Malignant myoepithelioma arising from recurrent pleomorphic adenoma of the soft palate

Malignant myoepithelioma is a rare salivary gland neoplasm that can arise either de novo or within a pre-existing pleomorphic adenoma. We report a case of malignant myoepithelioma arising from a pleomorphic adenoma of the soft palate. A 70-year-old woman presented in our department with a very large tumor of the soft palate. The patient had a history of a pleomorphic adenoma at the same location that was surgically removed 2 years ago. A second operation, with intraoral excision of the tumor was performed. Histological examination of the recurrence revealed a malignant spindle cell neoplasm with an infiltrative growth pattern and a high mitotic rate. Immunohistochemical investigation confirmed the diagnosis of a low-grade carcinoma of myoepithelial origin with free surgical margins. The patient remains free of disease for more than twelve months after the end of treatment.     

Relationship between processes of care and coronary bypass operative mortality and morbidity

BACKGROUND: Information is limited regarding the effects of processes of care on cardiac surgical outcomes. Correspondingly, many recommended cardiac surgical processes of care are derived from animal experiments or clinical judgment. This report from the VA Cooperative Study in Health Services, "Processes, Structures, and Outcomes of Cardiac Surgery," focuses on the relationships between 3 process groups (preoperative evaluation, intraoperative care, and supervision by senior physicians) and a composite outcome, perioperative mortality and morbidity. METHODS: Data on 734 risk, process, and structure variables were collected prospectively on 3,988 patients who underwent coronary artery bypass grafting at 14 VA medical centers between 1992 and 1996. Data reduction was accomplished by examining data completeness and variation across sites and surgeon, using previously published data and clinical judgment. We then applied multivariable logistic regression to the 39 remaining processes of care to determine which were related to the composite outcome after adjusting for 17 patient-related risk factors and controlling for intraoperative complications. RESULTS: Our first analysis showed several measures of operative duration, the use of inotropic agents, transesophageal echo, lowest systemic temperature, and hemoconcentration/ultrafiltration, to be powerful predictors of the composite outcome. Because the use of inotropic agents and operative duration may be related to an intermediate outcome (eg, intraoperative complications), we performed a second analysis omitting these processes. The use of intraoperative transesophageal echo and hemoconcentration/ultrafiltration remained significantly associated with an increased risk of an event (odds ratios 1.60 and 1.36, respectively). CONCLUSIONS: Our results viewed in the context of past studies suggest the possibility that inotropic use, TEE, and hemoconcentration/ultrafiltration may have adverse effects on operative outcome. Further evaluation of these processes of care using observational data, as well as randomized trials when feasible, would be of interest.     

Alternative bi-pectoral muscle flaps for postoperative sternotomy mediastinitis

Suppuration, mediastinitis, and disruption of median sternotomy are all rare, but nevertheless severe complications. We propose a simple mobilization of the two pectoralis major muscles for use as flaps to fill the sternal defect without the need for humeral detachment or a second cutaneous incision. These will be supplied from both the thoracoacromial vessels and the perforating arteries of the nongrafted internal mammary artery (IMA). Our technique is quick and easy, giving excellent results. Furthermore, by maintaining the perforating branches, we also preserve the nongrafted IMA.     

Inequalities in full immunization coverage: trends in low- and middle-income countries

ObjectiveTo investigate disparities in full immunization coverage across and within 86 low- and middle-income countries.MethodsIn May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries.FindingsIn each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations.ConclusionMost low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.