation-free survival rate between acute versus nonacute arterial occlusions, native artery versus bypass grafts, and suprainguinal versus infrainguinal arterial occlusions. Procedure time was 2.1 +/- 0.9 hours, and infusion time was 0.3 +/- 0.2 hours. There were no bleeding complications; however, 3 of 26 patients (11.5%) required further intervention to treat distal embolization. The overall mean cost for patients with TIC treatment was $3216 +/- $1740. CONCLUSIONS: Early results of TIC treatment in patients with arterial occlusions suggest that it is as effective as traditional catheter-directed thrombolysis. Furthermore, there were no bleeding complications, likely the result of TIC requiring shorter procedure and infusion times.     

结直肠癌患者血清可溶性CD26增高及其意义

目的评价血清可溶性CD2(6sCD26)对结直肠癌的诊断价值。方法收集我院59例结直肠癌患者、51例结直肠良性疾病患者和41例健康对照患者的血清,采用ELISA法检测血清中sCD26浓度。采用受试者工作曲线(ROC)法评价血清sCD26对结直肠癌的诊断价值,并采用logistic回归分析其对结直肠癌的关系是否独立于癌胚抗原(CEA)。结果结直肠癌患者血清sCD26水平较健康对照组和结直肠良性疾病组患者增高(P<0.01),但sCD26在Dukes不同分期间的差异无统计学意义(P=0.78)。sCD26诊断结直肠癌的曲线下面积为0.72〔95%可信区间(CI)为0.63～0.82,P<0.01〕,最佳诊断界值为526μg/L。sCD26的诊断敏感度和特异度分别为0.59(95%CI为0.48～0.72)和0.80(95%CI为0.67～0.90)。在包含了CEA的logistic回归模型中,sCD26阳性(≥526μg/L)的优势比为5.17(95%CI为1.72～15.53,P<0.01)。DukesA期结直肠癌患者sCD26较CEA具有更高的阳性率(P=0.03),但Dukes B、C和D期结直肠癌患者sCD26的阳性率均低于CEA(P<0.05)。结论sCD26对结直肠癌具有较高且独立于CEA的诊断价值。与CEA相比,sCD26更具有成为结直肠癌早期标志物的潜质。     

Favorable impact of stents after emergent coronary artery bypass for failed angioplasty

BACKGROUND: This study was undertaken to determine the impact of the use and availability of coronary stents on outcomes in patients requiring emergent coronary artery bypass graft (CABG) surgery following a failed percutaneous transluminal coronary angioplasty (PTCA). METHODS: Patients were divided into two groups based on the year of their CABG for a failed PTCA and the availability of stents: group 1, 1992 to 1994, stents not available (n = 34); and group 2, 1995 to 1997, stents available (n = 26). RESULTS: CABG patients in the group where stents were not available were more likely to have had an abrupt coronary occlusion (26 of 34 versus 3 of 26; p < 0.0001) and less likely to have had a dissection (8 of 34 versus 23 of 26; p < 0.0001) as their indication for emergent CABG. Patients in the stent era had a lower incidence of perioperative myocardial infarction (5 of 26 versus 17 of 34; p < 0.01) and a decreased mortality rate (0 of 26 versus 6 of 34; p < 0.03). In the 9 patients where stents were employed, patency of the lumen was restored in 8 patients and there was only 1 myocardial infarction. CONCLUSIONS: Stents have had a favorable impact on patients requiring an emergent CABG following a failed PTCA.     

Appendicitis in patients with previous spinal cord injury

BACKGROUND: Acute abdominal emergencies are particularly dangerous in patients with impaired sensation. METHODS: Thirty patients with spinal cord injury who later developed appendicitis were identified in Department of Veterans Affairs computer files over a 5-year period; 26 were evaluable. RESULTS: The mean age was 55 years (range 27 to 79); all were males. Abdominal distention or discomfort was present in 16 of 26 (62%), while 2 of 26 (8%) presented in shock. A palpable right lower quadrant mass was present in 6 of 26 (23%). The mean initial white blood cell count was 18,000/mm3. Only 9 of 26 (35%) had the diagnosis of appendicitis made on admission. In 12 of 26, computed tomography was done; all correctly diagnosed appendicitis. The mean delay in diagnosis after hospitalization was 2 days (range 0 to 5). Perforated appendicitis was found at surgery in 24 of 26 (92%). Twenty-three of 26 (88%) underwent appendectomy; 3 of 26 (12%) underwent right colectomy. The 30-day mortality rate was 4%. Six of 26 (23%) developed a postoperative complication. The mean length of stay was 16 days. CONCLUSIONS: Acute appendicitis in spinal-cord-injured patients frequently presents late and complications are common. Computed tomography appears to be an excellent diagnostic modality. Some of the adverse outcomes which are related to preexisting spinal cord injury may be preventable with early intervention.     

