Endovascular interventions training and credentialing for vascular surgeons

This article reviews issues concerning the training and credentialing of vascular surgeons in the use of endovascular techniques in the peripheral vascular system. These guidelines update a prior document that was published in 1993. They have been rewritten to accommodate the rapid evolution that has occurred in the field and to provide the appropriate requirements that a vascular surgeon should fulfill to be competent in the basic skills needed to safely and effectively perform all presently accepted diagnostic and therapeutic endovascular procedures.     

Internal auditory artery infarction: clinicopathologic correlation

Immunocytochemical examination for mitochondrial protein and cytochrome oxidase was performed to demonstrate oncocytes in normal adenohypophysis obtained from 28 patients of various age. A small number of solitary large epithelial cells showed intense cytoplasmic granular immunoreactivities for mitochondrial protein and cytochrome oxidase. The proportions of the cells positive for the former and the latter ranged from 0% to 5.9% (mean+/-SD; 1.5+/-1.7%) and from 0% to 4.9% (1.4+/-1.6%), respectively. These cells were either absent or extremely rare in young patients (under 10 years) but tended to increase in number with age (P < 0.0001). On the other hand, the mirror section technique showed that most of these cells were negative for adenohypophysial hormones, but a few of them were faintly positive for: alpha-subunit (8.0%), beta-subunits of follicle-stimulating hormone (4.8%), luteinizing hormone (2.5%), thyroid-stimulating hormone (1.0%), and growth hormone (0.5%), and were negative for prolactin and adrenocorticotropic hormone. We considered that these cells represent oncocytes that exist in varying numbers in normal adenohypophysis. It was suggested that oncocytes in normal adenohypophysis share various common features with tumorous oncocytes of pituitary oncocytomas.     

New alkaloids from the indopacific sponge Stylissa carteri

Two samples of the marine sponge Stylissa carteri collected in Indonesia yielded two new bromopyrrole alkaloids: debromostevensine (1) and debromohymenin (2), as well as nine other known congeners (3-11). The structures of the new compounds were unambiguously established on the basis of their NMR and mass spectra.     

Medication adherence in rheumatoid arthritis patients: older is wiser

OBJECTIVES: To create a profile of individuals nonadherent to their medications in an age-stratified sample (ages 34-84) of community-dwelling rheumatoid arthritis patients. The relative contributions of age, cognitive function, disability, emotional state, lifestyle, and beliefs about illness to nonadherence were assessed. DESIGN: A direct observation approach was used in conjunction with structural equation modeling. All participants were administered a preliminary assessment battery. Medications were then transferred to vials with microelectronic caps that recorded medication events for all medications for the next 4 weeks. PARTICIPANTS AND SETTING: A volunteer sample of 121 community-dwelling rheumatoid arthritis (RA) patients were recruited from newspaper ads, posters, and via informal physician contact from private rheumatology practices in Atlanta and Athens, Georgia. Written verification of the RA diagnosis and a disease severity rating were obtained from personal physicians before patients were enrolled in the study. Patients were tested in a private physician's office, and their medication adherence was monitored electronically for a month in their every-day work and home settings. MEASUREMENTS AND RESULTS: Structural equation modeling techniques were used to develop a model of adherence behavior. Cognitive and psychosocial measures were used to construct latent variables to predict adherence errors. The model of medication adherence explained 39% of the variance in adherence errors. The model demonstrated that older adults made the fewest adherence errors, and middle-aged adults made the most. A busy lifestyle, age, and cognitive deficits predicted nonadherence, whereas coping with arthritis-related moods predicted adherence. Illness severity, medication load, and physical function did not predict adherence errors. Omission of medication accounted for nearly all errors. CONCLUSION: Despite strong evidence for normal, age-related cognitive decline in this sample, older adults had sufficient cognitive function to manage medications. A busy lifestyle and middle age were more determinant of who was at risk of nonadherence than beliefs about medication or illness. Thus, practicing physicians should not assume that older adults have insufficient cognitive resources to manage medications and that they will be the most likely to make adherence errors. Very busy middle-aged adults seem to be at the greatest risk of managing medications improperly.     

