Mechanical thrombectomy: results of early experience

PURPOSE: To evaluate the clinical application of a mechanical thrombectomy device in occluded lower extremity arteries and bypass grafts. MATERIALS AND METHODS: A mechanical thrombectomy device was used in five patients with acutely occluded lower extremity bypass grafts (n = 2) or superficial femoral arteries (n = 3). RESULTS: The thrombus was completely removed in three cases (two bypass grafts and one native superficial femoral artery). In two of the patients with occlusions in the native superficial femoral artery, the thrombus was partially removed. In these two patients, the aspirate demonstrated a more fibrous thrombus that was not easily fragmented. In one of these two patients, the coagulum was thought to be embolic from the heart. CONCLUSION: The thrombectomy device works well in recent thromboses, particularly in polytetrafluoroethylene grafts in which organization does not occur. Its efficacy in chronically occluded vessels is not certain.     

Z-plasty template: an innovation in Z-plasty fashioning

Although Z-plasty is one of the basic skills in the armamentarium of a plastic surgeon, one is rarely found using a protractor to measure the exact angles. Two types of simple gadgets are described here to fashion Z-plasties with desired (fixed or variable) angles useful in various types of Z-plasties. These gadgets are made from transparent plastic sheets. They can be sterilized by formalin vapor or ethylene oxide gas. Since they are pliable, they can be adapted to the contours on the body. These are found to be particularly useful in cases where asymmetrical Z-plasties are needed.     

Tentorial and posterior cranial fossa meningiomas: operative results and long-term follow-up: experience with twenty-six cases

In spite of significant recent advancements in imaging technology, monitoring [12] and surgical techniques [1,5,7,18,21,24], complete and safe removal of tentorial and posterior fossa meningiomas remains a formidable challenge for most neurosurgeons [6,8,9,14,15,17]. This paper reviews our experience with 28 patients with tentorial and posterior fossa meningiomas.     

The celluloid-acetone-dressing in palatoplasty

The article describes an older, simple, and effective method of postoperative fixation of the palatal flaps using celluloid-acetone dressing (CAD). Veau pedicle flaps and the construction of two nasal meatuses are used for the palatoplasty. After the surgery, a wire is round around teeth IV and V on each side: a prolene mattress suture, instead of wire, is used for infants without teeth. A celluloid-acetone paste is applied to the wire or suture over a layer of gauze and petroleum jelly. The CAD mixture hardens in less than 1 hour and is removed after 4 days by cutting the wire or suture. This method prevents the palatal flaps from descending; scar tissue is minimal, and assists in the formation of a high-arched roof of the palate. In addition, the patient feeds normally after the operation.     

Pyloric stenosis: a 13-year experience in operative management

Infantile hypertrophic pyloric stenosis is best treated surgically, after an appropriate period of rehydration and resuscitation. Our experience with this entity has resulted in the performance of fewer contrast studies to establish the diagnosis as well as the use of an operative technique which can be safely applied to the teaching environment.     

The Graf stabilisation system: early results in 50 patients

The results of the first 50 consecutive patients using the Graf stabilisation system are presented. The average age of the patients was 41 years; there were 32 women and 18 men in the group. All patients suffered from intractable symptomatic degenerative disc disease which could be localised to one or more levels. All patients gave a history of chronic back pain, but the mean period of severe disability was 24 months. The mean preoperative disability score (Oswestry questionnaire) was 59%. The average period of follow-up was 24 months (range 19-36 months). At the latest review, the mean disability score was 31%. The clinical results were classified as "excellent" or "good" in 72% of patients, "fair" in 10%, "the same" in 16% and "worse" in 2%. All but three patients felt that surgery was worthwhile. The results have not deteriorated over the period of follow-up.     