Thoracoscopic surgery for intractable pneumothorax under epidural and local aesthesia

Thoracoscopic surgery under epidural and local anesthesia for intractable pneumothorax were performed in 26 patients. A total of 29 thoracoscopic operation were performed in 26 patients. Twenty-three patients undervent only a single thoracoscopic operation, and 3 patients underwent twice thoracoscopic operations. We could control the air leak of intractable pneumothorax with the covering of polyglycolic acid sheets using aerosolized fibrin glue in 25 patients. In all patients postoperative course was uneventful and there was no operative death.     

术后早期炎性肠梗阻26例诊治分析

目的分析我院2000年～2006年收治术后早期炎性肠梗阻患者的病例特点,探讨术后早期炎性肠梗阻的诊断及治疗措施。方法回顾性分析26例术后早期炎性肠梗阻患者的临床资料。结果24例病人经保守治疗治愈,其中治愈时间在1周内者6例,1～2周者10例,2～3周者6例,3～4周者2例;平均治愈时间10d;2例行手术治疗,其中1例保守治疗时出现绞窄性肠梗阻,行部分小肠切除术,1例保守治疗4周未缓解,行肠粘连松解术。结论术后早期炎性肠梗阻应以保守治疗为主,重视胃肠外营养及生长抑素的应用。     

Primary follicular lymphoma of the gastrointestinal tract: a clinical and pathologic study of 26 cases.

Although the gastrointestinal tract represents the most common site of extranodal lymphoma, primary follicular lymphoma of the gastrointestinal tract is an uncommon and poorly defined disease. We report the clinical and pathologic features of 26 patients with primary gastrointestinal follicular lymphoma. Ten of 26 patients (38.5%) were stage IIE, and 16 patients (61.5%) were stage IE. Of the 26 patients, 13 were female and 13 were male. The age range was 26-81 years (median 54.5 years). Abdominal pain was the most common presenting symptom, seen in 12 of 24 patients (50%). Nodularity of the mucosal surface was the most common endoscopic finding, seen in 10 of 14 patients (71.4%). The majority of cases (22 of 26, 84.6%) involved small bowel, four involved colorectum alone, and two involved the ileocecal valve. Within the small bowel the duodenum was the most commonly involved site (10 cases). Transmural involvement by follicular lymphoma was identified in 11 of the 16 patients who underwent surgical resection; five showed involvement of mucosa and submucosa only. The most common histologic grade was grade 1. Thirteen of 26 cases were grade 1, ten grade 2, and three grade 3. Twenty-one of 26 cases showed a predominantly follicular growth pattern, four mixed follicular and diffuse, and one predominantly diffuse. All cases were positive for CD20 and BCL2 and negative for CD3, CD5, CD23, CD43, and cyclin D1. Twenty-four of 26 were positive for CD10. Four of four cases showed cytogenetic or molecular genetic evidence of t(14;18). Initial treatment modalities included surgery plus chemotherapy (nine cases), surgery alone (seven cases), chemotherapy alone (four cases), observation alone (four cases), and chemotherapy and abdominal radiation (one case). One case presented with rectal polyps and was treated with polypectomy. A complete response was observed in 15 of 22 cases that received treatment, and of the 15 cases, five recurred 27-60 months after the initial diagnosis. Recurrence and progression were associated with histologic transformation to diffuse large cell lymphoma in one case. No significant correlation was identified between treatment response and various clinical and pathologic features. Overall, none of the 26 patients died of lymphoma. One patient died of a concomitant pancreatic carcinoma. Of the remaining 25 patients, 14 were disease free and 11 were alive with disease at a mean follow-up of 43 months. The estimated 5-year disease-free survival was 62%, and median disease-free survival was 69 months. The estimated 5-year relapse-free survival was 54%, and the median relapse-free survival was 63 months.     

