Showing papers by "University of Iowa Hospitals and Clinics published in 2012"

Improved survival with MEK Inhibition in BRAF-mutated melanoma for the METRIC Study Group

Abstract: Background Activating mutations in serine–threonine protein kinase B-RAF (BRAF) are found in 50% of patients with advanced melanoma Selective BRAF-inhibitor therapy improves survival, as compared with chemotherapy, but responses are often short-lived In previous trials, MEK inhibition appeared to be promising in this population Methods In this phase 3 open-label trial, we randomly assigned 322 patients who had metastatic melanoma with a V600E or V600K BRAF mutation to receive either trametinib, an oral selective MEK inhibitor, or chemotherapy in a 2:1 ratio Patients received trametinib (2 mg orally) once daily or intravenous dacarbazine (1000 mg per square meter of body-surface area) or paclitaxel (175 mg per square meter) every 3 weeks Patients in the chemotherapy group who had disease progression were permitted to cross over to receive trametinib Progression-free survival was the primary end point, and overall survival was a secondary end point Results Median progression-free survival was 48 months in the trametinib group and 15 months in the chemotherapy group (hazard ratio for disease progression or death in the trametinib group, 045; 95% confidence interval [CI], 033 to 063; P<0001) At 6 months, the rate of overall survival was 81% in the trametinib group and 67% in the chemotherapy group despite crossover (hazard ratio for death, 054;95% CI, 032 to 092; P = 001) Rash, diarrhea, and peripheral edema were the most common toxic effects in the trametinib group and were managed with dose interruption and dose reduction; asymptomatic and reversible reduction in the cardiac ejection fraction and ocular toxic effects occurred infrequently Secondary skin neoplasms were not observed Conclusions Trametinib, as compared with chemotherapy, improved rates of progression-free and overall survival among patients who had metastatic melanoma with a BRAF V600E or V600K mutation (Funded by GlaxoSmithKline; METRIC ClinicalTrials gov number, NCT01245062)

Trends in Survival after In-Hospital Cardiac Arrest

Abstract: Background Despite advances in resuscitation care in recent years, it is not clear whether survival and neurologic function after in-hospital cardiac arrest have improved over time. Methods We identified all adults who had an in-hospital cardiac arrest at 374 hospitals in the Get with the Guidelines–Resuscitation registry between 2000 and 2009. Using multivariable regression, we examined temporal trends in risk-adjusted rates of survival to discharge. Additional analyses explored whether trends were due to improved survival during acute resuscitation or postresuscitation care and whether they occurred at the expense of greater neurologic disability in survivors. Results Among 84,625 hospitalized patients with cardiac arrest, 79.3% had an initial rhythm of asystole or pulseless electrical activity, and 20.7% had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P<0.001 for trend). Risk-adjus...

Long-term health-related quality of life in survivors of head and neck cancer

Abstract: Objective To examine health-related quality of life (HRQOL) reported by 5-year head and neck cancer survivors and factors that predicted these long-term scores. Design Prospective, observational outcomes study. Setting Tertiary care institution. Patients A total of 337 patients diagnosed as having head and neck carcinoma between January 1995 and December 2004, who enrolled in the Outcomes Assessment Project and survived at least 5 years. Interventions While participating in the longitudinal Outcomes Assessment Project, patients filled out surveys measuring HRQOL at numerous points in time. Main Outcome Measures Outcomes included 5-year scores in eating, speech, aesthetics, social disruption, physical and mental health, depressive symptoms, and overall quality of life (QOL). In addition to analyzing patients' 5-year HRQOL outcomes, multivariate analyses were performed to determine which patient, clinical, treatment, and 1-year HRQOL factors independently predicted these 5-year outcomes. Results Overall, the cohort's long-term general health was similar to that to age-matched norms from the general population. But over 50% of these survivors had problems eating, 28.5% reported depressive symptoms, and 17.3% reported substantial pain. At long-term follow-up, 13.6% continued to smoke, and 38.9% used alcohol. Multivariate analyses demonstrated that 1-year pain and diet were the strongest independent predictors of 5-year HRQOL outcomes. Conclusions Eating problems due to poor oropharyngeal functioning and persistent pain are the most prevalent problems that these survivors face. Early interventions addressing eating issues, swallowing problems, and pain management will be a crucial component in improving this patient population's long-term QOL, especially in those who are functioning poorly 1 year after diagnosis.