TGF-alpha sustains clonal expansion by promoter-dependent, chemically initiated rat hepatocytes

A series of promoting and non-promoting barbiturates and hydantoins were examined for their ability to sustain the growth of a phenobarbital (PB)-dependent hepatocyte line in cell culture. The effective liver tumor promoters, pentobarbital, allobarbital and 5-ethyl-5-phenylhydantoin, replaced PB and supported 6/27C1 hepatocyte colony formation in vitro at 52-87% of the level induced by PB. The weak promoters secobarbital and amobarbital supported colony formation at only 11-19% of the PB control. A significant correlation was observed for in vivo and in vitro promotion activities of barbiturates and hydantoins, indicating that clonal expansion by 6/27C1 hepatocytes was promoter-dependent. Cell density also appeared to influence hepatocyte growth in vitro. Hepatocyte colonies acquired the ability to grow in the absence of PB, such that after 10 days incubation with PB, approximately 50% of colonies continued to grow in the absence of promoter. This phenomenon of clone-size-dependent hepatocyte growth suggested the operation of an autocrine growth factor pathway. Addition of the hepatocyte mitogen and autocrine growth factor, transforming growth factor-alpha (TGF-alpha), to culture medium lacking PB induced a dose-dependent increase in 6/27C1 hepatocyte colony formation. At the optimal concentration of 3 ng/ml, TGF-alpha sustained hepatocyte clonal expansion at 84% of the level induced by 2 mM PB. Individual 6/27C1 colonies that grew from single cells in the presence of TGF-alpha were tested for promoter-dependent colony formation. Either PB or TGF-alpha supported colony formation by these cells at similar levels and when combined at optimal concentrations, the response appeared to be saturated. When these factors were tested in combination at suboptimal concentrations, the two compounds were additive for supporting colony formation by the parental 6/27C1 line. The ability of TGF-alpha to replace PB and sustain hepatocyte clonal expansion was confirmed with the tumorigenic 6/15 hepatocyte line. These results suggest that TGF-alpha and PB may promote hepatocarcinogenesis by stimulating a common signal transduction pathway.     

Immunogenetics of the A-E alloantigen complex

OBJECTIVE: To examine noradrenergic (NA) function in children with attention-deficit hyperactivity disorder (ADHD) by replicating and expanding upon a previous finding that ADHD children with and without reading disabilities (RD) differ in plasma levels of the NA metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG). METHOD: Plasma levels of MHPG were compared in ADHD children who were subdivided on the basis of the presence or absence of RD. Subsequently, this replication sample was combined with a previously studied sample to further explore the relationship between plasma MHPG levels and measures of cognitive function in children with ADHD. RESULTS: Plasma levels of MHPG were significantly lower in ADHD children without RD, compared with those with RD, replicating a published finding. Analyses in the combined sample indicated that, among children with ADHD, plasma MHPG levels were inversely associated with measures of academic achievement and verbal processing, but not parent or teacher ratings of behavior or continuous performance test measures of attention and impulsivity. CONCLUSIONS: These data indicate that children with ADHD are not homogeneous with regard to NA function and that neurochemical variation is closely associated with differences in clinical characteristics of the children.     