多发伤的漏诊分析

目的分析多发伤患者漏诊的原因并探讨其预防对策,以降低漏诊的发生率。方法对2008年1月～2009年12月本院收治的207例多发伤患者进行回顾性分析,分为漏诊组（26例）和无漏诊组（181例）进行比较。结果 207例患者中有26例漏诊（12.56%）。与无漏诊组比较,漏诊组患者ICU治疗时间、住院时间长、创伤评分（ISS）、死亡率较高（P〈0.05）。造成漏诊的原因以患者意识障碍无法提供病史、医师评估不充分、患者生命体征不稳定无法进一步检查有关。结论对多发伤患者特别应防止发生脊柱、胸腹部等部位重大漏诊,而使患者致残或失去抢救机会。努力避免主观因素,规范、反复的创伤评估,是减少多发伤早期诊断时漏诊的关键。     

Mycophenolate mofetil monotherapy in liver transplantation

Aim

Calcineurin inhibitors (CI) are associated with significant morbidity in transplant recipients. The aim of this study was to evaluate the effectiveness and safety of mycophenolate mofetil (MMF) monotherapy in liver transplantation (LT).

Methods

We analysed 32 patients (24 males, 8 female, of mean age 55.7 years) who underwent LT between 1994 and 2003. In 29 patients immunosuppressive therapy was cyclosporine; in three patients it was tacrolimus. Eleven patients were submitted for LT due to hepatitis B cirrhosis; eight for hepatitis C cirrhosis, six for alcoholic cirrhosis, and seven for other diseases. In these patients, MMF was added gradually, simultaneously reducing the dosage of CI up to complete withdrawal. We considered the efficacy (decrease in serum creatinine) and the incidence of complications (acute and chronic rejection, leukopenia, diarrhea).

Results

Patients were converted to MMF after a median of 50 months after LT. MMF monotherapy was started after a median of 9 months in association with CI. Indications for switch to MMF monotherapy were adverse effects of CI (renal disfunction in 30 patients) and de novo tumoral evidence after LT in two patients. Median dosage of MMF was 750 mg twice daily (500-1500 mg). There was a statistically significant decrease in serum creatinine levels (2.02-1.7 mg/dL; P = .0001). Side effects were: leukopenia in five of 32 patients (15.6%), diarrhea in four of 32 patients (12.5%), and one acute rejection.

Conclusion

MMF monotherapy improved renal function and was not associated with a significant risk of allograft rejection. Side effects were mild with dose regimens up to 750 mg twice daily.     

原发性肝癌合并门静脉高压的外科处理(附26例报告)

目的：评价不同手术方法治疗肝癌合并门静脉高压的效果。方法：回顾性分析肝癌合并门静脉高压同期手术治疗26例患者的临床资料。结果：全组无手术死亡。术后并发症发生率为50%（13/26）。术后1、3、5年存活率为84.6%（22/26）、57.7%（15/26）、34.6%（9/26）。术后随访上消化道出血10例,死亡15例,死亡原因：肝癌复发7例,肝功能衰竭2例,上消化道出血6例。结论：加强围手术期处理、合理选择个体化术式、联合手术对肝癌合并门静脉高压患者是安全、可行的,可以延长此类患者生存期,减少术后并发症。     

A pilot study to investigate the role of the 26S proteasome in radiotherapy resistance and loco-regional recurrence following breast conserving therapy for early breast cancer

Breast conserving therapy is a currently accepted method for managing patients with early stage breast cancer. However, approximately 7% of patients may develop loco-regional tumour recurrence within 5 years. We previously reported that expression of the 26S proteasome may be associated with radio-resistance. Here we aimed to analyse the 26S proteasome in a pilot series of early breast cancers and correlate the findings with loco-regional recurrence. Fourteen patients with early breast cancer who developed loco-regional recurrence within 4 years of completing breast conserving therapy were selected according to strict criteria and compared with those from 14 patients who were disease-free at 10 years. Decreased expression of the 26S proteasome was significantly associated with radio-resistance, manifested as the development of a loco-regional recurrence within 4 years of breast conserving therapy (p = 0.018). This small pilot study provides further suggestion that the 26S proteasome may be associated with response to radiotherapy.     