A fiberscopic analysis of velopharyngeal movement before and after primary palatoplasty in cleft palate infants

The usefulness of bioelectrical impedance (BI) with anthropometry to measure total body water (TBW) was evaluated in very-low-birth-weight (VLBW) infants. A specific regression equation to measure TBW in a VLBW population was developed by simultaneously using the H2[(18)O] dilution method and BI in 12 infants with a gestational age of 24-30 wk and weighing <1200 g at birth. After an oral dose of H2[(18)O], the tracer dilution was measured in expired carbon dioxide. BI measurements were made with a model BIA-101 apparatus (RJL Systems, Detroit). Electrodes were placed in the standard position as well as proximally on the leg and the forearm. The best correlation was observed between body weight and TBW (r = 0.989). For BI, the best correlation was obtained when gestational age was used as a covariable along with body weight and crown-heel length (r = 0.985). The correlation was comparable with proximal electrode placement (r = 0.985). The new correlation was evaluated in 6 infants weighing < 1008 g. A significant correlation between BI and H2[(18)O]-measured TBW was observed (r = 0.988). Published regression equations for infants consistently gave higher estimates of TBW in another group of 14 infants weighing <1200 g than did the new correlations. TBW represented 84-95% of body weight in these VLBW infants. TBW could be computed simply from body weight alone. Use of BI and length as covariables did not add significantly to the estimate of TBW in VLBW infants.     

Selective operative treatment for tetraology of Fallot: rationale and results

Eighty-one patients with tetralogy of Fallot malformations evaluated between July 1, 1971 and November, 1975 are presented. Fifty-one patients underwent primary intracardiac repair; three died. Twenty-seven patients were corrected after a previous palliative shunt; there was one death. Three additional patients have been palliated and are awaiting repair. While the overall mortality in these patients was less than 5%, the infants undergoing total correction before the age of two years appeared to be at greater risk (25%). There were no deaths in the group of patients undergoing palliative procedures. Based on these data it appears that a safely performed palliative shunt in the symptomatic small infant is a reasonable first step, particularly if the outflow tract of the right ventricle is diffusely hypoplastic.     

Laparoscopic rectopexy: early results

Five patients with complete rectal prolapse were operated by laparoscopic approach. Technical details are described. Preliminary results are excellent.     

Virtual bronchoscopy in children: early clinical experience

OBJECTIVE: Virtual bronchoscopy is a new noninvasive technique that provides an internal view of the tracheobronchial tree. The purpose of our study was to assess the role of this technique as compared with fiberoptic bronchoscopy in the evaluation of suspected compression or narrowing of the trachea and main bronchi in children. CONCLUSION: Preliminary results suggest that virtual bronchoscopy may have a useful complementary role to fiberoptic bronchoscopy in evaluation of the tracheobronchial tree of children.     

The results of primary radiotherapy in vaginal carcinoma

The results of two previous and two recent studies of middle-aged males and females are presented to exemplify the clinical importance of lipoprotein(a) (Lp(a)) as a risk factor for atherosclerosis and coronary heart disease. In these studies various conventional and recently suggested risk factors were included and different methods for Lp(a) quantification were used. Lp(a) was a significant risk factor in all four studies. In the recent prospective case-control study, Lp(a) and cholesterol were found to act synergistically and predict primary acute myocardial infarction in Swedish males. A cholesterol level above 6.5 mmol/l increased the risk of acute myocardial infarction if the Lp(a) level was above 200 mg/l. The plasma apo A-I level was a protective factor. In the other recent case-control study, an Lp(a) level above 500 mg/l was a highly significant risk factor in Black and White US women with myocardial infarction or advanced coronary artery disease in addition to low density lipoprotein cholesterol levels above 130 mg/dl. A high apo A-I level was a protective factor. In these studies no other factors tested reached significance in multivariate logistic regression analysis. A hypothetical association between high Lp(a) levels and intracellular infection with Chlamydia pneumoniae is discussed. The results suggest that the Lp(a) level is useful in identifying high-risk individuals. Lowering low density lipoprotein cholesterol below 100 mg/dl (<2.6 mmol/l) seems to be most important in both males and females with high-risk Lp(a) levels.     

