The indications for operations on the penile veins in venogenic erectile impotence

Unsatisfactory results of surgical management of venous erectile failure are attributed to difficult selection of relevant patients. The operation is to be performed in patients with isolated distal venous outflow. The diagnosis of occult proximal or mixed outflow may be made at dynamic cavernosography with loading test on the device for stimulation of erection. After obtaining the erection and removal of the constriction ring, distal venous outflow is blocked, thus creating the conditions for detection of occult proximal venous outflow. Surgical treatment (ligation of the dorsal vein or its insertion under tunica albuginea) is indicated only for patients free of mixed venous outflow.     

Juvenile psoriatic arthritis: followup and evaluation of diagnostic criteria

Platelet counts in newborns are similar to those of adults and children. However, newborn infants admitted to intensive care nurseries have a high prevalence of thrombocytopenia. The mechanisms responsible for the increased susceptibility to thrombocytopenia are not known. In addition, some studies have documented functional abnormalities in newborn platelets. In an effort to understand differences between platelets in newborns and in adults, we examined megakaryocyte ploidy in bone marrow from fetuses and compared it with bone marrow from adults, using a modified Feulgen stain to measure DNA of individual megakaryocytes. Faced with small fixed tissue samples, we developed a technique for use on bone marrow biopsies to estimate megakaryocyte ploidy and compared the results obtained with this method to those obtained from bone marrow aspirates. This study demonstrated that the overall mean ploidy of fetal megakaryocytes is decreased compared with adults. Additionally, fetal megakaryocyte ploidy increases as megakaryocyte maturation increases, but not to the same extent that adult megakaryocyte ploidy increases with megakaryocyte maturation. Over the gestational period studied, there was no relationship between gestational age and mean ploidy. The small size, shift to a less mature population, and decreased ploidy of fetal megakaryocytes indicate that there are differences in the post mitotic phase of megakaryocyte development in the fetus. Such differences may be related to quantitative and qualitative platelet abnormalities in the newborn. Understanding the physiology and regulation of megakaryocytopoiesis in the fetus and newborn will be valuable in determining the pathophysiologic basis of platelet dysfunction in the newborn.     

Rotationplasty in skeletally immature patients. Long-term followup results

Twenty-one skeletally immature patients with a Grade IIB osteosarcoma about the knee were treated with a modified Van Nes rotationplasty. Fourteen patients were followed up for 4 to 10.5 years (mean followup, 8 years). Functional assessment using Enneking's method showed all had good or excellent results. No patient thought that the reconstruction affected their ability to achieve recreational, sporting, or career goals. The reconstruction is durable and is not associated with an increase in late complications.     

Visual stimulation facilitates penile responses to vibration in men with and without erectile disorder.

This study compared reflexogenic and psychogenic penile responses in men with and without erectile disorder. It was hypothesized that men with psychogenic erectile dysfunction respond minimally to vibrotactile stimulation. An enhancement of penile responses was expected when vibration was combined with erotic film. Patients were 50 men with psychogenic erectile dysfunction, 45 men with organic erectile dysfunction, and 50 sexually functional men. The combination of film and vibration resulted in stronger penile responses than the stimuli presented separately. Men with psychogenic erectile dysfunction and sexually functional men did not differ in responses to film and film-and-vibration conditions. As predicted, responses of the 2 groups were different in the vibration condition. Interpretations are provided in terms of attention and appraisal. The findings are relevant to the development of psychophysiological diagnostic procedures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

APD: selection criteria and training methods

Over a 15-year period, thirteen thymolipomas are histologically demonstrated in a total of 182 myasthenia gravis patients undergoing thymectomy. The incidence of this rare histological diagnosis in the aforementioned group appears to be considerably higher than the one so far reported in the pertinent literature. In the series reviewed men in advanced age prevail which is by no means typical of myasthenia patients. The postoperative results are very good, with not a single fatal outcome being recorded. There are basically three types of histological findings in thymolipomas--fat tissue alone, fat tissue with thymic tissue in involution, and fat tissue with thymic tissue.     

Long-term experience of self-injection therapy with prostaglandin E1 for erectile dysfunction

A total of 42 evaluable patients 36-80 years old were treated with intracavernous injection of prostaglandin E1 for erectile dysfunction. They reported retrospectively via a questionnaire their long-term experience of this method. Twenty-four patients (57%) were after 46.9 months still using the technique, while 18 patients (43%) had abandoned the method after 21.4 months of use. No major complications were observed or reported.     

Conservation surgery for breast cancer: selection criteria and technical considerations

Patients with stage I or II breast cancer are candidates for either modified radical mastectomy or breast preservation therapy involving limited resection of the primary tumor, axillary dissection, and breast irradiation. The overall survival rates of both these approaches are comparable according to retrospective reviews and ongoing clinical trials, and long-term follow-up confirms the earlier findings. Thus, patients should be given the choice between these two options by surgeons, radiation therapists, and other physicians involved in their care. However, not all breast cancer patients will choose breast preservation surgery, and because of tumor-related and other factors not all patients are candidates. The patient selection criteria are discussed herein and the optimal surgical techniques are reviewed.     