Preliminary experience with the pulsed dye laser for treatment of urolithiasis

We report our initial experience using the pulsed dye laser in 26 patients with urolithiasis. The patients ranged in age from 27 to 82 years; 11 patients were female and 15 were male. Of the 26 patients, 4 stones were in the kidney, 21 were in the ureter, and one was in the bladder. Surgical time ranged from 32 to 130 minutes. All patients were treated under spinal or general anesthesia. The size of ureteral stones ranged from 0.2 to 1.5 cm, and the renal stones 3.0 to 4.0 cm. Chemical analysis of the stones was not available on all patients, but when available, chemical analysis revealed the stones to be calcium monohydrate, calcium dihydrate, or struvite. The use of the Candela miniscope in 11 patients permitted access without ureteral dilation. In 19 patients, ureteral stents were placed. One patient suffered a ureteral perforation. Success was defined as adequate disintegration of the stone for passage of the fragments without the necessity of a secondary procedure. Using this criterion, 22 of 26 patients were successfully treated for an overall success rate of 85%.     

Complications in orthopedic management of exstrophy

The objective of this study was to examine the complications associated with the orthopedic management of bladder exstrophy. The records of all patients seen for bladder exstrophy repair at the authors' institution between 1988 and 2002 were examined. Orthopedic complications were found to have occurred in 26 of 624 patients, yielding a complication rate of 4%. The observed complications were divided into five categories: bony complications at the osteotomy site, neurologic complications at the osteotomy site, complications of traction, deep infection, and late infections of the plate. Five of the 26 (19.2%) complications were bony and involved non-union, delayed union, joint pain, or leg length inequality stemming from the osteotomy. Thirteen of the 26 (50%) were neurologic complications. Four of the 26 (15.4%) resulted from traction. All were due to tight dressing around the legs following surgery. Two of the 26 (7.7%) were early deep infection and of the 26 (7.7%) were late infections. This study highlights many of the complications associated with the management of exstrophy and provides suggestions on how to minimize them.     

The effect of thoracoscopic sympathectomy on quality of life and symptom management of hyperhidrosis

BACKGROUND: Success with thoracoscopic sympathectomy (TS) for hyperhidrosis is 93% to 100%. We wished to determine if hyperhidrosis patients who do not undergo TS have decreased quality of life (QOL). STUDY DESIGN: Data collection was retrospective, with telephone calls to hyperhidrosis patients who qualified for sympathectomy. Data collection included assessing sweating severity; overall QOL; social, professional, and cosmetic satisfaction; and comfort with daily activities. RESULTS: Between 1998 and 2005, 60 patients met the criteria for sympathectomy. Twenty-two patients who qualified but did not undergo operations (no TS) and 26 TS patients were contacted. Change in symptoms on a 10-point scale for hands was: no TS, -0.30 and TS, -6.25, p < 0.0001, and QOL, on a 1-to-5 scale, increased (no TS, 0.27 and TS, 1.65, p=0.0003). Satisfaction was very good/excellent socially for 9 of 22 no TS patients and 23 of 26 TS patients (p=0.002); professionally for 12 of 22 no TS patients and 23 of 26 TS patients (p=0.021); and cosmetically for 10 of 22 no TS patients and 23 of 26 TS patients (p=0.004). Patients were very satisfied with shaking hands (9 of 22 no TS patients and 24 of 26 TS patients, p=0.0003); writing (9 of 11 no TS patients and 25 of 26 TS patients, p=0.0001); eating (11 of 22 no TS patients and 25 of 25 TS patients, p=0.0008). TS patients had more sweating on the abdomen (no TS patients, 0.0 and TS patients, 1.75, p=0.0001), on the groin (no TS patients, 0.00 and TS patients, 2.9, p=0.0009), and on the back (no TS patients, 0.48 and TS patients, 4.96, p=0.0001). QOL was very good/excellent at followup for 13 of 22 no TS patients and 23 of 26 TS patients (p=0.04). CONCLUSIONS: TS controls palmar hyperhidrosis, and, despite compensatory sweating, patients having the procedure are very satisfied. Patients who did not have surgery have decreased satisfaction, comfort, and QOL, and increased symptoms.     

Clinical significance of carriage of rare variants of connexin-26 genetic polymorphism in gastric cancer

The authors present first results of investigations of the connexin-26 gene in DNA obtained from peripheral blood of 55 patients operated on for gastric cancer. Gastric cancer patients were found to have carriage of the Cx 26 gene that was reliably associated with the invasive ability of the tumor. Change of the connexin-26 gene in gastric cancer is evidence of an important role of intercellular gap junctions in the arising and development of gastric cancer.     