Postoperative Complications of Posterior Ankle and Hindfoot Arthroscopy

Abstract: Background: Posterior ankle and hindfoot arthroscopy, performed with use of posteromedial and posterolateral portals with the patient in the prone position, has been utilized for the treatment of various disorders. However, there is limited literature addressing the postoperative complications of this procedure. In this study, the postoperative complications in patients treated with posterior ankle and hindfoot arthroscopy were analyzed to determine the type, rate, and severity of complications. Methods: The study included 189 ankles in 186 patients (eighty-two male and 104 female; mean age, 37.1 ± 16.4 years). The minimum duration of follow-up was six months, and the mean was 17 ± 13 months. The most common preoperative intra-articular diagnoses were subtalar osteoarthritis (forty-six ankles), an osteochondral lesion of the talus (forty-two), posterior ankle impingement (thirty-four), ankle osteoarthritis (twenty), and subtalar coalition (five). The most common extra-articular diagnoses were painful os trigonum (forty-six), flexor hallucis longus tendinitis (thirty-two), and insertional Achilles tendinitis (five). Results: The most common intra-articular procedures were osteochondral lesion debridement (forty-four ankles), subtalar debridement (thirty-eight), subtalar fusion (thirty-three), ankle debridement (thirty), and partial talectomy (nine). The most common extra-articular procedures were os trigonum excision (forty-eight), tenolysis of the flexor hallucis longus tendon (thirty-eight), and endoscopic partial calcanectomy (five). Complications were noted following sixteen procedures (8.5%); four patients had plantar numbness, three had sural nerve dysesthesia, four had Achilles tendon tightness, two had complex regional pain syndrome, two had an infection, and one had a cyst at the posteromedial portal. One case of plantar numbness and one case of sural nerve dysesthesia failed to resolve. Conclusions: Our experience demonstrated that posterior ankle and hindfoot arthroscopy can be performed with a low rate of major postoperative complications. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Macrophage imbalance (M1 vs. M2) and upregulation of mast cells in wall of ruptured human cerebral aneurysms: preliminary results

Abstract: M1 and M2 cells are two major subsets of human macrophages that exert opposite effects on the inflammatory response. This study aims to investigate the role of macrophage M1/M2 imbalance and mast cells in the progression of human cerebral aneurysms to rupture. Ten patients with cerebral aneurysms (five ruptured and five unruptured) underwent microsurgical clipping. During the procedure, a segment of the aneurysm dome was resected and immunostained with monoclonal antibodies for M1 cells (anti-HLA DR), M2 cells (anti-CD 163), and mast cells (anti-tryptase clone AA). A segment of the superficial temporal artery (STA) was also removed and immunostained with monoclonal antibodies for M1, M2, and mast cells. All ten aneurysm tissues stained positive for M1, M2, and mast cells. M1 and M2 cells were present in equal proportions in unruptured aneurysms. This contrasted with a marked predominance of M1 over M2 cells in ruptured aneurysms (p = 0.045). Mast cells were also prominently upregulated in ruptured aneurysms (p = 0.001). Few M1 and M2 cells were present in STA samples. M1/M2 macrophages and mast cells are found in human cerebral aneurysms; however, M1 and mast cell expression seems to markedly increase in ruptured aneurysms. These findings suggest that macrophage M1/M2 imbalance and upregulation of mast cells may have a role in the progression of cerebral aneurysms to rupture.

Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study.