Role of intracellular Ca2+ stores in smooth muscle of human penile erectile tissue

The image of plastic surgery as portrayed by the media is of concern to all plastic surgeons. In order to assess knowledge about the specialty, a questionnaire was devised and given to five groups of participants: general practitioners, medical students, nurses, plastic surgical out-patient attendees, and the general public. The results revealed that general practitioners, nurses and medical students in the Cambridge area are, on the whole, knowledgeable about the role of plastic surgery. However, the general public are not so well educated and 23.7% of them could not think of five conditions treated by plastic surgeons, and felt that burns and cosmetic problems were the commonest conditions dealt with. Improved liaison with general practitioners, other specialties and more teaching of undergraduates, coupled with more effective promotion of the skills on offer might permit better use to be made of the specialty.     

Cochlear implants: selection criteria and shifting borders

Cochlear implants have proven to be effective and reliable in postlingually deaf adults. This is also true for congenitally deaf and perilingually deaf children up to the age of six years. Due to the increasing experience, the improvement of implant technology and the proven reliability the selection criteria are broadened with shifting borders. The main extensions are related to age, additional handicaps, residual hearing and special etiologies of deafness. Increasing evidence shows that very early implantation results in better performance and better hearing and speech development. Near-normal language acquisition can be achieved in children implanted under the age of four. Additional handicaps do not automatically exclude a candidate from cochlear implantation. A case-to-case decision has to be made based on additional diagnostics and the experience of the implant centre. A list of suitable handicaps is provided. Severely hearing impaired patients may also be considered for cochlear implantation if their residual hearing provides no benefit for speech discrimination. The same holds true for children. Cochlear implantation in obliterated cochleae and inner ear malformation requires a special surgical technique and special electrode arrays. In this way even difficult cases can be managed with remarkable outcome. Over all, the selection criteria have been broadened with increasing experience and technological improvement. This development may continue and the borderline between hearing aids and cochlear implants will shift further towards severe hearing loss. However, the basis for success still remains good rehabilitation, a team approach and the willingness of the patient to undergo the whole process of cochlear implantation.     

Internship selection: Inclusion and exclusion criteria.

As an internship applicant, do you know what internship agencies look for to select or exclude you from further consideration? In a survey, the authors examined exclusion and inclusion criteria used at 402 internship sites accredited by the American Psychological Association (APA). The 249 respondents (62%) rated fit between applicant goals and site opportunities as the most important inclusion criteria. Four exclusion criteria (lack of completion of orals, lack of APA status of doctoral program, poor fit between applicant goals and site opportunities, and incomplete doctoral course work) were most commonly used to eliminate applicants from consideration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Functional outcome after myocardial revascularization in ischemic left ventricular failure

BACKGROUND: Myocardial revascularization in patients with left ventricular failure (ejection fraction < 30%) offers survival comparable to heart transplantation. The functional outcome, however, has yet to be determined. In order to assess the clinical results in patients with LVEF < 30% undergoing coronary artery bypass grafts (CABG), 101 consecutive patients operated between 1/91 and 1/97 were reviewed retrospectively. METHODS: The patients were stratified according to presentation: 65 pts had angina (Group 1) and 36 congestive failure (Group 2). Mean age (62 +/- 7 vs 60 +/- 8 yrs), sex (90 vs 88% male), LVEF (0.28 +/- 0.04 vs 0.29 +/- 0.04), prior myocardial infarction (1.2 +/- 0.4 vs 1.2 +/- 0.5 episodes/pt), presence of vital myocardium at scintiscan or low-dose dobutamine echocardiography (92 vs 93%), need for preoperative IABP (3.1 vs 8.3%), aortic cross-clamp (53 +/- 21 vs 60 +/- 21 min) and cardiopulmonary bypass (104 +/- 31 vs 114 +/- 36 min) times were comparable. RESULTS: There was only 1 (1%) perioperative death due to low-output syndrome. Eleven pts (6 vs 5, Group 1 vs Group 2) had postoperative low-output syndrome, requiring IABP in 7 pts (4 vs 3). There were 14 (10 vs 4, Group 1 vs Group 2) deaths during follow-up (29 +/- 19 months, range 2-67), with an overall actuarial survival of 91 +/- 4 vs 100% at 1 yr and 74 +/- 9 vs 78 +/- 10% at 5 yrs in Group 1 vs Group 2, respectively (p = ns). Actuarial symptom-free survival was 89 +/- 4 vs 84 +/- 6% at 1 yr and 49 +/- 9 vs 28 +/- 11% at 5 yrs, respectively (p = 0.05). Despite the high recurrence of congestive failure (22 vs 66% in Group 1 vs Group 2, p = 0.004), improvement in functional class (3.1 +/- 0.8 vs 1.5 +/- 0.7 in Group 1 and 2.7 +/- 0.7 vs 1.8 +/- 0.5 in Group 2) and LVEF (0.28 +/- 0.04 vs 0.38 +/- 0.04 in Group 1 and 0.29 +/- 0.04 vs 0.40 +/- 0.06 in Group 2) was found in both groups at follow-up. CONCLUSIONS: In spite of improving early and late survival after revascularization for ischemic left ventricular failure, patients presenting with congestive failure have an unsatisfactory symptom-free survival. Further studies are necessary to ascertain the relative indications to revascularization or transplantation in this specific patient subgroup.     