The results of radiotherapy for ependymomas: the Mayo Clinic experience

It is known that exogenous 11-cis-retinol inhibits the recovery of photosensitivity of bleached rod outer segments (ROS) and 11-cis-retinol exists in the interphotorecepter matrix. We examined the conversion of 11-cis-retinol with bovine ROS. ROS was incubated with 11-cis-retinol under dim red light. Retinoids were extracted from the reaction mixture with hexane and analyzed by HPLC coupled with a fluorescence spectrophotometer. Isomerization of 11-cis-retinol to all-trans-retinol was observed in the presence of ROS. This isomerization was not suppressed by heat treatment and did not have stereospecificity. In addition, we incubated purified rhodopsin and phospholipids extracted from ROS with 11-cis-retinol. Rhodopsin was found to isomerize 11-cis-retinol to all-trans-retinol as well as ROS, but phospholipids did not. In contrast, the phospholipids inhibited the isomerization of 11-cis-retinol to all-trans-retinol by the purified rhodopsin. Commercially available phospholipids, especially phosphatidylserine, also inhibited the isomerization. Our results suggest that rhodopsin has activity for the isomerization of 11-cis-retinol to all-trans-retinol and may play an important role in the detoxification of 11-cis-retinol in the ROS.     

Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study

Phosphoribosyl-ATP pyrophosphohydrolase (PRA-PH) and phosphoribosyl-AMP cyclohydrolase (PRA-CH) are encoded by HIS4 in yeast and by hisIE in bacteria and catalyze the second and the third step, respectively, in the histidine biosynthetic pathway. By complementing a hisI mutation of Escherichia coli with an Arabidopsis cDNA library, we isolated an Arabidopsis cDNA (At-IE) that possesses these two enzyme activities. The At-IE cDNA encodes a bifunctional protein of 281 amino acids with a calculated molecular mass of 31,666 D. Genomic DNA-blot analysis with the At-IE cDNA as a probe revealed a single-copy gene in Arabidopsis, and RNA-blot analysis showed that the At-IE gene was expressed ubiquitously throughout development. Sequence comparison suggested that the At-IE protein has an N-terminal extension of about 50 amino acids with the properties of a chloroplast transit peptide. We demonstrated through heterologous expression studies in E. coli that the functional domains for the PRA-CH (hisI) and PRA-PH (hisE) resided in the N-terminal and the C-terminal halves, respectively, of the At-IE protein.     

Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair

PURPOSE: To determine the safety, effectiveness, and problems encountered with endovascular repair of abdominal aortic aneurysm (AAA). Initial experience with endoluminal stent grafts was examined and compared with outcome for a matched concurrent control group undergoing conventional operative repair of AAA. METHODS: Over a 3-year period, 30 patients underwent attempts at endovascular repair of infrarenal AAA. Of the 28 (93%) successfully implanted endografts, 8 were tube endografts, 8 bifurcated grafts, and 12 aortouniiliac grafts combined with femorofemoral bypass. Most of the procedures were performed in the past year because the availability of bifurcated and aortoiliac endografts markedly expanded the percentage of patients with AAA who might be treated with endoluminal methods. The follow-up period ranged from 1 to 44 months, with a mean value of 11 months. RESULTS: Endovascular procedures demonstrated significant advantages with respect to reduced blood loss (408 versus 1287 ml), use of an intensive care unit (0.1 versus 1.75 days), length of hospitalization (3.9 versus 10.3 days), and quicker recovery (11 versus 47 days). Although the total number of postoperative complications was identical for the two groups, the nature of the complications differed considerably. Local and vascular complications characteristic of endovascular repair could frequently be corrected at the time of the procedure and tended to be less severe than systemic or remote complications, which predominated among the open surgical repair group. On an intent-to-treat basis, 23 (77%) of the 30 AAAs were successfully managed with endoluminal repair. The seven (23%) failures were attributable to two immediate conversions caused by access problems, three persistent endoleaks, one late conversion caused by AAA expansion, and one late rupture. CONCLUSIONS: Although less definitive than those for conventional operations, these early results suggest that endovascular AAA repair offers considerable benefits for appropriate patients. The results justify continued application of this method of AAA repair, particularly in the treatment of older persons at high risk.     

