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Background Fever during neutropenia and after neutrophil engraftment (post-engraftment fever) occurs commonly during autologous transplantation (ASCT), but infections are infrequently identified. Tests that reliably exclude infection may reduce the cost and toxicity of unnecessary diagnostic testing and empiric treatment. We assessed whether serum levels of inflammatory cytokines could distinguish infectious from non-infectious causes of fever in patients undergoing ASCT. Methods Serum levels of IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12(p70), TNF-α and IFN-γ were measured by sandwich ELISA at multiple pre-determined times and at the onset of the first fever during neutropenia and after neutrophil engraftment in patients with hematologic malignancies undergoing ASCT. Standard clinical criteria were used to assess for the presence of infection. Results Seventy-two febrile episodes occurred in 54 of 65 enrolled patients; 29 (40%) of the episodes occurred after neutrophil engraftment. Infections were identified as the cause of 28% and 24% of the neutropenic and post-engraftment febrile episodes, respectively. The level of IL-12 decreased and that of IL-6 increased significantly during fever because of infection, such that the IL-12:IL-6 ratio accurately excluded infection. The area under the ROC curve for the IL-12:IL-6 ratio was 0.88 (95% CI 0.79–0.97). The sensitivity, specificity, positive predictive and negative predictive values associated with a cut-off ratio of 4.1 were 95%, 75%, 60%, and 97%, respectively. Discussion The IL-12:IL-6 ratio effectively discriminates infectious from non-infectious causes of fever during ASCT. It may be useful in assessing the probability of infection in patients with post-engraftment fever. [ABSTRACT FROM AUTHOR]

Objective: Impaired adipogenic differentiation exacerbates metabolic disease in obesity. This study reported that high-fat diet (HFD)-fed mice housed at thermoneutrality exhibited impaired adipogenic differentiation, attributed to increased expression of histone deacetylase 9 (HDAC9). However, the impact of HFD on adipogenic differentiation is reportedly variable, possibly reflecting divergent environmental conditions such as housing temperature., Methods: C57BL/6J (wild-type [WT]) mice were housed at either thermoneutral (28-30°C) or ambient (20-22°C) temperature and fed HFD or chow diet (CD) for 12 weeks. For acute exposure experiments, WT or transient receptor potential cation channel subfamily M member 8 (TRPM8) knockout mice housed under thermoneutrality were acutely exposed to ambient temperature for 6 to 24 h., Results: WT mice fed HFD and housed at thermoneutrality, compared with ambient temperature, gained more weight despite reduced food intake. They likewise exhibited increased inguinal adipose tissue HDAC9 expression and reduced adipogenic differentiation in vitro and in vivo compared with CD-fed mice. Conversely, HFD-fed mice housed at ambient temperature exhibited minimal change in adipose HDAC9 expression or adipogenic differentiation. Acute exposure of WT mice to ambient temperature reduced adipose HDAC9 expression independent of sympathetic β-adrenergic signaling via a TRPM8-dependent mechanism., Conclusions: Adipose HDAC9 expression is temperature sensitive, regulating adipogenic differentiation in HFD-fed mice housed under thermoneutrality., (© 2023 The Obesity Society.)