Abstract: Background: Recent studies have shown that it is difficult to accurately reduce and assess the reduction of the syndesmosis after ankle injury. The syndesmosis is most commonly reduced with use of reduction clamps to compress across the tibia and fibula. However, intraoperative techniques to optimize forceps reductions to restore syndesmotic relationships accurately have not been systematically studied. The purpose of the present study was to evaluate the accuracy of syndesmosis reduction with different rotational vectors of clamp placement. Methods: Ten through-the-knee cadaveric specimens were used. Markers were placed on the tibia and fibula to produce consistent clamp placement and radiographic evaluation. A computed tomographic scan of the ankle was made to serve as a control, followed by a stepwise destabilization of the anterior inferior tibiofibular ligament, syndesmosis, deltoid ligament, small posterior malleolus fracture, and large posterior malleolus fracture. Following each step in the destabilization, clamps were applied to compress the syndesmosis at varying angles and computed tomography was performed to measure the alignment of the syndesmosis as compared with that on the control scan. Results: In all degrees of induced instability, and for all vectors of clamp placement, a small but consistent amount of overcompression of the syndesmosis was observed. The average overcompression (and standard deviation) for all samples was 0.93 ± 0.70 mm. Both obliquely oriented clamp arrangements consistently caused fibular malreductions in the sagittal plane. Placing the clamp in the neutral anatomical axis reduced the syndesmosis most accurately, with an average displacement of 0.1 ± 0.77 mm compared with control through all degrees of instability. Conclusions: Clamp placement in the neutral anatomical axis reduced the syndesmosis most accurately in our cadaveric model, although slight overcompression was frequently observed. Placing the clamp obliquely malreduced the unstable syndesmosis. Clinical Relevance: Clampplacementintheneutralanatomicalaxisappearstobepreferredinthesyndesmosisreduction.

Automated segmentation of the choroid from clinical SD-OCT.

Abstract: Purpose We developed and evaluated a fully automated 3-dimensional (3D) method for segmentation of the choroidal vessels, and quantification of choroidal vasculature thickness and choriocapillaris-equivalent thickness of the macula, and evaluated repeat variability in normal subjects using standard clinically available spectral domain optical coherence tomography (SD-OCT). Methods A total of 24 normal subjects was imaged twice, using clinically available, 3D SD-OCT. A novel, fully-automated 3D method was used to segment and visualize the choroidal vasculature in macular scans. Local choroidal vasculature and choriocapillaris-equivalent thicknesses were determined. Reproducibility on repeat imaging was analyzed using overlapping rates, Dice coefficient, and root mean square coefficient of variation (CV) of choroidal vasculature and choriocapillaris-equivalent thicknesses. Results For the 6 × 6 mm(2) macula-centered region as depicted by the SD-OCT, average choroidal vasculature thickness in normal subjects was 172.1 μm (95% confidence interval [CI] 163.7-180.5 μm) and average choriocapillaris-equivalent thickness was 23.1 μm (95% CI 20.0-26.2 μm). Overlapping rates were 0.79 ± 0.07 and 0.75 ± 0.06, Dice coefficient was 0.78 ± 0.08, CV of choroidal vasculature thickness was 8.0% (95% CI 6.3%-9.4%), and of choriocapillaris-equivalent thickness was 27.9% (95% CI 21.0%-33.3%). Conclusions Fully automated 3D segmentation and quantitative analysis of the choroidal vasculature and choriocapillaris-equivalent thickness demonstrated excellent reproducibility in repeat scans (CV 8.0%) and good reproducibility of choriocapillaris-equivalent thickness (CV 27.9%). Our method has the potential to improve the diagnosis and management of patients with eye diseases in which the choroid is affected.

