Impact of Early Direct Patient Notification on Follow-Up Completion for Nonurgent Actionable Incidental Radiologic Findings

PURPOSE

The aim of this study was to evaluate whether early direct patient notification in addition to an existing multistage recommendation-tracking system (Backstop) increases follow-up completion rates for actionable incidental findings (AIFs). Patient attitudes toward early notification were also assessed.

METHODS

This prospective, randomized controlled trial recruited patients with AIFs requiring follow-up being enrolled into the Backstop system. Patients were randomized into four groups: those receiving additional early direct notification in a mailed letter (group 1, similar to Pennsylvania Act 112), by phone (group 2), or in an electronic portal message (group 3) and a control group (group 4) without additional notifications added to the existing Backstop system. Differences in follow-up completion rates among these groups were determined using χ2 tests. Patients were surveyed on binary yes/no and Likert-type scale questions, and descriptive statistics are reported.

RESULTS

Data from 2,548 randomized patients were analyzed for the study, including 593 patients notified by letter, 637 notified by phone, 701 notified by portal, and 617 control patients. Group 3 demonstrated the lowest rate of follow-up completion within 1 month of the follow-up due date at 36.4%, compared with 58.7% for group 1, 60.4% for group 2, and 53.2% for group 4 (P < .0001 for all). Group 2 was the only group to have a significantly higher completion rate than group 4 (P = .014). Patients responded positively regarding early notification and preferred electronic portal communication.

CONCLUSIONS

Early direct notification had a mixed impact on follow-up completion rates on the basis of communication modality but was positively received by patients and may have health care benefits when implemented within a recommendation-tracking system.

Responsibility and Organization Science: Integrating Micro and Macro Perspectives

Responsibility is an important issue in organizations and society. Employees, managers, and owners can behave responsibly in the workplace and beyond. In addition, these individuals can be influenced by the propensity of the organization to behave responsibly. Organizations can pursue strategies that take into account responsibility at the product, firm, industry, and societal levels. This virtual special issue examines 19 articles published in Organization Science that consider responsibility at multiple levels of analysis. An important theme that emerges is that although some studies have crossed levels of analysis, future research would benefit from cross-level or more meso-based approaches.

In vitro and in vivo efficacy of non-psychoactive cannabidiol in neuroblastoma

BACKGROUND

Neuroblastoma (nbl) is one of the most common solid cancers in children. Prognosis in advanced nbl is still poor despite aggressive multimodality therapy. Furthermore, survivors experience severe long-term multi-organ sequelae. Hence, the identification of new therapeutic strategies is of utmost importance. Cannabinoids and their derivatives have been used for years in folk medicine and later in the field of palliative care. Recently, they were found to show pharmacologic activity in cancer, including cytostatic, apoptotic, and antiangiogenic effects.

METHODS

We investigated, in vitro and in vivo, the anti-nbl effect of the most active compounds in Cannabis, Δ(9)-tetrahydrocannabinol (thc) and cannabidiol (cbd). We set out to experimentally determine the effects of those compounds on viability, invasiveness, cell cycle distribution, and programmed cell death in human nbl SK-N-SH cells.

RESULTS

Both compounds have antitumourigenic activity in vitro and impeded the growth of tumour xenografts in vivo. Of the two cannabinoids tested, cbd was the more active. Treatment with cbd reduced the viability and invasiveness of treated tumour cells in vitro and induced apoptosis (as demonstrated by morphology changes, sub-G1 cell accumulation, and annexin V assay). Moreover, cbd elicited an increase in activated caspase 3 in treated cells and tumour xenografts.

CONCLUSIONS

Our results demonstrate the antitumourigenic action of cbd on nbl cells. Because cbd is a nonpsychoactive cannabinoid that appears to be devoid of side effects, our results support its exploitation as an effective anticancer drug in the management of nbl.

Clinical Efficacy, Safety, and Feasibility of Using Video Glasses during Interventional Radiologic Procedures: A Randomized Trial

PURPOSE

To evaluate the clinical efficacy, safety, and feasibility of implementing video glasses in a variety of interventional radiologic (IR) procedures.

MATERIALS AND METHODS

Between August 2012 and August 2013, 83 patients undergoing outpatient IR procedures were randomized to a control group (n = 44) or an experimental group outfitted with video glasses (n = 39). State-Trait Anxiety Inventory (STAI) scores, sedation and analgesia doses, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), pain scores, and procedure times were obtained. Complications and adverse events related to the use of video glasses were recorded. Postprocedural staff surveys and patient satisfaction surveys were completed.