The Polish experience of quality improvement in primary care

THE POLISH HEALTH CARE SYSTEM: The health care system in Poland is based on a model typical of east-central European countries, with features such as state-owned health care organizations, centralized management and administration, and primacy of access to care over quality. Poorly planned and uncoordinated reforms have been undertaken to transfer some of the authority for health service management to local governments. PRIMARY HEALTH CARE IN POLAND: The reform of the health care system entails substitution of family physician-based for medical specialist-based primary care. Newly trained family physicians, as the first to start private surgery clinics financed from public sources, are the forerunners of the comprehensive reform and property structure transformation. MAKING THE TRANSITION FROM QUALITY ASSURANCE TO QUALITY IMPROVEMENT: Since the early 1990s, more and more organizations, individuals, and professional groups have begun to perceive health care regulations and other external control mechanisms as ineffective. Attempts have been made to replace periodic, restrictive activities with systematic continuous quality improvement efforts. Systems of voluntary accreditation are being developed and fostered. Groups have started meeting to develop medical practice guidelines and conduct peer review. Concern about quality of health care services is now reflected in the Polish legislation for the first time, as well as in numerous local and nationwide projects and publications. CONCLUSION: Despite some successes, the pioneers of quality improvement (QI) still have a long way to go. Continuation of educational activities and creation of a system of motivation for the development, of QI in primary care should be prioritized and encouraged.     

The descriptive epidemiology of primary intracranial neoplasms: the Connecticut experience

The age-specific incidence pattern for tumors of the brain and cranial meninges in Connecticut over a 30-year period shows an early peak followed by a taller and sharper peak with a maximum in the 55-65 year age group. This overall curve reflects the pattern shown for glioblastoma, the tumor accounting for the majority of the histologically confirmed cases. The reported rates are probably underestimates of the actual rates. The various histologic types of brain tumors reveal sufficiently distinct epidemiologic patterns to be considered as separate diseases.     

Undergraduate education in primary care: the Rockford experience

Four years of experience with an undergraduate program in primary care in a new community-based medical school are described. Students are intimately involved over a two-and-a-half-year period in the delivery of primary care in rural and semi-rural community health centers. Despite problems of financing and, especially, faculty recruitment and development, the program has been enthusiastically endorsed by students and patients and appears to represent a viable new model for medical education.     

The shoelace technique for wound closure in open fractures: report of early experience

A simple, reliable method of wound closure in open fractures is presented which has been used in this department. The necessity for split-skin grafting or flap cover, with the associated morbidity and cost implications, has been avoided by using this method. It has not been associated with any major complications in the patients studied, but it should be recognized that this method is not universally suitable in the treatment of all open injuries. We recommend this method as a simple way of achieving soft tissue cover in open injuries which are thoroughly debrided and cleaned, and in which there is no evidence of raised intracompartmental pressure.     

Venous valve repair: early results in fifty-two cases

PURPOSE: Chronic deep venous insufficiency, usually secondary to the postthrombotic syndrome, is due to primary valve failure in approximately 15% of cases. In these cases surgical repair of the valvular mechanism may be indicated. METHODS: Fifty-two limbs in 42 patients were treated with superficial femoral vein valvuloplasty after appropriate investigation. Adjunctive operations on the superficial or perforating veins were performed on 49 limbs during the same hospital admission. RESULTS: Of the 27 patients who have completed one year of follow-up, 85% are free of reflux on duplex scanning and 68% have had normalization of venous refilling times. Of 11 limbs with venous ulceration followed up for more than 1 year, only one has had a recurrent ulcer (9%). In patients without ulceration the procedure has been successful in alleviating symptoms of venous insufficiency. CONCLUSIONS: We conclude that the procedure, in conjunction with appropriate superficial venous operation, is effective in selected patients with deep vein reflux whose conditions remain uncontrolled by conservative measures. At 1 year, 85% of valvuloplasties in this series remained competent.