Late complications after femoral artery catheterization in children less than five years of age

Fifty-eight children who underwent diagnostic femoral artery catheterization before 5 years of age, from 5 to 14 years before the study, were randomly selected from approximately 300 surviving patients undergoing diagnostic femoral artery catheterization at our institution during the interval. Each patient underwent vascular laboratory segmental pressure and waveform examination and arterial duplex scanning, as well as lower extremity bone length radiographs, which were considered positive if the catheterized leg was greater than or equal to 1.5 cm shorter than the opposite leg. Thirteen children who had only venous catheterization served as controls. No arterial abnormalities were present in the control patients (mean ankle/brachial index, 1.01). Arterial occlusion was present in both limbs of five patients who had bilateral diagnostic femoral artery catheterization and in 14 limbs of 51 patients who had unilateral diagnostic femoral artery catheterization. Thus arterial occlusion was present in 33% of patients (19 of 58) and in 37% of limbs (24 of 65). The mean ankle/brachial index in the catheterized limbs was 0.79. Leg growth retardation was present in four limbs (8%) of 51 children undergoing unilateral diagnostic femoral artery catheterization and in one (8%) control patient. The inverse relationship between ankle/brachial index and leg growth retardation was significant (R = 0.47, p less than 0.0005). Only one patient had symptoms of arterial occlusion (claudication), and one patient had symptoms of leg growth retardation (gait disturbance). We conclude that arterial occlusion is common after diagnostic femoral artery catheterization in children less than 5 years of age, but that excellent collateral supply prevents leg growth retardation and/or symptomatic arterial insufficiency in most children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Breast‐Specific Gamma Imaging Influences Surgical Management in Patients with Breast Cancer

Breast‐specific gamma imaging (BSGI) is a physiologic breast imaging modality that provides more sensitive detection of breast lesions than mammography or ultrasound, and appears to have greater specificity than breast MRI. The purpose of this study was to evaluate how often BSGI changed surgical management in patients with breast cancer. Charts were reviewed from 218 consecutive eligible patients who had preoperative evaluation with BSGI or MRI before surgery for breast cancer from January 2008 to May 2010. Patients who were initially considered eligible for breast‐conserving therapy (BCT) were evaluated to determine how many ultimately had mastectomies. Patients who underwent mastectomy because of personal choice or ineligibility for BCT were excluded. Management was changed to mastectomy in 11.9% of those who had BSGI and 28.9% of those who had MRI. Review of pathology demonstrated that all patients who underwent mastectomies were not candidates for breast conservation. 15.4% of patients who underwent BCT based on BSGI findings required a single re‐excision due to positive surgical margins. 14.4% required mastectomy. In the MRI group, 18.8% required a single re‐excision, and 6.3% required mastectomy. Evaluation with BSGI changed management to mastectomy in a substantial proportion of patients believed to be eligible for BCT following standard imaging. BSGI is effective in evaluation of extent of disease in patients with breast cancer, and is comparable to MRI in terms of its influence on surgical management.     

Simultaneous operative repair of multilevel lower extremity occlusive disease

Sixty-two patients (39 men (63%), 23 women (27%), mean age 68 years) with multilevel lower extremity arterial occlusive disease underwent simultaneous inflow and outflow operative arterial repair consisting of aortofemoral bypass in 22 (35%), axillofemoral bypass in 17 (28%), femorofemoral bypass in 15 (24%), iliac endarterectomy in 7 (11%), and unilateral aortoiliac bypass in 1 (2%), combined with 69 outflow procedures (unilateral in 55 patients, 89%), including above-knee femoropopliteal in 12 (17%), below-knee femoropopliteal in 35 (51%), femoroinfrapopliteal in 20 (29%), popliteal tibial in 1 (1%), and femoropedal bypass in 1 (1%). Multiple criteria were used to identify patients with multilevel disease likely to benefit from multilevel procedures. The operations were performed by two operating teams in a median time of 240 minutes. Prosthetic grafts were used for eight (13%) distal bypasses, the remainder were autogenous vein. There was one operative death (1.8%). The mortality rate, morbidity rate, and operative time were not significantly different from a group of patients who underwent concurrent, isolated inflow operations (aortofemoral, axillobifemoral, femorofemoral bypass or iliac endarterectomy). Mean follow-up was 14.9 months (range, 0 to 120). The life-table primary patency for the inflow procedures was 92.6% at 24 months, the outflow was 94.9% at 24 months. Cumulative limb salvage was 90.9% at 48-month follow-up. All patients with claudication were relieved of their symptoms. We conclude that complete correction of multilevel disease can be accomplished with operative time, morbidity rate, and patency equal to that of single level repair. Multilevel procedures provide complete relief of symptoms in a higher percentage of patients than has been reported after single level repair.     