RESULTS

Women had greater preprocedural anxiety than men (P = .0056), and patients undergoing vascular interventions had greater preprocedural anxiety than those undergoing nonvascular interventions (P = .0396). When assessed after the procedure, patients who wore video glasses had significantly reduced levels of anxiety (-7.7 vs -4.4, respectively; P = .0335) and average MAP (-6.3 vs 2.1, respectively; P = .0486) compared with control patients. There was no significant difference in amount of sedation and analgesia, HR, RR, pain score, or procedure time between groups. No significant adverse events related to the use of video glasses were observed. Postprocedural surveys showed that video glasses were not distracting and did not interfere or pose a safety issue during procedures. Patients enjoyed using the video glasses and would use them again for a future procedure.

CONCLUSIONS

Video glasses can be safely implemented during IR procedures to reduce anxiety and improve a patient's overall experience.

Prevalence, presentation, and endovascular management of hemodynamically or clinically significant arterio-portal fistulae in living and cadaveric donor liver transplant recipients

PURPOSE

To compare the prevalence (cadaveric vs. living donor transplants), clinical features, and the effectiveness of endovascular management of significant arterio-portal fistulae (APF) in liver transplant recipients.

METHODS

A retrospective audit of liver transplant recipients in two institutions was performed (1996-2009). Significant APF were included and were defined as symptomatic and/or hemodynamically significant (causing graft dysfunction and/or having abnormal Doppler findings in the portal vein). Patients with significant APF were evaluated for presenting symptoms, imaging features, size/branch order portal vein involvement, and effectiveness of the endovascular management (coil embolization).

RESULTS

Four significant APF were found in 1992 (0.2%) liver transplants. Two were symptomatic and two were asymptomatic but were hemodynamically significant with liver function test abnormalities. All four APF were found in cadaveric donor graft recipients (0.23%, N = 4/1753) and none in 239 living donor graft recipients. However, there was no statistical difference between cadaveric and living donor graft recipients (p = 1.0, odds ratio = 1.23). Coil embolization was technically and clinically successful in all 4 without complications and causing normalization of the abnormal Doppler findings.

CONCLUSION

Significant APF are a rare diagnosis (0.2% of transplants). Coil embolization is a safe and effective treatment option for APF in transplants.

Perthes' disease and the search for genetic associations: collagen mutations, Gaucher's disease and thrombophilia

The role of heritable thrombophilic risk factors in the pathogenesis of the Perthes' disease is controversial. The clinical and radiological findings of Perthes' disease may be indistinguishable from those of Gaucher's disease, and the most common Jewish N370S Gaucher mutation is threefold greater in patients with Perthes' disease. Familial osteonecrosis of the femoral head is associated with variant mutations of collagen type II (COL2A1 mutations). We therefore studied the potential role of genetic thrombophilia and the Gaucher and COL2A1 mutations in children with Perthes' disease. Genomic DNA of 119 children with radiologically-confirmed Perthes' disease diagnosed between 1986 and 2005 was analysed for the thrombophilic polymorphisms Factor V Leiden, 677T-MTHFR and FIIG20210A. The results were compared with those of a group of 276 children without Perthes' disease. DNA was also analysed for the Gaucher mutations N370S, G insertion (84GG), L444P, Intron 2 (IVS2+1G>A) and R496H. Enzymic assays confirmed the Gaucher disease status. Collagen (COL2A1) mutations of the 12q13 gene were also analysed. The prevalence of thrombophilic markers was similar among the 119 patients with Perthes' disease and the 276 control subjects. The prevalence of the Gaucher mutation was consistent with Israeli population carriership data and did not confirm an earlier-claimed association with Perthes' disease. All 199 patients were negative for the studied COL2A1 mutations. We found no genetic association between Perthes' disease and either Gaucher's disease or COL2A1 mutations or increased genetic thrombophilia among our patients compared with the control group. A systematic review of case-control studies suggested that there was a positive association between Perthes' disease and Factor V Leiden. The impact of this association upon the disease, although not consistent across the studies, remains unclear.

Predictors of early mortality after transjugular intrahepatic portosystemic shunt creation for the treatment of refractory ascites

PURPOSE

Currently there is no consensus regarding a target portosystemic gradient (PSG) after transjugular intrahepatic portosystemic shunt (TIPS) creation for the treatment of refractory ascites. The goal of this study was to examine whether the PSG after TIPS creation is predictive of subsequent mortality risk.

MATERIALS AND METHODS

Retrospective review of 99 patients who underwent successful TIPS creation for refractory ascites between January 1997 and December 2004 was performed. Follow-up consisted of clinic and emergency department visits, hospital admissions, and radiology studies (mean, 7 months). Comparison of baseline patient characteristics was performed between survivors and patients who died. Survival rates were calculated with use of the Kaplan-Meier method and compared with the log-rank test based on Model for End-stage Liver Disease (MELD) scores and PSGs before and after TIPS creation. Univariate and multivariate analysis of potential predictors of mortality was performed with Cox proportional-hazards analysis.