Background: Although specific guidelines exist for diagnosing COPD on the basis of spirometry testing data (FEV 1 /FVC < 0.70 or above the lower limit of normal), the literature suggests that overdiagnosis is common. Whether overdiagnosis increases 30-d readmission rates has not yet been explored. The objective of this study was to determine the prevalence of COPD overdiagnosis and its effect on 30-d hospital readmission rates in our institution., Methods: We retrospectively identified all subjects who were coded with a COPD hospital discharge in 2018 at Cleveland Clinic main campus and had spirometry data available, including FEV 1 and FVC. FEV 1 /FVC was calculated and compared with the predicted lower limit of normal values. Hospital discharge diagnosis and 30-d hospital readmission data were captured along with comorbidities and other demographics., Results: In 2018, there were 424 hospital discharges with a COPD diagnosis with spirometry testing available. Of these subjects, 124 (29%) were overdiagnosed in the lower limit of normal group and 99 (23.3%) were in the ≥ 0.70 group. One hundred subjects (23.6%) had a 30-d hospital readmission. Of these subjects, 35 had FEV 1 /FVC that was greater than their predicted lower limit of normal on spirometry. Of the 324 subjects who were not readmitted within 30 d, 89 (27.5%) had FEV 1 /FVC greater than the lower limit of normal. If the 35 readmitted subjects had not been coded with COPD, the 30-d readmission rate would have decreased significantly from 23.6% to 16.7% (100 of 424 vs 65 of 389, P = .01). Even if all of the 124 subjects who had pulmonary function test data greater than the lower limit of normal had not been counted, the readmission rate would still have decreased from 23.6% to 21.7%, but this was not significant (from 100 of 424 to 65 of 300, P = .3)., Conclusions: COPD was overdiagnosed in our cohort of subjects; this was true whether the FEV 1 /FVC < 0.70 standard or the lower limit of normal standard was used. Furthermore, this overdiagnosis artificially inflated the 30-d readmission rate. These results illustrate the caution providers should use when making a COPD diagnosis., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2021 by Daedalus Enterprises.)

Pectus excavatum repair using a Nuss bar is a widely performed procedure and generally regarded to be quite safe. Rare catastrophic cardiovascular complications have been previously reported, by even the most experienced surgeons. These cases typically present with fulminant cardiogenic shock and have an associated high mortality rate. We present a delayed and atypical presentation for a patient with a cardiac perforation after repair of pectus excavatum who underwent successful repair., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The majority of giant hepatic cavernous hemangiomas are asymptomatic and can safely be observed. However, when a lesion becomes symptomatic, affecting quality of life or cannot be distinguished from a malignancy, then operative therapy should be considered. We herein present a case of a symptomatic 12cm × 14cm × 17cm "mega" hemangioma (>10cm) of the left hepatic lobe. This lesion was initially refractory to transarterial embolization of the left hepatic artery, but was subsequently treated successfully with a left lateral extended hepatic segmentectomy (resection). We thus advocate a rational treatment algorithm for management of hepatic "mega" hemangiomas., Competing Interests: None of the authors identify a conflict of interest.

Introduction: Esophageal leiomyosarcoma and arteria lusoria represent rare entities in thoracic disease. In the setting of arteria lusoria, careful surgical planning and preoperative imaging is essential., Presentation of Case: A 53-year old male presented with a history of cough. Imaging demonstrated a 7-cm mediastinal mass at the level of the trachea and upper esophagus, abutting an incidentally found retroesophageal right subclavian artery. The right carotid artery originated from the aortic arch. Comprehensive evaluation demonstrated a mediastinal sarcoma. Given the tumor size and close association with vital structures, induction chemotherapy was given without response. He was therefore taken for resection, including possible esophagectomy. The mass was well-encapsulated, permitting mobilization off the surrounding structures, and was identified arising from the muscular layer of the esophagus. Postoperatively, he had a low-volume chyle leak, which resolved with conservative management. He was offered mediastinal adjuvant radiation due to close margins, but declined. The patient remained without evidence of disease for over two years, at which time a single pulmonary metastasis was noted and resected., Discussion: Esophageal leiomyosarcoma are an uncommon intrathoracic malignancy and may present with symptoms of mass effect. While patients with arteria lusoria are typically asymptomatic, they may suffer surgical morbidity if this entity is not identified preoperatively. In this case, the aberrant artery was intimately involved with the leiomyosarcoma, increasing complexity and rendering complete oncologic resection challenging., Conclusion: Herein we present a challenging surgical resection of esophageal leiomyosarcoma in the setting of arteria lusoria, which was successfully treated tumor enucleation., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation., (© The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Given the high-risk nature and nurse sensitivity of chemotherapy infusion and extravasation prevention, as well as the absence of an industry benchmark, a group of nurses studied oncology-specific nursing-sensitive indicators. 
., Objectives: The purpose was to establish a benchmark for the incidence of chemotherapy extravasation with vesicants, irritants, and irritants with vesicant potential.
., Methods: Infusions with actual or suspected extravasations of vesicant and irritant chemotherapies were evaluated. Extravasation events were reviewed by type of agent, occurrence by drug category, route of administration, level of harm, follow-up, and patient referrals to surgical consultation.
., Findings: A total of 739,812 infusions were evaluated, with 673 extravasation events identified. Incidence for all extravasation events was 0.09%.