Transit-time flow measurement for detection of early graft failure during myocardial revascularization

BACKGROUND: A low-flow situation in arterial and venous grafts has been associated with high rates of perioperative infarction and mortality. This study was designed to look at intraoperative graft flow and resistance in patients with coronary artery disease. METHODS: Coronary artery bypass graft flow was measured in 46 patients. Transit-time flow was used for coronary flow measurements at rest as well as after maximal vasodilation with adenosine infusion. RESULTS: Forty-three of the 46 patients showed normal internal mammary artery graft flow (>20 mL/min); 3 patients had no or minimal graft flow. Redoing the graft anastomosis in these 3 patients resulted in normalization of graft flow. The mean flow increased significantly after correction from 0.5 +/- 0.7 mL/min to 15.7 +/- 9.6 mL/min (p < 0.02). Conversely, vascular resistance decreased significantly from 138 +/- 10 to 4.8 +/- 1.8 Ohmv (p < 0.0001), as did the pulsatility index (from 146.9 +/- 95.7 to 3.4 +/- 1.8; p < 0.001). After correction, coronary flow reserve was 2.5 +/- 1.1. CONCLUSIONS: Measurements of intraoperative flow and resistance as well as derived variables allow assessment of early graft function and thus help prevent graft failure and reduce perioperative infarction. Transit-time volume flow might be a simple tool for quality control in coronary bypass procedures.     

Lung transplantation. The indications and selection criteria]

OBJECTIVE: To survey physicians' attitudes toward the pulmonary artery catheter (PAC) and to assess physicians' knowledge of pulmonary artery catheterization. DESIGN: Mail survey/examination. PARTICIPANTS: Physician members of the Society of Critical Care Medicine in the United States. METHODS: A 51-question two-part survey was mailed to U.S. Society of Critical Care Medicine physician members by an independent research firm. The participants were instructed to answer the questions unassisted and to return the survey within one month. The first 20 questions surveyed physicians' attitudes toward the PAC. The remaining 31 multiple-choice questions tested the physicians' knowledge of the PAC and its use. The multiple-choice questions were obtained from a previous study which assessed physicians' knowledge of pulmonary artery catheterization. RESULTS: Five thousand surveys were mailed in October of 1996; 1095 surveys were returned in November of 1996, yielding a 22% return rate. The survey results were significant in that 95% of the respondents felt that a moratorium against PAC use was not warranted and that 75% of the respondents favored a prospective, randomized, controlled trial involving pulmonary artery catheterization. The mean test score for the multiple-choice questions was 25.6 (82.6%) with a standard deviation of +/- 3.46 and a range of 3 to 31 (10%-100%). The mean score was found to be significantly associated (p <0.001) with the following variables: specialty, practice pattern, number of PAC insertions performed per month, and whether or not the physician was trained and/or certified in critical care medicine. One third of respondents incorrectly identified the pulmonary artery occlusion pressure on a clear tracing and could not identify the major components of oxygen transport. CONCLUSION: The results of this mail survey/examination reflect the current attitudes and knowledge of the responding U.S. physician members of the Society of Critical Care Medicine regarding the PAC. The majority of the respondents are in favor of a prospective, randomized, controlled trial involving the PAC; 95% of the respondents feel that a moratorium on further use of the PAC is currently not warranted. Rather than a call for such a moratorium, a call for the development and maintenance of educational, credentialing, and continuous quality improvement policies involving the PAC is warranted and overdue.     

Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. Pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.     

Long-term experience with controlled expansion cylinders in the AMS 700CX inflatable penile prosthesis and comparison with earlier versions of the Scott inflatable penile prosthesis

OBJECTIVEs. To determine complication and survival rates of the AMS 700CX penile prosthesis and to compare its reliability with earlier versions of the Scott inflatable penile prosthesis. METHODS: Retrospective chart review and telephone interviews were used. RESULTS: Actual 4-year survival of the AMS 700CX device was 85%, whereas earlier versions of the device had actual 4-year survival of 46% (p < 0.0001). The observed difference in prosthesis reliability could not be accounted for by differences in patient population, surgical technique, or incidence of infections. The most significant factor that contributed to improved prosthesis survival was the lack of cylinder complications (leaks and aneurysms). CONCLUSIONS: The controlled expansion cylinders of the AMS 700CX penile prosthesis are a significant advance in reliable, low-morbidity surgical therapy for impotence.