RESULTS

Sixteen patients died during follow-up (mean, 1.9 months after TIPS creation). The patients who died had significantly higher MELD scores before TIPS creation than did survivors (P = .04) and significantly lower PSGs before and after TIPS creation (P = .02 and P = .03, respectively). Survival rates were significantly lower for patients with higher MELD scores (P = .01) and lower PSGs before TIPS creation (P = .01) and after TIPS creation (P = .01). Multivariate analysis demonstrated that Child class C cirrhosis, MELD score greater than 25, and PSG less than 8 mm Hg after TIPS creation were the most significant predictors of mortality (increased likelihood by factors of 4, 5, and 3, respectively).

CONCLUSION

Excessive reduction of the PSG along with severe liver dysfunction is associated with an increased risk of mortality after TIPS creation in patients presenting with refractory ascites.

Arc of buhler: incidence and diameter in asymptomatic individuals

The purpose of this study was to determine the incidence and diameter of the Arc of Buhler by power injection digital subtraction angiography in asymptomatic patients. A retrospective evaluation of 120 combined celiac (CAx) and superior mesenteric artery (SMA) angiograms was carried out on potential live related liver transplant donors (asymptomatic patients) performed from January 1999 to May 2002. The diameter of the Arc of Buhler was calculated with reference to the 5 French catheters used to perform the diagnostic angiograms. It was considered hemodynamically significant if it preferential filled the branches of the other visceral vessel. An Arc of Buhler was identified in 4 patients (3.3%). All 4 patients had a patent gastroduodenal artery (GDA) and none of the 4 had a hemodynamically significant stenosis of either the SMA or the CAx. All Arcs of Buhler found measured less than 2.5 mm in diameter and half of them (2 of the 4) filled the CAx when power injecting the SMA and/or vice versa. There is a low incidence of Arc of Buhler in asymptomatic patients; however, 50% of those encountered were hemodynamically significant. When evaluating the Arc of Buhler by angiography in the setting of pathology, it is important to have a reference diameter and hemodynamic reference in the normal setting, particularly when the prospect of GDA ligation or embolization is entertained in the presence of CAx or SMA occlusion.

Five-year results of a merger between vascular surgeons and interventional radiologists in a university medical center

OBJECTIVES

We examined economic and practice trends after 5 years of a merger between vascular surgeons and interventional radiologists.

METHODS

In 1998 a merger between the Division of Vascular Surgery and the Section of Interventional Radiology at the University of Rochester established the Center for Vascular Disease (CVD). Business activity was administered from the offices of the vascular surgeons.

RESULTS

In 1998 the CVD included five vascular surgeons and three interventional radiologists, who generated a total income of $5,789,311 US dollars (34% from vascular surgeons, 24% from interventional radiologists, 42% from vascular laboratories). Vascular surgeon participation in endoluminal therapy was limited to repair of abdominal aortic aneurysms (AAAs). Income was derived from 1011 major vascular procedures, 10,510 catheter-based procedures in 3286 patients, and 1 inpatient and 3 outpatient vascular laboratory tests. In 2002 there were six vascular surgeons (five, full-time equivalent) and four interventional radiologists, and total income was $6,550,463 US dollars despite significant reductions in unit value reimbursement over the 5 years, a 4% reduction in the number of major vascular procedures, and a 13% reduction in income from vascular laboratories. In 2002 the number of endoluminal procedures increased to 16,026 in 7131 patients, and contributions to CVD income increased from 24% in 1998 to 31% in 2002. Three of the six vascular surgeons performed endoluminal procedures in 634 patients in 2002, compared with none in 1998.

CONCLUSIONS

Gross revenues increased in a declining reimbursement and conventional practice environment, because of the increased number of endoluminal procedures, in part provided by vascular surgeons. The implications of these data should be considered by those responsible for training vascular surgeons.

Benefits of external beam irradiation for peripheral arterial bypass: preliminary report on a phase I study

PURPOSE

To perform a Phase I study to determine the safety and feasibility of using external beam radiotherapy to prevent neointimal hyperplasia in patients after surgical bypass of occluded infrainguinal arteries.

METHODS AND MATERIALS

All patients undergoing operative infrainguinal bypass for chronic ischemia were eligible for enrollment, although those requiring a prosthetic graft were preferentially considered. Immediately after bypass, the distal anastomosis was marked with clips, and the baseline anatomy of the anastomosis was documented with an intraoperative angiogram. The distal anastomotic site and 2 cm of surrounding tissues were irradiated to a total dose of 30 Gy, delivered in 10 fractions. The first dose was given within 48 h of surgery.

RESULTS

Twenty-one patients were enrolled in this study. No anastomotic or wound problems or any other short-term complications of the treatment developed. However, at a mean follow-up of 10 months (range 3-18), 12 (57%) of the 21 grafts had occluded. Angiography was performed in 2 patients after successful thrombolysis and demonstrated normal anastomoses without residual stenosis. Evidence of stenosis at the irradiated anastomosis was seen in only 1 of the 21 patients by ongoing ultrasound surveillance.