Background: Traditionally cardiothoracic residents spent dedicated research time during general surgery equipping them for a potential academic career. Recent changes in training paradigms, including integrated programs that may not include research time, could affect the development of future academic cardiothoracic surgeons., Methods: Responses to the 2015 Thoracic Surgery Directors' Association/Thoracic Surgery Residents' Association survey accompanying the in-training examination taken by current cardiothoracic surgery residents were analyzed. Three hundred fifty-four residents were surveyed with a response rate of 100%, although one was excluded from the analysis because of inconsistencies in responses. Statistical analysis included χ(2), Fisher's exact test, and multinomial logistic regression with significance set at a probability value of 0.05., Results: Two hundred sixty-seven of 353 residents (76%) intended on performing research as part of their careers. Integrated residents as opposed to traditional residents (85% versus 69%; p = 0.003), males (78% versus 65%; p = 0.02), those pursuing additional training (85% versus 69%; p = 0.003), and those interested in academic careers (93% versus 33%; p < 0.001) were more likely to pursue research. Differences were also noted in specialty interest, with congenital and heart failure specialties most likely to pursue research careers (92% and 100%, respectively; p < 0.05). Residents intending on research careers were more likely to have had previous research experience, and the most common type of intended research was clinical outcomes (78%). On multinomial logistic regression, previous clinical outcomes research and academic practice were identified as predictors of a research career (odd ratios of 9.7 and 4.1, respectively; each p < 0.05)., Conclusions: The majority of residents plan on pursuing research during their careers. Previous research experience appears to be a key determinant as well as specialty interest., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The cardiothoracic surgical workforce is changing. Although 5% of practicing surgeons are women, 20% of current cardiothoracic surgery residents are women. The purpose of this study was to evaluate the influence of gender on specialty interest, satisfaction, and career pathways of current residents., Methods: Responses to the mandatory 2015 Thoracic Surgery Residents Association/Thoracic Surgery Directors Association in-training examination survey taken by 354 residents (100% response rate) were evaluated. The influence of gender was assessed with the use of standard univariate analyses., Results: Women accounted for 20% of residents, and the percentage did not vary with postgraduate year or program type (traditional versus integrated). Although no differences were found between the genders related to specialty interest, academic versus private practice career, or pursuit of additional training, women were more likely to pursue additional training in minimally invasive thoracic surgery (10% versus 2.5%, p = 0.001) and less likely to perform research in their careers (65% versus 88%, p = 0.043). Although women were equally satisfied with their career choice, had similar numbers of interviews and job offers, and felt equally prepared for their boards, graduating women felt less prepared technically (77% versus 90%, p = 0.01) and for practicing independently (71% versus 87%, p = 0.01). Women were less likely to be married (26% versus 62%, p < 0.001) and have children (19% versus 49%, p < 0.001)., Conclusions: Although career satisfaction and specialty interest were similar between the genders, women were less likely to intend to perform research during their careers despite similar previous research experience. Women also demonstrated lower rates of marriage and childbearing compared with their male counterparts., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The present study aimed to describe and compare the operative experience of cardiothoracic surgical residents for basic and advanced cardiac surgical procedures., Methods: Data were obtained from the 2015 Thoracic Surgery Directors Association Survey administered to all thoracic surgical residents taking the yearly In-Service Training Examination (n = 356). Residents were asked whether they routinely served as the operative surgeon on various cardiac operations and operative tasks. Results were stratified by postgraduate year (PGY), residency type, and primary career interest., Results: The survey response rate was 100%. Considering all training pathways, only 2 of 13 cardiac operations surveyed were routinely performed by graduating chief residents as the operative surgeon: coronary artery bypass grafting (CABG; 92%) and aortic valve replacement (AVR; 88%). Off-pump CABG, minimally invasive mitral valve operation, and transcatheter aortic interventions were infrequently (<30% of the time) performed by graduating residents as the operative surgeon. These results were similar when residents with a career interest in general thoracic surgery were excluded from the analysis. For the operative progression of integrated 6-year (I-6) residents, most began to routinely cannulate for cardiopulmonary bypass, perform proximal coronary anastomoses, and harvest the mammary artery during PGY3. The majority (>50%) of I-6 residents performed CABG as the operative surgeon by PGY4., Conclusions: There is pronounced heterogeneity in the cardiac operative experience of cardiothoracic surgical residents in the United States, with only CABG and AVR routinely performed by graduating residents as the operative surgeon. This heterogeneity may lead to insufficient training in certain procedures for many graduates., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We describe the development of an oncology solid tumor disease-focused care coordination model. Consistent with our strategic plan to provide patient- and family-centered care and to organize care around disease management teams, we developed the role of nurse care coordinator as an integral team member in our care delivery model. Managing a defined high-risk patient population across the care trajectory, these nurses provide stable points of contact and continuity for patients and families as they navigate the complex treatments and systems required to deliver cancer care. We describe role delineation and staffing models; role clarity between the role of the nurse care coordinator and the case manager; core curriculum development; the use of workflow management tools to support the touch points of the patient and members of the care team; and the incorporation of electronic medical records and data streams to inform the care delivery model. We identify measures that we will use to evaluate the success of our program.