Early Change in Ferumoxytol-Enhanced Magnetic Resonance Imaging Signal Suggests Unstable Human Cerebral Aneurysm A Pilot Study

Abstract: Background and Purpose— The clinical significance of early (ie, within the first 24 hours) uptake of ferumoxytol by macrophages in the wall of human cerebral aneurysms is not clear The purpose of this study was to determine whether early uptake of ferumoxytol suggests unstable cerebral aneurysm Methods— Thirty unruptured aneurysms in 22 patients were imaged with magnetic resonance imaging 24 hours after infusion of ferumoxytol Eighteen aneurysms were also imaged 72 hours after infusion of ferumoxytol Aneurysm dome tissue was collected from 4 patients with early magnetic resonance imaging signal changes, 5 patients with late signal changes, and 5 other patients with ruptured aneurysms The tissue was immunostained for expression of cyclooxygenase-1, cyclooxygenase-2, microsomal prostaglandin E2 synthase-1, and macrophages Results— In 23% (7/30) of aneurysms, there was pronounced early uptake of ferumoxytol Four aneurysms were clipped The remaining 3 aneurysms were managed conservatively; all 3 ruptured within 6 months In 53% (16 of 30) of aneurysms, there was pronounced uptake of ferumoxytol at 72 hours Eight aneurysms were surgically clipped, and 8 were managed conservatively; none ruptured or increased in size after 6 months Expression of cyclooxygenase-2, microsomal prostaglandin E2 synthase-1, and macrophages was similar in unruptured aneurysms with early uptake of ferumoxytol and ruptured aneurysms Expression of these inflammatory molecules was significantly higher in aneurysms with early uptake of ferumoxytol versus aneurysms with late uptake Conclusions— Uptake of ferumoxytol in aneurysm walls within the first 24 hours strongly suggests aneurysm instability and probability of rupture within 6 months, and may warrant urgent intervention

Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery

Abstract: Object Postoperative CSF leakage can be a serious complication after a transsphenoidal surgical approach An elevated body mass index (BMI) is a significant risk factor for spontaneous CSF leaks However, there is no evidence correlating BMI with postoperative CSF leak after transsphenoidal surgery The authors hypothesized that patients with elevated BMI would have a higher incidence of CSF leakage complications following transsphenoidal surgery Methods The authors conducted a retrospective review of 121 patients who, between August 2005 and March 2010, underwent endoscopic endonasal transsphenoidal surgeries for resection of primarily sellar masses Patients requiring extended transsphenoidal approaches were excluded A multivariate statistical analysis was performed to investigate the association of BMI and other risk factors with postoperative CSF leakage Results In 92 patients, 96 endonasal endoscopic transsphenoidal surgeries were performed that met inclusion criteria Thirteen postoperative leaks

Growth in VLBW infants fed predominantly fortified maternal and donor human milk diets: a retrospective cohort study

Abstract: To determine the effect of human milk, maternal and donor, on in-hospital growth of very low birthweight (VLBW) infants. We performed a retrospective cohort study comparing in-hospital growth in VLBW infants by proportion of human milk diet, including subgroup analysis by maternal or donor milk type. Primary outcome was change in weight z-score from birth to hospital discharge. Retrospective cohort study. 171 infants with median gestational age 27 weeks (IQR 25.4, 28.9) and median birthweight 899 g (IQR 724, 1064) were included. 97% of infants received human milk, 51% received > 75% of all enteral intake as human milk. 16% of infants were small-for-gestational age (SGA, 75% human milk had a greater negative change in weight z-score from birth to discharge compared to infants receiving 75% human milk, there was no significant difference in change in weight z-score by milk type (donor −0.84, maternal −0.56, mixed −0.45, p = 0.54). Infants receiving >75% donor milk had higher rates of SGA status at discharge than those fed maternal or mixed milk (56% vs. 35% (maternal), 21% (mixed), p = 0.08). VLBW infants can grow appropriately when fed predominantly fortified human milk. However, VLBW infants fed >75% human milk are at greater risk of poor growth than those fed less human milk. This risk may be highest in those fed predominantly donor human milk.

Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65 patients.