CONCLUSION

Fractionated external irradiation to a total dose of 30 Gy delivered to the distal surgical anastomosis immediately after operative bypass has no short-term complications and was associated with an apparently low rate of intimal hyperplasia. However, any possible gains made by reducing the neointimal hyperplasia at the site of anastomosis were significantly diminished by the high frequency of thrombotic events.

Arterioportal fistulae following segmental liver transplantation in a child

We report a case of arterio-portal fistulae in a 12-month-old-child following a segmental liver transplantation. The fistula, probably the result of mass ligature of a vascular pedicle during back table allograft reduction, is to our knowledge the first such case reported. Diagnosed on the third post-operative day, the fistula was successfully managed with transcatheter coil embolization. The child is well and asymptomatic, 33 months after transplantation. In addition to those seen in whole organ transplantation, there are a few complications specifically related to segmental transplantation. These complications, although infrequent, are a direct consequence of the back table liver partition, as in the case herein reported.

Hepatitis B vaccination: long-term follow-up of the immune response of preterm infants and comparison of two vaccination protocols

BACKGROUND

We conducted a 3-year follow-up study of long-term antibody persistence following vaccination of low-risk preterm infants with recombinant hepatitis B vaccine (HBV). Two three-dose protocols were compared: vaccination beginning within 24 h of birth to initial vaccination delayed until a weight of 2,000 g was reached.

SUBJECTS AND METHODS

The study population included 136 children, divided into three groups: children born prematurely (< or = 35 weeks, n = 57), children born at term (> or = 37 weeks, n = 39), both groups receiving the first dose of HBV within 24 h of birth, and children born prematurely (< or = 35 weeks, n = 40), who received the first dose of HBV when a weight of 2,000 g was reached. All infants received the second hepatitis vaccination 1 month after the first, and the third dose 6 months after the first. Hepatitis B surface antibody (AntiHBs) was measured at an age of 3-3.5 years (at least 2.5 years after completion of the three-dose HBV series). An AntiHBs level of > or = 10 IU/l was considered positive.

RESULTS

At 3-3.5 years of age, a higher percentage of the premature-delayed vaccination group had a positive AntiHBs level (92.5%) compared to both the premature (54.4%, p < 0.001) and full-term groups (71.8%, p < 0.05) vaccinated soon after birth. The premature-delayed vaccination group also had a significantly higher geometric mean concentration (GMC) (119 vs 14.2 IU/l, p < 0.001 and 119 vs 32.7 IU/l, p < 0.005, respectively).

CONCLUSION

Delaying vaccination of premature infants against hepatitis B until a weight of 2,000 g was reached resulted in both a significantly higher percentage of children with positive antibody levels and a significantly higher GMC at 3-3.5 years of age as compared to early-vaccinated preterm and full-term infants. The known short-term advantage of delayed vaccination of preterm infants was shown to persist for at least the first 3 years of life.

Safety and efficacy of limited-dose tissue plasminogen activator in acute vascular occlusion

OBJECTIVE

The purposes of this study were to evaluate the safety and efficacy of limited-dose tissue plasminogen activator (t-PA) in patients with acute vascular occlusion and to compare these results with those obtained in equivalent patients receiving urokinase.

METHODS

We compared the results of 60 patients receiving catheter-directed urokinase from November 1997 to November 1998 (240,000 units/h x 4 h, 120,000 units/h thereafter for a maximum of 48 h) with those of 45 patients receiving catheter-directed t-PA from November 1998 to August 2000 (2 mg/h, total dose < or =100 mg) for acute arterial occlusion (AAO) and acute venous occlusion (AVO). Interventional approaches such as cross-catheter and coaxial techniques were used to reduce the dose of lytic agent needed to achieve pre-lysis-treatment goals (eg, complete lysis of all thrombus/unmasking graft stenosis or establishing outflow target). Statistical analysis was performed using Student t test and Fisher exact test.

RESULTS

The urokinase and t-PA groups were comparable with regard to age, comorbidities (coronary artery disease, hypertension, diabetes, renal insufficiency, smoking), duration of ischemic or occlusive symptoms, location of occlusive process, pretreatment with warfarin, and thrombotic versus embolic and native versus graft occlusion in patients with AAO. In patients with AAO and in those with AVO, t-PA was equivalent to or better than urokinase with regard to percent of clot lysis, incidence of major bleeding complications, limb salvage, and mortality. Achievement of pretreatment goals (arterial patients only) was 50% for urokinase patients and 76% for t-PA patients (P =.02). Analysis of success in individual pretreatment-goal achievement showed urokinase and t-PA to be equivalent in unmasking stenoses (85% and 84%, respectively; P = NS), whereas t-PA was superior to urokinase in the more critical task of establishing run-off (39% versus 81% for urokinase and t-PA, respectively; P =.001). Additional interventions, either endovascular or surgical, were required in 60% and 51% (P = NS) of patients receiving urokinase and t-PA, respectively, for AAO, and in 54% and 62% (P = NS) of patients receiving urokinase and t-PA, respectively, for AVO.