Background: Acute type A aortic dissection (ATAAD) is a surgical emergency associated with high mortality and morbidity. We analyzed our 15-year experience in the management of ruptured ATAAD (rATAAD) and non-rATAAD to determine the predictors of early and late mortality., Methods: We reviewed all cases with ATAAD between 1999 and 2014. Patients were grouped into rATAAD and non-rATAAD based on intraoperative confirmation. Clinical data on preoperative characteristics and in-hospital and long-term outcomes were analyzed to determine risk factors for early and long-term mortality. Survival was analyzed using Kaplan-Meier and log rank statistics., Results: Of the 489 total ATAAD repairs, 75 patients (15.3%) had rATAAD. The rATAAD patients were older compared with non-rATAAD (64.4 ± 16.2 versus 57.3 ± 14.2 years, respectively; p = 0.0001) and commonly female (31 of 75 [41.3%] versus 107 of 414 [25.9%], respectively; p = 0.006). Early mortality was higher among rATAAD patients that among non-rATAAD patients (19 of 75 [25.3%] versus 48 of 414 [11.6%], respectively; p = 0.002); predictors included rupture, age, malperfusion syndrome, and coronary artery disease. Patients aged 70 years or more with malperfusion syndrome had a 7.7-fold risk of 24-hour mortality (p = 0.0003) that was augmented by rATAAD (p = 0.004). Long-term survival was lower among rATAAD than non-rATAAD (57.4% versus 78.2%, respectively, at 5 years; p < 0.0001); independent predictors included rupture (p = 0.01), low glomerular filtration rate (p = 0.001), and high-risk group (p = 0.004). These risk factors were used to construct a predictive model for estimating the probability of early mortality in ATAAD., Conclusions: Rupture is associated with significantly higher mortality in ATAAD. This predictive model provides surgical risk assessment for early mortality after rATAAD. For acceptable surgical candidates, immediate aortic repair can provide favorable outcomes., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: As acute type A aortic dissection (ATAAD) remains a challenge, the extent of resection of the transverse arch remains debated during operative repair. The purpose of this study was to compare the outcomes of total arch repair versus ascending/proximal arch repair for ATAAD., Methods: We retrospectively reviewed our aortic database of ATAAD between October 1999 and December 2014. Patients were divided into two groups: total arch repair versus proximal arch repair (hemiarch). Indications for arch replacement during ATAAD include aneurysm greater than 5 cm, complex arch tear, and arch rupture. Inhospital and long-term outcomes were compared between the two groups using univariate analysis and multiple logistic regression analysis. Survival was analyzed using Kaplan-Meier and log rank statistics, and assessment of risk factors for survival was conducted by Cox proportional hazards regression analysis., Results: During the study period, we performed 489 repairs of ATAAD, 49 patients (10%) with total arch replacement and 440 patients (90%) with proximal arch replacement. Patients with total arch repair were older (62.4 ± 13.4 years versus 57.9 ± 14.8 years, p = 0.046) and had significantly increased retrograde aortic dissection, circulatory arrest, and retrograde cerebral perfusion times. The incidences of early mortality, stroke, and need for renal dialysis between the total arch and proximal arch group were not significantly different: 20.4% (10 of 49) versus 12.9% (57 of 440), 8.2% (4 of 49) versus 10.5% (46 of 440), and 27% (13 of 49) versus 17.6% (76 of 432), respectively. Late survival did not demonstrate a difference between groups., Conclusions: Acute type A aortic dissection remains a challenge associated with significant mortality and morbidity. When compared with a less aggressive resection, total arch replacement performed in an individualized fashion can be associated with acceptable early and late outcomes for ATAAD and was not associated with worse outcomes., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Endoscopic resection is increasingly utilized for treating early stage esophageal cancer, and endoscopic ultrasound (EUS) frequently guides treatment selection. Studies report greater than 80% sensitivity and 90% specificity, but our experience suggests less accuracy at the gastroesophageal (GE) junction. The objective of this study is to determine the accuracy of EUS for depth of GE junction cancer and the potential treatment implications., Methods: A retrospective review of a prospective database was performed for patients from 1995 to 2014 with GE junction esophageal cancer that underwent EUS staging and resection (surgical or endoscopic) without neo-adjuvant therapy. Patient, tumor, EUS, and pathologic characteristics were examined., Results: For the 181 patients that met criteria, the median age was 66 years, 17% were female, 91% white, and 98% had adenocarcinoma. Concordance between EUS (u) T and pathologic (p) T was 48%, with 23% under-staged and 29% over-staged. The EUS was accurate in the following: uT0 6% (1 of 18); uT1a 56% (23 of 41); uT1b 58% (41 of 71); uT2 10% (2 of 21); and uT3 70% (21 of 30). Inaccurate EUS depth had potential to lead to over-treatment in 38% (27 of 71) of uT1b and 76% (16 of 21) of uT2. In 50% of pT1a tumors, EUS depth was T1b or greater. Logistic regression revealed tumor length (continuous variable) to be associated with inaccurate uT (p = 0.016). Accurately staged tumors were significantly longer than inaccurately staged tumors (2.7 vs 1.7 cm, p = 0.011)., Conclusions: Early to intermediate GE junction tumors are frequently over-staged. This highlights the importance of diagnostic endoscopic resection for determining accurate tumor depth and selecting correct therapy., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The high doses of chemotherapy used for the preparatory regimens before autologous blood or marrow stem cell transplantation leave patients at risk for neutropenic complications. The administration of filgrastim post transplant reduces the time to neutrophil recovery and therefore has become a standard practice at many institutions. In 2006, we implemented a practice change from filgrastim to pegfilgrastim. We present data on 164 consecutive patients (82 patients who received filgrastim compared with 82 patients who received pegfilgrastim) who received an auto-SCT between January 2006 and November 2007. Patients who received pegfilgrastim had faster engraftment (9.6 days compared with 10.9 days, P<0.0001), a lower incidence of febrile neutropenia (59% compared with 78%, P=0.015), as well as shorter hospital stay, fewer days of treatment with i.v. antibiotics (6.3 days compared with 9.6 days, P=0.006), and fewer radiographic tests, which translated to an estimated total cost savings of over $8000 per patient. Overall, there were no differences in toxicity with these two agents. We conclude that a single dose of pegfilgrastim is a safe and efficacious alternative to daily injections of filgrastim and can be a cost-effective approach in auto-SCT patients.