Endoscopic CO2 laser excision of large or recurrent laryngeal saccular cysts in adults

BACKGROUND: Most paediatric cardiac arrest studies have been conducted in the USA, where paramedics provide prehospital emergency care. We wanted to study the outcome of paediatric cardiac arrest patients in an emergency medical system which is based on physician staffed emergency care units. METHODS: We analysed retrospectively the files of 100 prehospital cardiac arrest patients from Southern Finland during a 10-year study period. The patients were less than 16 years of age. RESULTS: Fifty patients were declared dead on the scene (DOS) without attempted resuscitation, and cardiopulmonary resuscitation (CPR) was initiated in 50 patients. The sudden infant death syndrome was the most common cause of arrest in the DOS patients (68%) as well as in those receiving CPR (36%). Asystole was the initial cardiac rhythm in 70% of the patients in whom CPR was attempted. Resuscitation was successful in 13 patients, 8 of whom were ultimately discharged. Six of the patients survived with mild or no disability and 4 of them had near-drowning aetiology. In multivariate analysis, the short duration of CPR (< or = 15 min) was the only factor significantly associated with better survival. CONCLUSIONS: Although prehospital care was provided by physicians, the overall rate of survival was found to be equally poor as reported from systems with paramedics. The only major difference between physician- and paramedic-staffed emergency care units is the ability of physicians to refrain from resuscitation already on the scene when prognosis is poor.     

Transtemporal power- and frequency-based color-coded duplex sonography of cerebral veins and sinuses

PURPOSE: To determine the ability of transtemporal power- and frequency-based transcranial color-coded duplex sonography to aid in the assessment of cerebral veins and sinuses, as well as to provide reference data for flow direction and velocity. METHODS: Using a color duplex device equipped with a 2.0/2.5-MHz sector scan, we insonated 120 healthy volunteers and three patients with cerebral venous thrombosis. RESULTS: In subjects 20 to 59 years old, deep middle cerebral veins were identified in 88%, basal veins in 97%, straight sinuses in 60%, and transverse sinuses in 42%. The corresponding values for subjects 60 to 79 years old were 53%, 86%, 23%, and 20%, respectively. Velocities were highest in transverse and straight sinuses, slower in basal veins, and slowest in deep middle cerebral veins. Flow was directed lateromedially in the deep middle cerebral vein, rostrocaudally in the basal vein and straight sinus, and mediolaterally in the transverse sinus. Two patients with straight sinus thromboses showed reversed flow direction in the basal veins, and one patient with superior sagittal sinus thrombosis showed elevated velocities in a deep middle cerebral vein. CONCLUSION: Transtemporal power- and frequency-based color-coded duplex sonography enabled imaging and velocity measurements in deep cerebral veins in subjects 20 to 59 years old, but detection of the straight and transverse sinuses was low. In older subjects, only the basal vein was regularly assessed.     

Suppression of anchorage-independent growth and matrigel invasion and delayed tumor formation by elevated expression of fibulin-1D in human fibrosarcoma-derived cell lines

Using differential display, we identified an mRNA that is markedly down-regulated in cell line 6A/SB1, derived from a fibrosarcoma formed in an athymic mouse following injection of carcinogen-transformed MSU-1.1 cells. The nontumorigenic parental cell strain, MSU-1.1, expresses high levels of this mRNA. Sequencing of the corresponding cDNA fragment revealed that it corresponded to an expressed sequence tag, which ultimately led to its identification as the fibulin-1D gene. Fibulin-1 is a cysteine-rich, calcium-binding extracellular matrix and plasma protein, which has four isoforms, A-D, derived from alternative splicing. Northern and Western blotting analysis of 16 cell lines established from tumors formed in athymic mice by MSU-1.1-derived cell strains independently transformed in culture showed that 44% exhibited low level or lack of expression of fibulin-1D mRNA and protein. In a similar analysis of 15 malignant cell lines derived from patients, 80% showed low level or no expression. To study the role of fibulin-1D in transformation, we transfected 6A/SB1 cells and a human fibrosarcoma-derived cell line (SHAC) with a fibulin-1D cDNA expression construct. Transfectants displaying high levels of fibulin-1D were isolated and characterized. Elevated expression of fibulin-1D led to reduced ability to form colonies in soft agar and reduced invasive potential as tested in a matrigel in vitro invasion assay. Furthermore, expression of fibulin-1D resulted in a markedly extended latency in tumor formation in athymic mice. These results indicate that low expression of fibulin-1D plays a role in tumor formation and invasion.