Abstract: Background Stent-assisted coiling in the setting of subarachnoid hemorrhage remains controversial. Currently, there is a paucity of data regarding the utility of this procedure and the risks of hemorrhagic and ischemic complications. Objective To assess the utility of stent-assisted coil embolization and pretreatment with antiplatelet agents in the management of ruptured wide-necked aneurysms. Methods A retrospective study of 65 patients with ruptured wide-necked aneurysms treated with stent-assisted coiling. Patients with hydrocephalus or a Hunt and Hess grade ≥ III received a ventriculostomy before endovascular intervention. Patients were treated intraoperatively with 600 mg of clopidogrel and maintained on daily doses of 75 mg of clopidogrel and 81 mg of aspirin. The Glasgow outcome scale (GOS) score was recorded at the time of discharge. We identified major bleeding complications secondary to antiplatelet therapy and cases of in-stent thrombosis that required periprocedural thrombolysis. Results Of the aneurysms, 66.2% arose within the anterior circulation; 69.2% of patients presented with hydrocephalus or a Hunt and Hess grade ≥ III and required a ventriculostomy. A good outcome (GOS of 4 or 5) was achieved in 63.1% of patients, and the overall mortality rate was 16.9%. There were 10 (15.38%) major complications associated with bleeding secondary to antiplatelet therapy (5 patients, 7.7%) or intraoperative in-stent thrombosis (5 patients, 7.7%). Three (4.6%) patients had a fatal hemorrhage. Conclusion Our findings suggest that stent-assisted coiling and routine treatment with antiplatelet agents is a viable option in the management of ruptured wide-necked aneurysms.

Upregulation of Cyclooxygenase-2 (COX-2) and Microsomal Prostaglandin E2 Synthase-1 (mPGES-1) in Wall of Ruptured Human Cerebral Aneurysms Preliminary Results

Abstract: Background and Purpose—Cyclooxygenase-2 (COX-2) and Microsomal Prostaglandin E2 Synthase-1 (mPGES-1) catalyze isomerization of the cyclooxygenase product PGH2 into PGE2. Deletion of COX-2/mPGES-1 suppresses carotid artery atherogenesis and angiotensin II-induced aortic aneurysms formation, and attenuates neointimal hyperplasia after vascular injury in mice. The upregulation of COX-2/mPGES-1 in the wall of ruptured human cerebral aneurysms is not known. Methods—Ten patients with intracranial aneurysms (5 ruptured and 5 nonruptured) underwent microsurgical clipping. During the procedure, a segment of the aneurysm dome was resected and immunostained with monoclonal antibodies for COX-1, COX-2, and mPGES-1. A segment of the superficial temporal artery was also removed and immunostained with monoclonal antibodies for COX-1, COX-2, and mPGES-1. Results—All 10 aneurysm tissues stained positive for mPGES-1 monoclonal antibody. Expression of mPGES-1 was more abundant in ruptured aneurysm tissue than in nonruptured...

Association between severity of dysphagia and survival in patients with head and neck cancer