Laparoscopic sleeve gastrectomy (LSG) has gained support as a single-staged and stand-alone bariatric procedure. Reports of excess weight loss of 35 to 83 per cent, reduction in comorbidities, and decreased operative morbidity have garnered support for LSG. This study represents an initial outcome analysis of LSG performed solely at a military treatment center. This study is a retrospective analysis of all patients receiving LSG at Dwight D. Eisenhower Army Medical Center from September 2007 to December 2009. The patients were planned for a stand-alone procedure. One hundred and fifteen patients received LSG over this time period with a mean body mass index of 45.5 +/- 6.2 (range 35.1-58.3). The average age was 47.4 +/- 12.5 years. Diabetes mellitus was seen in 47 per cent and 68 per cent of patients had hypertension. The mean and median length of operation was 124 +/- 48 and 115.5 minutes. The mean percentage of excess weight loss was 16.6 +/- 6.40 per cent at 1 month, 31.5 +/- 7.6 per cent at 3 months, 41.2 +/- 13.9 per cent at 6 months, and 53.7 +/- 12.5 per cent at 1 year from surgery. One or more of patient's preoperative diabetic or hypertensive medications were improved postoperatively in 18.7 per cent and 16.3 per cent, respectively. Incidence of major complications occurred in 4.35 per cent of patients in this study to include four leaks (3.4%), one death (0.87%), and 10 readmissions. Midterm analysis of outcomes related to LSG as a single-stage bariatric procedure is promising as long-term outcome data is collected; the efficacy of this procedure as a sole bariatric procedure will continue to be borne out.