Robot-assisted laparoscopic aortobifemoral bypass: initial experience developing a new program

Despite improved technology for endovascular treatment of aorto iliac occlusive disease, aortobifemoral bypass (ABF) continues to offer superior long-term patency. In an effort to reduce the morbidity of surgical ABF, multiple minimally invasive techniques have been reported. The da Vinci robot may facilitate the construction of a minimally invasive aortic anastomosis using standard vascular suture techniques. Our initial experience in the development of a minimally invasive surgical aortic reconstruction program is reported. After extensive time in the laboratory developing our surgical technique in human cadavers and a pig model, our team initiated a robotic vascular surgery program in 2007. A retrospective review of our initial six robot-assisted laparoscopic ABF cases was conducted. The aorta was exposed laparoscopically using the Stadler technique and the aortic anastomosis performed with the da Vinci robot. These results are compared with currently published reports of robotic ABF and alternative methods of minimally invasive aortic reconstruction. From January 2007 to August 2007, six robot-assisted laparoscopic ABFs were performed. Two patients had prior abdominal surgical procedures. Four patients had prior endovascular or surgical aorto iliac reconstruction. Operative time varied from 5 h 26 min to 8 h 12 min. Total clamp time, for the aortic anastomosis, ranged from 70 to 100 min with a mean of 75 min. Estimated blood loss ranged from 300 to 2,000 ml with a mean of 850 ml. Conversion with a short upper midline incision was required in one patient (16%) with an associated abdominal aortic aneurysm. Post operative length of stay ranged from five to ten days with a median of seven days. There was no operative mortality. Results from robotically assisted laparoscopic ABF are equivalent to those from other minimally invasive options while enabling a much shorter learning curve. Using the technique described, minimally invasive ABF was accomplished in a safe and reliable manner despite prior vascular treatment.     

小肠间质瘤20例诊治分析

目的　总结小肠间质瘤诊断和治疗经验。方法　对1993—2 0 0 4年收治的2 0例小肠间质瘤的临床资料进行回顾性分析。结果　临床表现为黑便、果酱样血便14例、头晕9例、贫血3例,伴腹部疼痛11例,发病时间2个月至7年。确诊方式:剖腹探查12例,腹腔镜探查6例,小肠镜检查2例;手术方式:小肠间质瘤切除18例,胰十二指肠切除术1例,肿瘤无法切除行保守治疗1例。随访6个月至9年,除1例死于脑干出血、2例长期服用甲磺酸伊马替尼(Gleevec)症状部分缓解外,其余17例均健在,间质瘤无复发。结论　小肠间质瘤预后较好,但对不明原因的消化道出血应及早探查,以避免误诊;Gleevec对晚期小肠间质瘤有较好疗效     

31例胰岛素瘤临床及定位诊断分析

目的提高对胰岛素瘤的认识、诊断和治疗。方法对31例胰岛素瘤患者的临床资料和定位诊断进行总结分析。结果患者病程3周~14年,23例手术治疗,术后病理诊断为胰岛细胞瘤,其中2例多发内分泌腺瘤(MEN-1型)。8例未行手术治疗,经临床检查诊断为胰岛素瘤。31例中有28例有典型的Whipple三联症,住院期间低血糖发作,血糖在0.57~2.7mmol/L之间。23例INS(血浆胰岛素)/G(血糖)>0.3。影像学检查阳性率:超声检查为53.3%,CT为50%,血管造影(DSA)为78.9%,内镜超声(EUS)为91.6%。结论胰岛素瘤患者常反复发作低血糖、有各种交感神经兴奋及神经精神症状,影像学检查以EUS、DSA检出率为高。尤其EUS检查创伤小,阳性率高,应作为临床胰岛素瘤定位诊断的主要手段之一。     

Regional and Voxel‐Wise Comparisons of Blood Flow Measurements Between Dynamic Susceptibility Contrast Magnetic Resonance Imaging (DSC‐MRI) and Arterial Spin Labeling (ASL) in Brain Tumors