Abstract: Dysphagia is a common and potentially life-threatening occurrence in patients with head and neck cancer, often associated with anatomic and physiologic changes in the oral and pharyngeal cavities due to surgical, radiation, and/or chemoradiation treatments.1–4 The incidence of posttreatment dysphagia in these patients has previously been reported as falling between approximately 50% and 60%.5–9 It has been suggested, though, that dysphagia and rates of aspiration are often underreported because physicians, the common source of referral for swallowing function assessment services, may underestimate or misidentify severity and refer only overtly symptomatic patients.7,9–11 It has also been estimated that 30% to 50% of patients with head and neck cancer demonstrate some degree of malnutrition.12 The combination of dysphagia with poor nutrition, significant weight loss, and impaired immune function often results in cachexia (full-body wasting and muscle atrophy), fatigue, high susceptibility to infection, poor wound healing, or death.12,13 Regardless of the shift toward organ-sparing, non-surgical treatment to preserve function in patients with head and neck cancer, all current modalities can result in swallowing problems, along with aspiration and aspiration pneumonia.14 Surgical resection can damage the muscles most critical to swallowing, including the intrinsic and extrinsic muscles of the tongue and larynx, which can lead to dysphagia.4,15 Radiation and chemotherapy often cause mucositis, neuromuscular fibrosis, and lymphedema changes in the mucosa and muscle tissues and can alter the coordination and flexibility of the swallowing process.1,4,16 These swallowing difficulties can be further exacerbated by the secondary consequences of prolonged NPO ([L.] nil per os or “nothing by mouth”) status, which is a common sequela among patients with head and neck cancer. Prolonged NPO status is directly correlated with worse swallowing outcomes and increased risk for dysphagia.7,17 Atrophy of pharyngeal and tongue-base musculature and increased pharyngeal fibrosis with overall deconditioning can result both from general nonuse of swallowing musculature and from a marked decrease in patient swallows (volitional or spontaneous).3,7 The biopsychosocial ramifications of dysphagia are widespread. Dysphagia can directly result in decreased eating, malnutrition, and weight loss, and the necessity for prolonged enteral feeding, all of which are associated with decreased survival.18–20 Swallowing problems can also result in decreased social participation and increased anxiety, social isolation, and depression, which in turn can lead to decreased quality of life.9 One goal of head and neck cancer research is to identify factors predictive of survival, which can lead to more effective treatment decisions and more accurate prognosis. Although tumor stage and site are well-known predictors of survival in patients with head and neck cancer,18,21 nutritionally related variables also appear to have potent prognostic implications. Weight loss has been shown to be one of the strongest independent predictors of survival, more powerful than stage or site.18 Patients with continued oral intake, in the presence of a gastrostomy tube, were more likely to maintain their weight and have higher survival rates compared with patients who had no continued oral intake.19 Domains specifically related to health-related quality of life, including eating, were also positively associated with survival.20 The extent of the correlation between dysphagia and survival, however, remains unclear. The purpose of this study was to determine the risk factors for developing dysphagia in patients with head and neck cancer and to examine whether the severity of dysphagia was associated with survival. A retrospective design was used to merge existing cancer registry and billing data with ratings provided by speech-language pathologists that quantified the severity of swallowing problems in patients with documented dysphagia.

Congenital pancytopenia and absence of B lymphocytes in a neonate with a mutation in the ikaros gene

Abstract: Background Congenital pancytopenia is a rare and often lethal condition. Current knowledge of lymphoid and hematopoietic development in mice, as well as understanding regulators of human hematopoiesis, have led to the recent discovery of genetic causes of bone marrow failure disorders. However, in the absence of mutations of specific genes or a distinct clinical phenotype, many cases of aplastic anemia are labeled as idiopathic, while congenital immune deficiencies are described as combined immune deficiency.

Cementless total hip arthroplasty in patients fifty years of age or younger: a minimum ten-year follow-up.

Abstract: Background: The durability of total hip arthroplasty in younger patients has been reported to be less than that in older patients. The purpose of this study was to evaluate the results of cementless total hip arthroplasty performed in a consecutive series of patients fifty years of age or younger who were followed for a minimum of ten years. Methods: We prospectively followed 100 consecutive patients (115 hips) who were fifty years of age or younger when they were treated with primary cementless total hip arthroplasty with use of a second-generation, extensively porous-coated femoral stem and a cementless acetabular component. The patients were followed for a minimum of ten years, and the results were compared with our patients in the same age group who had total hip arthroplasty with cement. Evaluation included the need for revision, activity questionnaires, six-minute walks, activity level monitoring with an accelerometer, and radiographic evaluation for evidence of loosening, wear, and osteolysis. Results: Seventy-three patients (eighty-two hips) were available for follow-up at ten years (mean, twelve years). Seventeen patients (twenty-three hips) had died, and ten patients (ten hips) were lost to follow-up. The average age at the time of surgery was 40.1 years. Three femoral stems were revised for periprosthetic fracture. No acetabular shell or femoral stem was revised for loosening, and none were loose on radiographs made at the time of a minimum ten-year follow-up. This compares favorably with the cemented cohort, which had poorer survivorship of the implant with regard to revision for aseptic loosening and radiographic loosening. Reoperation for any reason was similar between the two cohorts at ten years, primarily because of the relatively large numbers of revisions for polyethylene wear in the cementless group. Conclusions: Cementless total hip arthroplasty with use of a second-generation, extensively porous-coated stem demonstrated durable fixation in an active, younger population at a minimum follow-up of ten years and had better survivorship with respect to fixation compared with our previously reported cemented cohort. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Heat stress and cardiovascular, hormonal, and heat shock proteins in humans.