Background: Surgisis and AlloDerm, two biosynthetic materials, have been previously used with success in abdominal wall repairs in the setting of contaminated fields. Historically, Vicryl Woven Mesh, a synthetic material, has also been used in such settings as a temporary bridge for abdominal wall reconstruction. This study compares Surgisis and AlloDerm with Vicryl Woven Mesh with respect to tensile strength, collagen remodeling, and neovascularization using a rat hernia model., Methods: A prospective randomized trial of 54 Sprague-Dawley rats were assigned to the Surgisis, AlloDerm, or Vicryl Woven Mesh group with baseline, 30-day, and 60-day end points. A 1.5-cm x 5.0-cm defect was created in the right abdominis rectus muscle and repaired with an underlay bridge graft using the different treatment materials. Tensile strength was measured using an Instron tensiometer. Histologic specimens were evaluated for neovascularization, collagen deposition, and collagen organization at the 30- and 60-day time points., Results: Surgisis had significantly greater tensile strength compared to Vicryl Woven Mesh at the baseline time point (0.142 vs. 0.091 MPa, p < 0.05). There were no differences between groups tensile strength at 30 or 60 days postoperatively. The Vicryl Woven Mesh and AlloDerm groups showed increases in tensile strength at 30 days postoperatively versus baseline (p < 0.05). Vicryl Woven Mesh, Surgisis, and AlloDerm all showed increases in tensile strength at 60 days postoperatively compared to 30 days postoperatively and at baseline (p < 0.05). Surgisis and AlloDerm had significantly greater (p < 0.05) amounts of collagen deposition and organization at 30 and 60 days compared to Vicryl Woven Mesh. There was no significant difference between AlloDerm and Surgisis with respect to collagen deposition and organization. Surgisis and AlloDerm showed a significantly greater amount (p < 0.05) of neovascularization than Vicryl Woven Mesh at both time points. In addition, Surgisis had a significantly greater amount (p < 0.05) of neovascularization than AlloDerm at both 30 and 60 days., Conclusion: Surgisis has increased baseline tensile strength compared to Vicryl Woven Mesh. Tensile strength in Vicryl Woven Mesh is equal to biosynthetic grafts after tissue incorporation. Biosynthetic grafts showed superior collagen deposition and organization. Surgisis mesh showed increased neovascularization over both AlloDerm and Vicryl Woven Mesh.

