Occlusion of a saphenous vein graft aneurysm with a vein-covered stent

A 67-year-old man was admitted with unstable angina, 15 years after saphenous vein graft bypass surgery. Cardiac catheterization demonstrated a large saccular aneurysm arising from the proximal segment of the vein graft to the obtuse marginal artery. Intravascular ultrasound revealed the opening of the aneurysm that measured 15 mm in length. The aneurysm was successfully occluded by deployment of a vein-covered stent.     

Intracisternal sodium nitroprusside fails to prevent vasospasm in nonhuman primates

OBJECTIVE: Hemoglobin contributes to vasospasm after subarachnoid hemorrhage. One mechanism may involve binding of nitric oxide, destruction of nitric oxide, or both. Support for this mechanism would be evidence that nitric oxide donors prevent vasospasm. This study attempted to provide such evidence. METHODS: A randomized, blinded study was conducted in which 13 monkeys underwent cerebral angiography and creation of a right subarachnoid hemorrhage. Subcutaneous osmotic pumps were implanted to deliver sodium nitroprusside (n = 7) or vehicle (n = 6) via catheters into the right basal cisterns. Seven days later, angiography was repeated, and the animals were humanely killed. Levels of cyclic nucleotides, hemoglobins, and thiocyanate were measured. RESULTS: Significant vasospasm of the right middle cerebral artery was present in animals treated with sodium nitroprusside (35 +/- 22% reduction in diameter, P < 0.05, paired t test) and placebo (28 +/- 20% reduction, P < 0.05, not significantly different from nitroprusside group by unpaired t test). Adequate delivery of sodium nitroprusside was supported by the finding of a significant increase in cyclic guanosine monophosphate levels in the cerebral arteries of treated animals compared with placebo (P < 0.05, unpaired t test). Thiocyanate was not present in significantly increased amounts in animals treated with nitroprusside, although this group did display elevated concentrations of nitrosyl hemoglobin (measured by electron paramagnetic resonance spectroscopy) and cyanomethemoglobin (measured by spectrophotometry) in the cerebrospinal fluid on Day 7. CONCLUSION: The lack of effect of sodium nitroprusside was not the result of inadequate drug delivery because cyclic guanosine monophosphate levels were significantly increased in vasospastic arteries. Vasospasm may not have been prevented because of a toxic effect of sodium nitroprusside metabolites, involvement of smooth muscle relaxation or contraction processes downstream of cyclic guanosine monophosphate, or both.     

Magnetic source imaging demonstrates altered cortical distribution of function in patients with arteriovenous malformations

OBJECTIVE: Arteriovenous malformations (AVMs) can be treated successfully, but treatment can pose unacceptable risks if the AVM is located in eloquent cortex. Because AVMs are developmental lesions, the location of primary cortical function may be deranged. We used magnetic source imaging (MSI) to identify the central sulcus and to determine whether primary cortical function was shifted in a set of 30 patients. We correlated these findings with outcome after treatment. METHODS: We retrospectively analyzed the clinical data of 30 patients with AVMs who underwent MSI. Nonparametric statistical comparisons were made to correlate the proximity of AVMs to primary cortex and somatosensory shift to outcome at 12 months. RESULTS: Using MSI, 14 patients (47%) were found to have AVMs involving primary cortex, and 10 patients (33%) were found to have shift in the somatosensory homunculus. Primary cortical involvement was neither required nor sufficient to cause shift (Mann-Whitney U test, z = -0.02, P = 0.31). Patients with AVMs involving primary cortex fared worse after treatment than did patients with AVMs that spared primary cortex (Mann-Whitney U test, z = -2.3, P = 0.02). The presence or absence of shift did not correlate with outcome after treatment (Mann-Whitney U test, z = -0.18, P = 0.48). CONCLUSION: MSI showed that some patients with AVMs have abnormal cortical distribution of function. The involvement of primary cortex correlated with worse outcome after treatment. Our results suggest that preoperative functional imaging may help to better estimate treatment risks and ultimately to guide therapeutic planning.     