CONCLUSIONS

Limited-dose t-PA is a safe and effective therapy for AAO and AVO when administered by experienced teams using innovative but well-established interventional techniques.

Immunomodulatory effects of moxifloxacin in comparison to ciprofloxacin and G-CSF in a murine model of cyclophosphamide-induced leukopenia

We analyzed the effect of the two quinolones moxifloxacin and ciprofloxacin on the repopulation of hematopoietic organs and on the production of cytokines by various organs of cyclophosphamide (CP)-induced leukopenic mice. The effect was compared to that of G-CSF. Cyclophosphamide injection induced a severe leukopenia, with nadir at day 4 post-injection. All the quinolone and G-CSF-treated animals showed WBC>500/microL at the nadir, compared to 50% of saline-treated mice. Cyclophosphamide induced a marked decrease in the number of myeloid progenitors (CFU-C) in bone marrow (BM) and spleen. Quinolone or G-CSF treatment resulted in a 1.4-4.3-fold increase in CFU-C numbers in the BM; no enhancement was observed in the spleen. Treatment with CP resulted in enhanced colony-stimulating activity (CSA) in bone shaft and spleen and decreased activity in bladder and lung. Treatment of CP-injected mice with quinolones significantly enhanced CSA in the bone shaft, spleen, lung and bladder on different days. In normal mice the highest levels of GM-CSF and IL-6 were observed in lung-conditioned medium (compared to bone shaft, spleen and bladder). Injection of CP resulted in a 22.5- and 93-fold decrease in GM-CSF and IL-6 levels, respectively, in lung-conditioned medium, while treatment with quinolones resulted in 2-4-fold increase in GM-CSF with no effect on IL-6 production. G-CSF treatment had no enhancing effect on GM-CSF nor on IL-6 production. We conclude that moxifloxacin and ciprofloxacin administered to CP-injected mice revert some of the immune suppressive effects of cyclophosphamide.

Alcohol withdrawal after open aortic surgery

This study was designed to test the hypothesis that unexpected alcohol withdrawal-like syndrome (AWLS) is more common following aortic, but not other, vascular or nonvascular procedures. All patients undergoing open aortic surgery at our institution in 1997 who survived at least 48 hr were identified, as were those undergoing carotid endarterectomy, infrainguinal bypass, and total colectomy. AWLS was defined as prolonged confusion or agitation and response to conventional treatment for withdrawal, providing that all other sources had been ruled out or a significant history was present. Our results show that, for unknown reasons, AWLS is more common after aortic surgery than after other vascular and high-stress, nonaortic intraabdominal procedures at our institution, and is associated with increased length of stay and morbidity. Because prophylaxis may improve outcome, better efforts to identify patients at risk are required.

Claviculectomy for subclavian venous repair: long-term functional results

OBJECTIVES

The purpose of this study was to determine the long-term functional results after medial claviculectomy and venous patch angioplasty or bypass grafting using internal jugular vein after incomplete thrombolysis of effort thrombosis of the subclavian vein.

METHODS

The records of 11 patients with effort thrombosis who were treated over the past 9 years were reviewed. Patients have been followed up between 3 and 9 years at 6-month intervals with duplex imaging and contrast venography when indicated and have had an orthopedic evaluation of their shoulder function.

RESULTS

All reconstructed veins are patent, and only one patient complains of any arm swelling after prolonged usage. This patient is one of three with postphlebitic changes at the site of repair and has similar findings in her basilic vein. All patients have returned to their prethrombosis vocation without limitation. Four of the 11 patients have jobs requiring heavy physical labor. No patient describes any limitations of shoulder function, but one man who works as a diesel mechanic complains of shoulder aching with overuse with repetitive pulling. Three patients describe upper extremity paresthesias when lying on the operated side. Two patients (one man and one woman) are bothered by the large scar and indentation at the site of the incision. Every patient considers the overall result completely successful from a functional standpoint.

CONCLUSIONS

Early subclavian venous repair performed through a medial claviculectomy is a durable operation with excellent long-term functional results. Half of the patients noted minor but significant symptoms, but all are uniformly able to return to normal function.

Mechanical versus chemical thrombolysis: an in vitro differentiation of thrombolytic mechanisms

PURPOSE

To assess differing mechanisms of thrombolysis determining time to reperfusion, completeness of thrombus dissolution, and embolic potential.