We previously reported that three risk factors (RF): initial remission duration <1 year, active B symptoms, and extranodal disease predict outcome in relapsed or refractory Hodgkin lymphoma (HL). Our goal was to improve event-free survival (EFS) for patients with multiple RF and to determine if response to salvage therapy impacted outcome. We conducted a phase II intent-to-treat study of tailored salvage treatment: patients with zero or one RF received standard-dose ifosfamide, carboplatin, and etoposide (ICE); patients with two RF received augmented ICE; patients with three RF received high-dose ICE with stem cell support. This was followed by evaluation with both computed tomography and functional imaging (FI); those with chemosensitive disease underwent high-dose chemoradiotherapy and autologous stem cell transplantation (ASCT). There was no treatment-related mortality. Compared to historical controls this therapy eliminated the difference in EFS between the three prognostic groups. Pre-ASCT FI predicted outcome; 4-year EFS rates was 33% vs. 77% for patients transplanted with positive versus negative FI respectively, P = 0.00004, hazard ratio 4.61. Risk-adapted augmentation of salvage treatment in patients with HL is feasible and improves EFS in poorer-risk patients. Our data suggest that normalisation of FI pre-ASCT predicts outcome, and should be the goal of salvage treatment.

Pre-engraftment syndrome (PES) occurring after cord blood transplantation (CBT) is poorly characterized. We reviewed 52 consecutive double-unit CBT recipients treated for high-risk hematologic malignancies. PES was defined as unexplained fever >38.3 degrees C (101 degrees F) not associated with infection and unresponsive to antimicrobials, and/or unexplained rash occurring before or at neutrophil recovery. CBT recipients (median age, 38 years; range, 3-66 years) received either myeloablative (MA; n=36) or nonmyeloablative (NMA; n=16) conditioning. Sixteen patients (31%) fulfilled PES criteria: 15 with fever (median at onset, 39 degrees C [102.2 degrees F]), 13 of whom also had rash, and 1 with rash alone. The median onset was 9 days (range, 5-12 days) posttransplantation (a median of 14 days before neutrophil recovery). Sixteen patients (14 with PES and 2 with infection and possible PES) received intravenous methylprednisolone (median dose, 1mg/kg; median duration, 3 days); 15 (94%) experienced resolution of fever within 24 hours. Recurrent PES (n=3) resolved with retreatment. There was no association between the development of PES and the likelihood of sustained donor engraftment, speed of neutrophil recovery, grade II-IV acute graft-versus-host disease (aGVHD), day-180 treatment-related mortality (TRM), or survival. PES is common after CBT, precedes neutrophil recovery, is distinct from and does not predict for aGVHD, and responds promptly to short-course corticosteroid therapy., (Copyright (c) 2010 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.)

Fibromuscular dysplasia is a rare vascular disease that is characterized as nonatherosclerotic and noninflammatory in nature. This disease most commonly afflicts the renal and cerebrovascular beds but can rarely affect the upper extremity. We present the case of a 76-year-old woman who complained of a symptom complex, congruent with Raynaud's phenomenon on the right side. The patient had evidence of distal ischemia without the classic angiographic evidence of fibromuscular dysplasia on arteriography. The abnormal arterial section of the right brachial artery was resected and grafted with reversed saphenous vein. She has had no reoccurrence of her symptoms and no stenosis of her graft over a 3-year follow-up period., (Published by Elsevier Inc.)

Pertussis is a highly contagious respiratory infection characterized by prolonged cough and inspiratory whoop. Despite widespread vaccination of children aged<7 years, its incidence is steadily increasing in adolescents and adults, because of the known decrease in immunity following childhood immunization. In an effort to reduce pertussis in adolescents and adults, 2 vaccines containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) (BOOSTRIX and Adacel) were licensed in 2005 for use in adolescents, 1 of which (Adacel) contains less pertussis toxoid (PT) for use in adults. This study assessed pertussis titers in 57 adult survivors of an autologous peripheral blood stem cell transplantation (PBSCT; median age, 37.5 years), 28 of whom were subsequently vaccinated with Tdap containing 2.5microg of PT (Adacel). The median time to Tdap administration was 3 years posttransplantation. Before vaccination, 87% of the patients lacked pertussis immunity. Only 2 of the 28 patients developed a >2-fold response to PT following vaccination with Tdap. These data suggest that autologous transplantation recipients are highly susceptible to pertussis and that immunization with 2.5microg of PT induces an inadequate response. Prospective trials evaluating BOOSTRIX, containing 8microg/dose of PT (approved for adults in December 2008) are warranted in this vulnerable population undergoing transplantation.