Retrospective study of the management of chemotherapeutic extravasation injury

Despite the now widespread experience with the administration of chemotherapeutic agents in oncology, extravasation injuries still occur. Furthermore, the most appropriate management of such injuries is not known. The authors examined the current treatment options for extravasation injury and the incidence of this problem. All cases of extravasation referred to the plastic surgery service at one institution from 1994 through 1996 were examined. During a 6-year period there were 44 cases of extravasation injury identified in 42 patients. Comparison with a previous study conducted 15 years before at the same institution revealed a significant reduction in the incidence of extravasation injuries during that time (0.01% vs. 0.1%; = 0.00). The site of extravasation was peripheral in 32 cases and central in 12. Paclitaxel and doxorubicin were the two most common drugs involved. The local infusion of antidotes was not performed routinely. Only 26 of the 42 patients were referred to the plastic surgery service for care. Only 10 of those 26 patients required local ulcer excision and closure to achieve a healed wound. The mean time between injury and referral was 40 days. This time did not predict the subsequent need for a surgical procedure. Most patients, including the remaining 16 referred to the plastic surgery service, did not require surgical intervention. All were watched expectantly, and their injuries healed spontaneously. In conclusion, the incidence of extravasation is decreasing, most likely as a result of the diligence in the administration and identification of extravasation injuries as well as the result of the use of more central infusion sites. Most cases can be managed conservatively, with directed surgical treatment of the ulceration when appropriate.     

Chronic evaluation of the Cleveland Clinic CorAide left ventricular assist system in calves

The Cleveland Clinic CorAide left ventricular assist system is based on a third-generation, implantable, centrifugal pump in which a rotating assembly is suspended fully. To evaluate chronic in vivo system performance and biocompatibility, the CorAide blood pump was implanted in 18 calves for either 1 month or 3 months. Hemodynamics were stable in all calves with a mean pump flow of 5.9 +/- 1.2 L/min and a mean systemic arterial pressure of 98 +/- 5 mm Hg. There were no incidences of bleeding, organ dysfunction, or mechanical failure in any of the 18 calves. Hemolysis occurred in only 1 calf due to outflow graft stenosis. Thrombus inside the pump, seen in 4 of the first 6 cases, was totally eliminated by a final redesign in the remaining cases, including the last 6 implants conducted without anticoagulation therapy. The CorAide blood pump demonstrated good biocompatibility and reliable, effective system performance.     

Isolated Horner syndrome and syrinx of the cervical spinal cord

PURPOSE: To alert ophthalmologists to the possibility of a spinal cord lesion in individuals with Horner syndrome and no neurologic symptoms. DESIGN: Observational case report. METHODS: Neuro-ophthalmic and neuroimaging assessment of a 16-year-old man with an isolated Horner syndrome localizing to a first- or second-order neuron. RESULTS: With magnetic resonance imaging, a syrinx of the cervical spinal cord extending from C5 to C7 was found. No Chiari malformation was present. CONCLUSION: Patients with an isolated Horner syndrome localizing to a first- or second-order sympathetic neuron should undergo magnetic resonance imaging of the head, neck, spinal cord, and chest to investigate for possible origins. An isolated Horner syndrome may be the presenting manifestation of a cervical syrinx.     

Cutting out the middleman: physicians can contract directly with employers--a viable alternative to adversarial managed care agreements

HMOs, PPOs, and other managed care "middlemen" control the means by which most physicians do business with employers. As physicians face dwindling reimbursements, greater practice restrictions, and increased pressure to sign adversarial middleman contracts, interest in direct contracting has grown. This article introduces direct contracting as an important alternative to commercial managed care agreements; cites the key advantages and process of direct contracting; and offers practical recommendations for helping physician practices successfully negotiate direct physician/employer agreements.     