MATERIALS AND METHODS

An in vitro perfusion model designed to mimic arterial flow conditions was created. Bifurcated limbs allowed continuous flow through one channel and the placement of radiolabeled (iodine-125) thrombus housed in a 5-cm segment of polytetrafluoroethylene graft in the other. The three experimental groups consisted of a standard continuous urokinase infusion, a pulsed pressurized injection of saline, and a similar injection with urokinase. A continuous infusion of 5% dextrose served as a control group. Time to reflow (as assessed with ultrasonic flow monitoring), completeness of thrombus dissolution (I-125 liberated into solution), and the number and size of embolic particles produced (detected by a series of graduated filter sizes) were analyzed.

RESULTS

Time to reflow was significantly faster for both groups when pressurized injections were used (P < .001). There was no reflow in the control arm at 90 minutes. Completeness of thrombus dissolution was higher when a continuous infusion of urokinase was used in comparison to either of the power injection groups or the control (P < .05). The amount of embolic debris produced was significantly lower with a continuous infusion of urokinase compared with either of the power lysis groups (P < .05), but significantly greater than the control arm (P < .001). The size of the embolic particles in the power pulsed lysis groups was significantly decreased by the addition of urokinase (P < .05).

CONCLUSIONS

Reflow is more rapidly established by the use of mechanical means. However, a less complete dissolution of thrombus in conjunction with a greater amount of embolic debris is achieved with this approach. The size of the embolic particles produced is reduced by the addition of a thrombolytic agent.

An endoluminal method of hemorrhage control and repair of ruptured abdominal aortic aneurysms

PURPOSE

To report our initial experience with endovascular grafting to treat ruptured abdominal aortic aneurysms (AAAs).

METHODS

Three consecutive patients with severe comorbid illnesses and symptoms of aneurysm rupture and hemodynamic instability were treated with aortomonoiliac grafts. The Z-stent-based devices were implanted with the assistance of an occlusion balloon placed in the distal descending thoracic aorta.

RESULTS

All patients survived the procedure with successfully excluded AAAs. Two patients had relatively short hospital stays (4 and 14 days), while the third required prolonged treatment for pre-existing conditions. All patients required blood transfusions; 2 developed significant coagulopathies. Definitive management was delayed significantly by imaging protocols and graft construction.

CONCLUSIONS

Endovascular repair of ruptured aortic aneurysms is feasible. Proximal aortic control is readily attainable with the use of an aortic occlusion balloon placed through the left axillary artery. The absence of a laparotomy, extensive retroperitoneal dissection, and aortic cross-clamping likely contributes to patient survival; however, the delay in operative therapy to obtain adequate imaging and construct an endograft could be a hindrance to the ultimate success of this approach. The concepts of alternative aortic imaging techniques and endograft design, construction, and storage must be addressed.

Photoplethysmography and calf muscle pump function after subfascial endoscopic perforator ligation

OBJECTIVE

Subfascial endoscopic perforator surgery (SEPS) results in acceptable healing and recurrence rates. The role of hemodynamic venous testing in this situation, however, is poorly understood and inconsistently used. Our ongoing experience was reviewed to explore how SEPS affects the photoplethysmographic assessment of the leg.

METHODS

Preoperative and postoperative venous refill times (VRTs) were measured with photoplethysmography in 30 limbs in 28 patients who underwent SEPS and superficial ablation, when indicated, with complete clearing of the anterolateral surface of the tibia, thus opening the deep posterior compartment from mid calf to close to the malleolus. Postoperative healing and duplex scanning were used to assess clinical and anatomic success, respectively. The VRTs were classified as "interpretable" if the leg emptied or "uninterpretable" if the calf could not empty. The "interpretable" study results were further classified as "normal" if the refill took 20 seconds or more or "abnormal" if less.

RESULTS

Before the patients underwent SEPS, six study results (20%) showed inability of the calf to empty and thus were judged uninterpretable. After the patients underwent SEPS, 12 study results (40%) were uninterpretable (NS; P =.09 with the chi(2) test). Of the 24 preoperative interpretable study results, two (8%) were normal, and of the 18 postoperative interpretable study results, seven (39%) were normal (P <.03). With the consideration of only interpretable study results, the mean VRT increased slightly from 12.0 +/- 5.1 seconds (mean +/- standard deviation) to 14.3 +/- 8.1 seconds (NS). Seventeen of 19 ulcers (89%) had healed at a mean follow-up period of 8.6 +/- 4.8 months.

CONCLUSION

Although VRT is unpredictably affected by SEPS, the most consistent finding is the inability of the calf to empty, which invalidates the remainder of the test. In addition, most ulcers heal, even with uninterpretable or abnormal postoperative VRTs. This suggests that photoplethysmography is a poor method of assessment of venous reflux after SEPS.

Treatment of transplant ureteral stenosis with endoureterotomy

PURPOSE

The safety and efficacy of treating renal transplant ureteral stenosis with the Acucise endoureterotomy catheter are described.