The objective of the current study was to evaluate the regional and voxel‐wise correlation between dynamic susceptibility contrast (DSC) and arterial spin labeling (ASL) perfusion magnetic resonance imaging (MRI) measurement of cerebral blood flow (CBF) in patients with brain tumors. Thirty patients with histologically verified brain tumors were evaluated in the current study. DSC‐MRI was performed by first using a preload dose of gadolinium contrast, then collecting a dynamic image acquisition during a bolus of contrast, followed by posthoc contrast agent leakage correction. Pseudocontinuous ASL was collected using 30 pairs of tag and control acquisition using a 3‐dimensional gradient‐echo spin‐echo (GRASE) acquisition. All images were registered to a high‐resolution anatomical atlas. Average CBF measurements within regions of contrast‐enhancement and T2 hyperintensity were evaluated between the two modalities. Additionally, voxel‐wise correlation between CBF measurements obtained with DSC and ASL were assessed. Results demonstrated a positive linear correlation between DSC and ASL measurements of CBF when regional average values were compared; however, a statistically significant voxel‐wise correlation was only observed in around 30‐40% of patients. These results suggest DSC and ASL may provide regionally similar, but spatially different measurements of CBF.     

Contrasting effects of electroconvulsive shock on rnRNAs encoding the high affinity kainate receptor subunits (KA1 and KA2) and cyclophilin in the rat

Kainate-preferring glutamate receptors may contribute to the glutamatergic responses to seizures. The cloning of their encoding genes overcomes limitations of the receptor ligands available for their investigation. We have examined the expression of the high affinity kainate receptor subunits KA1 and KA2 mRNAs in the rat hippocampus, using electroconvulsive shock (ECS) as a seizure paradigm not confounded by neurotoxicity. A single shock reduced the levels of KAI mRNA in the CA3c region, while increasing the expression of KA2 mRNA in the dentate gyrus. Following repeated ECS (5 shocks over 10 days), KAI mRNA was reduced in CA3c and in CA3a-b but was unchanged in dentate gyrus. KA2 mRNA, on the other hand, significantly increased in dentate gyrus, and to a lesser extent in CA3c and CA1. All changes in KAI and KA2 mRNAs had returned to baseline 3 weeks after the last shock. We also measured the expression of cyclophilin mRNA, and found it to be reduced in all hippocampul subfields, and in the parietal cortex, after a single ECS. It returned to control levels after repeated ECS but was again reduced following 3 weeks recovery from repeated ECS. These results indicate that the expression of KA1 and KA2 not only change in opposite directions in the rat hippocampus after ECS, but that the alterations are anatomically and temporally regulated. In the respect that cyclophilin is regarded as a housekeeping gene, the reduction in its mRNA suggests that ECS may have more persistent and widespread effects on brain gene expression than previously suspected.     

The role of informal caregivers during cancer patients’ recovery from chemotherapy

Scand J Caring Sci; 2013; 27; 147–155 The role of informal caregivers during cancer patients’ recovery from chemotherapy Aims: (i) To investigate the availability, perceived importance and roles of informal caregivers in the recovery of patients treated at day oncology centres and (ii) identify differences between patients with and without informal caregivers in the extent to which they experienced symptoms, and the level of bother symptoms caused. Method: Patients from three Australian hospitals (n = 122) were recruited during cycles 1 or 2 of adjuvant chemotherapy. Participants completed a modified version of the Rotterdam Symptom Checklist (RSCL) each day for 5 days after chemotherapy. A telephone interview conducted 10 days post‐treatment explored the availability, importance and roles of caregivers. During the interview, participants also completed the modified RSCL in which they were asked about the extent to which they experienced, and were bothered by, each symptom over the prior 5 days combined. Results: Overall, 71% of participants had an informal caregiver in the 5 days postchemotherapy, commonly a partner. More women (71%) than men (48%) had a caregiver (p < 0.05). Caregivers were perceived to be highly important; they were more important for women than men (U = 213.50, p < 0.01). The most common assistance caregivers provided was meal preparation and emotional support and companionship. On days 6–10 postchemotherapy, the extent to which overall physical symptoms were experienced was higher for patients with a caregiver than without (U = 987.50, p < 0.05); similarly their symptoms caused more bother (U = 966.00, p < 0.01). Conclusions: These findings highlighted the importance of informal caregivers to patients postchemotherapy. It is imperative that patients are informed of the importance of this support so a caregiver can be arranged, if possible. Understanding the needs of patients following chemotherapy would enable health professionals to advise patients, with or without caregivers, how to best prepare for and manage their recovery at home.