Abstract: Context: Conditions such as osteoarthritis, obesity, and spinal cord injury limit the ability of patients to exercise, preventing them from experiencing many well-documented physiologic stressors. Recent evidence indicates that some of these stressors might derive from exercise-induced body temperature increases. Objective: To determine whether whole-body heat stress without exercise triggers cardiovascular, hormonal, and extra-cellular protein responses of exercise. Design: Randomized controlled trial. Setting: University research laboratory. Patients or Other Participants: Twenty-five young, healthy adults (13 men, 12 women; age = 22.1 ± 2.4 years, height = 175.2 ± 11.6 cm, mass = 69.4 ± 14.8 kg, body mass index = 22.6 ± 4.0) volunteered. Intervention(s): Participants sat in a heat stress chamber with heat (73°C) and without heat (26°C) stress for 30 minutes on separate days. We obtained blood samples from a subset of 13 participants (7 men, 6 women) before and after exposure to heat stress. Main Outcom...

The effect of lung size mismatch on complications and resource utilization after bilateral lung transplantation.

Abstract: Background Oversizing the lung allograft, as estimated by a donor-to-recipient predicted total lung capacity (pTLC) ratio > 1.0, was associated with improved long-term survival after lung transplantation (LTx) but could be associated with increased post-operative complications and higher resource utilization. Methods The prospectively maintained LTx database at The Johns Hopkins Hospital was retrospectively reviewed for bilateral LTx patients in the post-Lung Allocation Score (LAS) era. Patients were grouped by pTLC ratio ≤ 1.0 (undersized) or > 1.0 (oversized). Post-operative complications and hospital charges were analyzed. Results The pTLC ratio was available for 70 patients: 31 were undersized and 39 oversized. Undersized patients had a higher LAS (40.4 vs 35.8, p = 0.009), were more often in the intensive care unit (ICU) pre-LTx (35% vs 10%, p = 0.01), and had a higher occurrence of primary graft dysfunction (PGD; 25% vs 5%, p = 0.013) and tracheostomy (32% vs 10%, p = 0.02), longer index hospitalizations (20 [interquartile range (IQR), 10–46] vs 16 [IQR, 12–25] days, p = 0.048), and higher index hospitalization charges ($176,247 [IQR, $137,646–$284,012] vs $158,492 [IQR, $136,250–$191,301], p = 0.04). After adjusting for LAS and pre-LTx ICU stay, a lower pTLC ratio remained associated with higher hospital charges ( p = 0.049). Airway complications were more frequent and severe in undersized patients. Conclusion Oversized allografts were not associated with an increase in post-LTx complications. However, LTx recipients of undersized allografts were more likely to experience PGD, tracheostomy, and had higher resource utilization. Higher acuity in the undersized group might explain these findings; however, multivariate models suggest an independent association between undersizing, PGD, and resource utilization.

Cervical decompression and reconstruction without intraoperative neurophysiological monitoring.

Abstract: Object The primary goal of this study was to review the immediate postoperative neurological function in patients surgically treated for symptomatic cervical spine disease without intraoperative neurophysiological monitoring The secondary goal was to assess the economic impact of intraoperative monitoring (IOM) in this patient population Methods This study is a retrospective review of 720 consecutively treated patients who underwent cervical spine procedures The patients were identified and the data were collected by individuals who were not involved in their care Results A total of 1534 cervical spine levels were treated in 720 patients using anterior, posterior, and combined (360°) approaches Myelopathy was present preoperatively in 308 patients There were 185 patients with increased signal intensity within the spinal cord on preoperative T2-weighted MR images, of whom 43 patients had no clinical evidence of myelopathy Three patients (04%) exhibited a new neurological deficit postoperatively Of

Epidemiology of sebaceous carcinoma of the head and neck: implications for lymph node management.