MATERIALS AND METHODS

We treated 4 women and 3 men 31 to 63 years old (mean age 45) with Acucise endoureterotomy for distal (6) and proximal (1) ureteral stenosis. Diagnosis was based on increasing serum creatinine and hydronephrosis on ultrasound, and confirmed by antegrade nephrostogram. One patient had recurrence and, therefore, 8 procedures were performed. Mean followup was 13 months (range 7 to 21).

RESULTS

Technical success was 100%. One patient had a recurrent stricture and was successfully re-treated. Of the patients 3 had chronic rejection and renal failure, and 4 had stable renal function. All ureters remain patent to date.

CONCLUSIONS

Treatment of short ureteral stenosis with Acucise endoureterotomy in a renal transplant is safe and effective. Furthermore, it can be performed in an ambulatory setting with minimal morbidity. This procedure should be considered as the initial approach for distal ureteral stenosis in the transplanted kidney.

A model for merging vascular surgery and interventional radiology: clinical and economical implications

BACKGROUND

The traditional separation of vascular surgery and interventional radiology into distinct units is associated with inefficiencies in patient care, practice management, and training. Traditional departmental politics, discrepant clinical backgrounds and philosophies, fear of decreasing remuneration, and basic differences in education, training, and practice have all rendered mergers difficult.

METHODS

We have implemented a model that incorporates all the clinical, fiscal, and educational activities of the 2 former entities into a single unit. A 5-physician vascular surgery group, its noninvasive laboratory, and a 3-physician interventional radiology group were unified. The revenue was deposited into a single account from which all the expenses were paid. The net income of the joint unit was apportioned on a predetermined pro rata basis, with scaled percentages for each practitioner. In an effort to separate clinical decision making from economic pressures, the individual physician remuneration was not on the basis of productivity. Clinical volume, gross revenue, and remuneration were compared with the 12-month period that immediately preceded the merger and contrasted to the previous 3-year historical trend (HT).

RESULTS

The number of vascular surgical procedures fell after the merger (-9.3%; HT, +4.7%). By contrast, the number of interventional radiology procedures rose (+56.1%; HT, +15.2%), as did the number of noninvasive testing (+9.2%; HT, +3.5%). In concordance with the number of procedures, the gross revenue of vascular surgery fell (-23.7%; HT, +1.1%) and that of interventional radiology rose (+53.5%; HT, +46.0%). The increased efficiencies allowed the total expenses of the 2 units to fall (-13.2%; HT, +7. 5%), and, despite the reduced revenue, the vascular surgeon remuneration was preserved (+0.7%; HT, -3.9%) and the radiology remuneration rose (+22.3%; HT, +8.3%). The merger allowed the vascular surgery fellows to actively participate in 26 interventional cases per month and the interventional radiology fellows to actively participate in 8 open surgical cases per month.

CONCLUSION

The merger of vascular surgery and interventional radiology resulted in a decrease in the surgical procedures and revenue, with a corresponding increase in the interventional radiology procedures and revenue. Despite these effects, the physician remuneration increased as a result of the improved efficiencies in practice management and the reduction in expenses. The merger of the 2 units excludes the economic pressures from clinical decision making and appears to be warranted on the basis of the fiscal and educational benefits that are achieved.

Endovascular treatment of renal artery thrombosis caused by umbilical artery catheterization

Renal arterial thrombosis, usually in association with aortic thrombosis, has been reported as a result of prolonged neonatal umbilical artery catheterization. A case of renal artery thrombosis attributable to umbilical artery catheterization, resulting in malignant renovascular hypertension, in a 15-day-old neonate, treated by catheter-directed thrombolysis through the involuting umbilical artery, was studied. Resolution of systemic hypertension and partial return of right renal function followed rapid thrombus dissolution.

Endovascular and open surgical treatment of brachiocephalic arterial disease

The treatment of occlusive lesions in the innominate, subclavian, and axillary arteries has, until recently, been entirely surgical. Recently, advances in endovascular technologies have provided an alternative means of therapy. The advent of balloon angioplasty has resulted in some turmoil between medical specialties regarding patient selection and acceptable applications. Innovations in imaging, guidewire, catheter, stent, and balloon technology allow one to obtain percutaneous access and perform therapeutic procedures in a relatively safe manner. However, the excellent and time-tested results of surgery remain a standard for developing new procedures. Despite the appeal of less invasive techniques, the morbidity, mortality, and durability of novel treatments must equal or exceed those standards set by surgical procedures. Proponents of the endovascular options must familiarize themselves with advantages and disadvantages of surgical procedures. In a similar manner, surgeons have an obligation to understand the less invasive technologies as well. The clinician must uphold the best interests of the patient as a fundamental factor in the determination of a particular form of therapy. This paradox is well illustrated by consideration of occlusive lesions in the upper extremity.