Day surgery dilatation and curettage: patients'' experiences

The purpose of this study was to describe the quality of care received by day case dilatation and curettage (D&C) patients. Data were collected by mailed, self-completed questionnaire administered to consecutive patients undergoing D&C in 35 NHS hospitals. The results from these questionnaires were used to assess satisfaction with the process of care, use of post-discharge services, rate of complications, effectiveness of operation, speed of recovery and overall satisfaction of the patients. The results showed that day case patients were very satisfied with the care they received from doctors and nurses. The majority of day case patients received information before and during their stay. The most common postoperative complication was bleeding, which affected 38% of day cases. We were able to conclude that performing D&C as day surgery is acceptable to patients and day surgery is an appropriate setting for this procedure.     

Tracheal rupture--an anaesthetic mishap?

The insulin response to a 75 g oral glucose load was studied in 26 indian patients with impaired glucose tolerance (IGT) and 26 controls matched for age, sex and weight. There were no significant differences between the mean insulin responses and incremental insulin areas between the patients with IGT and controls. However, when the patients were divided into obese and non-obese subgroups and their mean insulin levels compared, the obese patients with IGT had significantly higher insulin levels at 120 minutes than the obese controls.     

腹腔镜与开放手术治疗肾上腺嗜铬细胞瘤安全性的比较

目的:比较肾上腺嗜铬细胞瘤腹腔镜术与开放手术治疗的安全性,探讨保证和提高腹腔镜手术安全性的方法。方法:使用腹腔镜技术治疗肾上腺嗜铬细胞瘤26例,与同期26例开放手术进行比较。结果:两组手术均获成功,随诊未见复发。结论:有丰富腹腔镜肾上腺瘤的手术经验,在肿瘤体积、手术空间的创建、判断肿瘤的位置、肾上腺血管的处理、暴露和游离肿瘤等几方面遵循一定的原则,选择直径小于3.5 cm的肾上腺嗜铬细胞瘤开展腹腔镜手术的安全性不低于开放手术。     

Comparison of 26- and 27-G needles for spinal anesthesia for ambulatory surgery patients.

Seven hundred thirty ambulatory surgery patients, randomly assigned to receive spinal anesthesia with a 26- or 27-G needle, were studied for the incidence of post-dural puncture headache (PDPH), postoperative back pain, and patient acceptance. The incidence of PDPH following the use of 26- and 27-G needles was 9.6% and 1.5%, respectively (P less than 0.05). The incidence of PDPH was 5.7% among men and 13.4% among women following the use of 26-G needles (P less than 0.05), whereas no difference between men and women was noted after the use of 27-G needles. Of the patients who were 40 yr of age or younger, the overall incidence of PDPH was 11.9%, with a 7.5% incidence among men and a 16.4% among women following the use of 26-G needles (P less than 0.05) and a 1.8% incidence of PDPH following the use of 27-G needles, with no statistical difference between genders. Postoperative back pain was experienced in 18.3% of the patients in the 26-G group and 20.2% in the 27-G group (difference not significant). Favorable acceptance of spinal anesthesia was reported in 89.4% of patients in the 26-G group and 98.2% in the 27-G group (P less than 0.01). Results from this study demonstrate that, in patients who received spinal anesthesia for ambulatory surgery, the use of 27-G needles resulted in a significantly lower incidence of PDPH and greater patient acceptance compared with the use of 26-G needles. The incidence of postoperative back pain was not significantly different between the two groups.     

Combined intraarterial and systemic chemotherapy for intracerebral tumors

Twenty-six patients with intracerebral tumors (predominantly gliomas) were treated with intraarterial BCNU, VM-26, and cisplatin combined with the systemic administration of VM-26, methotrexate, vincristine, bleomycin, and procarbazine. Oral glycerol was given before i.v. VM-26. Twelve patients responded (46% of all patients and 63% of the fully evaluable patients). The response rate for gliomas was 50% if all patients were considered and 71% if only fully evaluable patients were considered. The response rate did not seem to be affected by glioma grade, prior chemotherapy, or pretreatment performance status. Median time to tumor progression for responders was 19 weeks. Median survival from initiation of treatment was 21 weeks for evaluable patients and 17 weeks for all patients. Median survival from initial diagnosis was 55 weeks. Myelosuppression was dose-limiting for the systemic chemotherapy. Reversible neurological toxicity was common, but tolerable. One patient developed ipsilateral blindness, and two patients developed prolonged neurological toxicity. Pulmonary toxicity was also seen. Vertebral artery infusions proved feasible, although difficult and more toxic than carotid infusions. Overall, this regimen was not more active than the intraarterial combination of BCNU, VM-26, and cisplatin without the systemic chemotherapy. Further studies of more intensive intracarotid therapy combined with different systemic drugs are being initiated.