Abstract: Background. The purpose of this study was to describe the incidence of nodal disease in sebaceous carcinoma and its impact on survival. Methods. Data from the 17 registries of the Surveillance, Epidemiology, and End Results (SEER) database was retrospectively collected for sebaceous carcinoma from 1973 to 2007. Information on location, histologic grade, stage of disease, and survival was gathered. Results. One thousand eight hundred thirty-six sebaceous carcinomas were diagnosed during the time period: 633 (34.5%) in the eyelid and 786 (42.8%) in the extraocular head and neck skin. Eyelid sebaceous carcinomas had higher histologic grade compared with tumors in extraocular sites (p < .001). Ocular sebaceous carcinomas had a higher incidence of regional or distant metastases at presentation (4.4%) compared with extraocular head and neck sites (0.9%; p ¼ .03). There was a high incidence of Nþ disease in poorly differentiated ocular sebaceous carcinomas (15.2%). Conclusion. The incidence of nodal disease was higher with eyelid tumors. Sentinel lymph node biopsy can be considered for eyelid tumors, but not for non-eyelid head and neck tumors. V C 2012 Wiley Periodicals, Inc. Head Neck 34: 1765-1768, 2012 Sebaceous carcinoma is a rare cutaneous tumor that origi- nates from adnexal structures of the skin. It is found pre- dominantly in the head and neck and is commonly found in the eyelid, in association with the meibomian glands, or glands of Zeis. 1 It is the third most common malignant tumor of the eyelids. 2 The incidence of the disease seems to be rising. 3 Risk factors for this disease are advanced age, white race, and genetic predisposition, where Muir-Torre syndrome is associated with sebaceous carcinoma. 3-5 Sebaceous carcinoma has an aggressive potential, with up to 14% to 25% locoregional and distant spread reported. 6 Standard surgical resection with wide margins (10 mm) is a common treatment for sebaceous carcinoma, whereas special care needs to be taken for resections of eyelid tumors. Radiation therapy alone is not recom- mended, and there is limited information regarding its use in the adjuvant setting. 6

Craniovertebral junction abnormalities with hindbrain herniation and syringomyelia: regression of syringomyelia after removal of ventral craniovertebral junction compression

Abstract: The hindbrain herniation syndrome occurs frequently with craniovertebral junction (CVJ) abnormalities that reduce posterior fossa volume. Syringohydromyelia (SHM) is often present. Posterior fossa dorsal decompression (PFD) is customary, but has an adverse outcome when ventral bony abnormality exists in these circumstances. The results of a prospective study on CVJ abnormalities with Chiari malformation I (CM1) and SHM are presented. Between 1984 and 1999 (MRI era), 428 patients aged 6–68 years underwent operation for CM1; 154 had ventral CV abnormalities; 44 had associated SHM. Twelve had bone softening states with secondary basilar impression (6 previous PFD and 6 fusions); 26 had primary basilar invagination (10 had PFD, 9 previous syrinx-subarachnoid shunts and syrinx to peritoneal shunts). Symptoms reflected brainstem and high cervical myelopathy and cranial nerve deficits. Neurodiagnostic imaging included CT and MRI in dynamic modes and cine flow studies. All 44 patients had irreducible ventral CVJ bony invagination and underwent transpalatopharyngeal decompression of the cervicomedullary junction and dorsal occipitocervical fusion. Cervicothoracic SHM was present in 30, thoracic in 6, and holocord in 6. Brainstem symptoms regressed in 36 of the 44 patients; myelopathy regressed in 38 of 44 patients; and SHM showed MRI resolution in 34 of 44. Neurological improvement and SHM resolution can occur with ventral cervicomedullary junction decompression in patients with basilar invagination and basilar impression, likely because of relief of the neural encroachment and reestablishment of CSF pathways.