Glaucoma patients' assessment of their visual function and quality of life

PURPOSE: To determine how glaucoma and glaucoma suspect patients' rating of their vision correlates with Esterman binocular visual field testing and other visual function tests. METHODS: One hundred ninety-one glaucoma patients and 46 glaucoma suspect patients underwent binocular visual field testing and evaluated their vision using the linear rating scale and time-tradeoff utility tests, the National Eye Institute Visual Functional Questionnaire (NEI VFQ-25), and the Short Form 36 (SF-36) quality-of-life instruments. RESULTS: The mean Esterman score was 88.2 +/- 17.4 for the glaucoma subjects and 95.2 + 6.9 for glaucoma suspect subjects (maximum score 100). On a scale from 0 (blind) to 100 (ideal), the mean rating of vision for glaucoma patients and glaucoma suspect patients was 74.8 +/- 17.3 and 78.9 +/- 18.5, respectively. The Esterman test correlated moderately with the overall NEI VFQ-25 score (partial correlation coefficient (PCC) = 0.32, P = 0.001), but only weakly with the linear rating scale (PCC = 0.17, P = 0.02), and the time-tradeoff (PCC = 0.14, P = 0.06). CONCLUSION: Utility values that glaucoma and glaucoma suspect patients assign to their vision do not correlate well with Esterman results. A challenge for the future is the design of clinical tests of vision that better correlate with patient perceptions.     

Clinical applications of capsular tension rings in cataract surgery

BACKGROUND: Although the open capsular tension ring was designed to manage zonular dialysis during cataract surgery, it also lowers the incidence of capsule contraction, stabilizes the capsular bag, and enhances IOL centration. With appendages, it provides a partial solution for those eyes with colobomata and aniridia. MATERIALS AND TECHNIQUES: Subsequent modifications to the capsular tension ring include the Cionni ring, capsular edge ring, coloboma ring, and aniridia ring. A square-edge design may inhibit posterior capsule opacification, and the aniridia and coloboma rings with appendages create an artificial it is in traumatic or congenital colobomata. RESULTS: Designs, functions, indications, and results of different types of capsular tension rings are reviewed, as well as applications in pediatric cases, and considerations for their routine use in adult cataract surgery. CONCLUSIONS: The potential benefits of capsular edge ring implantation in pediatric cataract surgery cases are explored.     

Regulatory effects of deoxycholic acid, a component of the anti-inflammatory traditional Chinese medicine Niuhuang, on human leukocyte response to chemoattractants

Niuhuang is a commonly used Chinese traditional medicine with immunoregulatory and anti-inflammatory properties. Deoxycholic acid (DCA) is a major active constituent of Niuhuang. The reaction of human leukocytes to chemoattractants is an important part of the host immune response and also plays a crucial role in the development of inflammation. We, therefore, investigated the in vitro effects of DCA on human monocyte and neutrophil responses to classic chemoattractants [fMet-Leu-Phe (fMLP), complement fraction 5a (C5a)], CC chemokine [monocyte chemoattractant protein-1 (MCP-1/CCL2)], and/or CXC chemokines [stromal cell-derived factor-1 (SDF-1alpha/CXCL12), interleukin-8 (IL-8/CXCL8)]. The results showed that DCA significantly inhibited fMLP-induced monocyte and neutrophil chemotaxis and calcium mobilization, and also blocked the binding of [3H]fMLP and anti-formyl peptide receptor (FPR) monoclonal antibodies (mAb) to the cells. The inhibitory effects of DCA on calcium mobilization and anti-FPR-mAb binding to the receptor could be abrogated by washing DCA out of the cell suspension, suggesting that DCA blocked fMLP receptors via a steric hindrance mechanism, not via receptor internalization. DCA had no significant inhibitory effects on MCP-1-, SDF-1alpha-, or C5a-induced monocyte function, or C5a- or IL-8-induced neutrophil function. Taken together, our experimental results suggest that blockade of fMLP receptors may contribute to the anti-inflammatory effects of traditional medicine containing DCA.