Prohibitive failure rate of the total articular replacement arthroplasty at five to ten years

Five- to 10-year follow-up was obtained on a series of total articular replacement arthroplasties performed at a single university-affiliated teaching hospital. Eighty arthroplasties were performed on 64 patients. Twelve patients (accounting for 14 hip arthroplasties) died. Follow-up was obtained on 62 of the 66 remaining hips (94%). Thirty-five hips had been revised (56%), 32 for acetabular loosening and 3 for femoral loosening, 1 of which led to femoral stem fracture. The average time to revision was 72 months (22 to 132 months). The revision procedures were extensive in terms of operative time, blood loss, and necessity of acetabular bone grafting. Follow-up of the 27 that had not been revised averaged 84 months and revealed 1 hip excellent, 5 good, 1 fair, and 20 poor results. The overall clinical failure rate (revisions plus clinically poor results) was 89% (55/62 hips). These results are far inferior to conventional total hip replacement, and the extent of the revision procedures indicates that this is not a conservative alternative to conventional total hip replacement.

MRI meningeal enhancement with intracranial hypotension caused by lumbar puncture

A 12-year-old girl with recent history of pseudotumor cerebri developed severe postural headache due to intracranial hypotension after lumbar puncture. Meningeal enhancement and thickening were demonstrated on magnetic resonance imaging. Repeated imaging 3 months later disclosed no abnormalities. This is the first report of a child with evident meningeal enhancement on magnetic resonance imaging related to lumbar puncture.

Nonoperative treatment of double lateral ligament tears of the ankle

In this article the objective evaluation of 39 cases of double lateral ligament tears of the ankle treated by cast immobilization is described. Such treatment resulted in a 79.5% success rate as determined by repeat stress roentgenograms. In addition, a statistical method which may aid the orthopaedist in deciding whether to use nonoperative or operative treatment is presented.

Treatment of chronic childhood asthma with beclomethasone dipropionate aerosols: II. Effect on pituitary-adrenal function after substitution for oral corticosteroids

The effects of beclomethasone, dipropionate aerosol (DBA) (400 microgram/day) on clinical course, pulmonary function, and pituitary-adrenal function was studied in 34 steroid-dependent asthmatic children. Asthma severity was assessed by daily symptom and medication scores, peak flow measured three times a day, and weekly spirometry. Pituitary-adrenal function was evaluated by diurnal cortisol levels, cortisol responses to intravenous (IV) corticotropin (ACTH), and steroid responses to IV metyrapone. After 12 weeks of BDA therapy, 30 of 34 patients no longer required prednisone. Mean weekly symptom and medication scores and the number of attacks decreased significantly (P less than .01)). A significant improvement was demonstrated in the patients' peak flow (P less than .01), forced expiratory volume in one second, and maximum midexpiratory flow rates (P less than .01). Thirty of the 34 patients initially had abnormal metyrapone responses, 28 had abnormal diurnal cortisol levels, whereas only 14 had abnormal IV ACTH response tests. Although significant improvement was noted in the mean metyrapone and diurnal cortisol tests, only partial recovery of pituitary-adrenal function was observed in 20 patients, complete recovery in 5, and no change in 9. BDA was found to be therapeutically superior to oral steroids in the group of steroid-dependent asthmatic children and produced no serious adverse effects.

Pulmonary vascular disease after systemic-pulmonary arterial shunt operations

More than 1,100 patients underwent a systemic-pulmonary arterial shunt operation at the Children's Memorial Hospital, Chicago, from 1946 to 1974. Of these patients, 294 were studied to assess the presence of pulmonary vascular disease and the time of its occurrence after surgery. They were selected either because lung tissue was available for histologic grading of pulmonary vascular disease (114 patients) or because hemodynamic studies were performed after the shunt operation (180 patients). The shunts, all patent at the time of the study, ranged in duration from 1 month to 23 years. After a subclavan-pulmonary arterial shunt (75 patients) there was little evidence of advatients) pulmonary vascular disease in either histologic C2 of 25 patients) or hemodynamic (1 of 50 patients) studies. After an aortic-pulmonary arterial shunt (44 Waterston, 175 Potts) there was small likelikhood of advanced pulmonary vascular disease with a shunt duration of less than 5 years (1 of 35 histologic, 0 of 27 hemodynamic studies). With a shunt duration of more than 5 years the incidence of advanced pulmonary vascular disease increased significantly (15 of 54 histologic, 17 of 103 hemodynamic studies). A mean pulmonary arterial pressure of 50 mm Hg or greater strongly suggests the presence of advanced pulmonary vascular disease. When a systemic-pulmonary arterial shunt has provided effective palliation with decreased pulmonary pressure there is small likelihood that advanced pulmonary vascular disease will develop, even with a long shunt duration of 20 to 25 years.