Computerized tomographic and magnetic resonance angiography for perforator-based free flaps: technical considerations

Perforator-based free flaps rely on the appropriate dominant vessel supplying the vascular territory of the flap. Preoperative knowledge of the vascular anatomy can improve outcome and diminish surgical time. Several preoperative imaging techniques exist for surgical planning. Computed tomographic and magnetic resonance angiography are two emerging modalities that provide exceptional anatomic detail. Despite the growing utilization of cross-sectional imaging for preoperative planning, each modality has specific technical considerations that are necessary to consider in order to produce a quality study.     

Gleason score concordance on biopsy‐confirmed prostate cancer: is pathological re‐evaluation necessary prior to radical prostatectomy?

Study Type – Diagnosis (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Following the updated Gleason grading system in 2005 by the International Society of Urological Pathologists (ISUP), studies demonstrated improved prediction of biochemical (PSA) progression‐free outcome by needle core biopsy specimens. To our knowledge, no studies have investigated the impact of the modified grading system on inter‐laboratory agreement of biopsy Gleason score (bGS) and the effect of re‐evaluation on accuracy in predicting the true underlying histopathology. We report that when biopsy re‐evaluation resulted in a change in bGS, there was a marked improvement in the prediction of underlying pathology as determined by prostatectomy Gleason score suggesting that when outside referral of bGS results in an equivocal clinical decision, biopsy re‐evaluation can provide clarity on the true underlying tumour architecture.

OBJECTIVES

? Gleason sum from prostate biopsy (bGS) is an important tool in classifying severity of disease, ultimately influencing clinical management. ? Commonly, pathology specimens are re‐evaluated internally prior to surgery. ? We evaluate agreement of bGS with prostatectomy Gleason sum (pGS) and the impact of re‐grading on prediction of true underlying tumor architecture.

MATERIALS AND METHODS

? Retrospective analysis of men who underwent robotic‐assisted radical prostatectomy (RARP) by two surgeons from 2005–2009. Initial transrectal ultrasound (TRUS) biopsy demonstrated carcinoma at an outside lab. Specimens were re‐evaluated by our GU pathologists prior to surgery. Biopsy data were correlated with pGS. ? Kappa (κ) statistics for agreement and linear regression analyses were used for categorical variables. Coefficient of concordance was used for continuous variables.

RESULTS

? 100 patients had 331 positive biopsies. Agreement (κ) for bGS between outside labs and our pathologists was 0.55 (p < 0.001). ? Internal read was twice as likely to upgrade vs. downgrade outside bGS (23% vs. 11%). ? When re‐evaluation resulted in a change in bGS, agreement with pGS was κ= 0.29, vs. κ=?0.04 for agreement of initial (outside) bGS with pGS. ? When no change was made to bGS, agreement with pGS was κ= 0.40 (p < 0.001).

CONCLUSION

? Good reproducibility seen between outside labs and our institution on bGS. Internal pathology re‐reads correlated better with pGS than original community bGS. When re‐reads result in a change in bGS, there is a marked improvement in prediction of underlying tumor architecture confirming the value of re‐evaluating all external biopsies prior to definitive surgery.     

Preoperative blood volume deficit influences blood transfusion requirements in females and males undergoing coronary bypass graft surgery

STUDY OBJECTIVE: To evaluate whether preoperative blood volume and postoperative blood loss influence blood transfusion in females and males undergoing coronary artery bypass graft (CABG) surgery. DESIGN: Prospective study. SETTING: Anesthesiology department of a teaching hospital. PATIENTS: 57 CABG patients (21 females and 36 males). MEASUREMENTS: Blood volume was determined using the radioactivity dilution method. Preoperatively, each patient received intravenous (IV) injection of 1 mL Albumin I(131) tracer having 25 microcuries of radioactivity. Five-milliliter blood samples were collected at different intervals. From these samples, hematocrit (Hct) value, preoperative total blood volume, red blood cell (RBC) volume, and plasma volume were determined. Postoperatively, some consenting patients received another 1 mL dose of the tracer, and the postoperative blood volumes were determined. If a patient received a blood transfusion, the units of packed red blood cells (PRBCs), platelets, or fresh frozen plasma (FFP) transfused were recorded. For each patient we recorded the gender, age, weight, height, body surface area (BSA), preoperative Hct, duration of surgery, and discharge Hct. RESULTS: Preoperatively, the mean total blood volume, RBC volume, and plasma volume, respectively, were 2095 mL/m(2), 631 mL/m(2), and 1,465 mL/m(2) in females; and 2,580 mL/m(2), 878 mL/m(2), and 1,702 mL/m(2) in males. The preoperative blood volumes were significantly lower (p < 0.01) in females than in males. There was no significant difference between males and females in the extent of blood loss during CABG. Intraoperatively, females received PRBC transfusion of 1.38 units, significantly more (p < 0.01) than the 0.39 units received by males. During the entire hospital stay, females received 4.33 units of PRBC, significantly more than (p < 0.02) the 1.33 units received by males. Significantly more (p < 0.01) females (12 of 21) received intraoperative PRBC transfusion than did males (6 of 36). Multiple logistic regression analysis of the data showed that PRBC transfusion was significantly correlated with the preoperative total blood volume and RBC volume. CONCLUSION: The greater need for blood transfusion in females than in males during CABG is primarily attributable to significantly lower preoperative total blood volume and RBC volume in females.     

Homozygous bisalbuminemia or homozygous mutant albumin?

IntroductionBisalbuminemia is a genetic condition in which an albumin variant is found in serum in addition to normal albumin.Methods and materialsSerum protein electrophoresis using the Sebia HYDRASYS electrophoresis system was performed on an 84 year old male.ResultsSerum protein electrophoresis showed a single albumin band migrating faster than normal albumin.ConclusionThe presence of a homozygous albumin variant band, albumin Naskapi, is noted.     

The role of the long-term acute care hospital

Long-term acute care hospitals (LTACHs) have a niche role in the health care system. They specialize in caring for patients who are ventilator-dependent, are on inpatient dialysis, or have multi-organ or multi-system failure, postsurgical or organ transplant complications, complex wounds that need care, or traumatic or acquired brain injury. Many physicians are unfamiliar with the work done by the interdisciplinary teams that serve these facilities.This article describes LTACHs and their approach to care.