Preparation of cord blood (CB) units for infusion by albumin-dextran dilution without centrifugation may be advantageous for adult patients to minimize cell loss and, unlike a bedside thaw, is still conducted in the controlled laboratory environment. Therefore, we studied CB transplantation (CBT) using this technique in 54 consecutive CBT recipients >20 kg. Patients (median age=42 years [range: 7-66 years]; median weight=71 kg [range: 24-109]) were transplanted for high-risk hematologic malignancies with myeloablative (n=35) or nonmyeloablative (n=19) conditioning and 4-6/6 human leukocyte antigen (HLA)-matched double-unit grafts. One hundred seven units were thawed with dilution, whereas 1 red blood cell (RBC)-replete unit was washed. A 5:1 dextran 40%/25% albumin solution was used. RBC-depleted units (n=104) were diluted >or=5.5-fold (median final volume 200 mL [range: 200-500]), whereas RBC-replete units (n=3) were diluted >or=4-fold (median final volume 400 mL [range: 400-535]). Total nucleated cell (TNC) recovery was 86%; the median infused TNC dose was 2.17x10(7)/kg/unit. Although 35 patients (65%) had a total of 45 infusion reactions (6 nausea, 31 hypertension, 3 pain, 1 rigors/fever, 2 transient hypoxia, 2 renal impairment) requiring additional therapy, there were no infusion-related serious adverse events, and reactions were not related to dimethyl sulfoxide (DMSO) dose/kg. Cumulative incidence of sustained donor engraftment was 94% (95% cumulative incidence [CI]: 87-100) with neutrophil recovery occurring at a median of 25 days (range: 13-43) in myeloablative and 10 days (range: 7-36) in nonmyeloablative recipients. CB thaw with albumin-dextran dilution reduces unit manipulation, and minimizes cell loss, speeds time to infusion, is associated with a tolerable infusion reaction profile, and a high rate of sustained engraftment in CBT recipients >or=20 kg.

We examined the role of fluorodeoxyglucose-positron emission tomography (FDG-PET) and the addition of involved field radiotherapy (IFRT) as potential modifiers of salvage therapy. From January 2000 to June 2007, 83 patients with chemosensitive relapsed or primary refractory diffuse large B-cell lymphoma (DLBCL) underwent FDG-PET scans following second-line chemotherapy before high-dose therapy with autologous stem cell rescue (HDT/ASCR). We evaluated the prognostic value of having a negative FDG-PET scan before HDT/ASCR and whether IFRT improved the outcomes. Median follow-up was 45 months, and the 3-year PFS, disease-specific survival (DSS) and OS were 72, 80 and 78%, respectively. Multivariate analysis revealed that a positive FDG-PET scan had worse PFS (hazard ratio=(HR) 3.4; P=0.014), DSS (HR=7.7; P=0.001) and OS (HR=5.4; P=0.001), and that patients not receiving IFRT had worse PFS (HR=2.7; P=0.03) and DSS (HR=2.8, P=0.059). Patients who received IFRT had better local control with fewer relapses within prior involved sites compared with those that did not receive IFRT (P=0.006). These outcomes confirm the important prognostic value of FDG-PET scans before undergoing HDT/ASCR. It also suggests that the role of IFRT should be evaluated further.

Occult injuries to arteries are common in trauma and evolution of their repair has been observed throughout military conflicts. Currently, autogenous vein and polytetrafluoroethylene (PTFE) are used as patch agents for arterial trauma. However, suitable vein is often lacking in multitrauma patients, and PTFE is prone to infection in the contaminated combat wound. The purpose of this study is to evaluate Permacol, porcine dermal collagen, and Alloderm, acellular cadaveric dermis, as suitable alternatives to PTFE with the potential benefit of being used in contaminated wounds. A New Zealand White rabbit common carotid arteriotomy model was used to compare Permacol (n = 12), Alloderm (n = 11), and PTFE (n = 13) for patch repair. Thrombin generation was examined using an enzyme-linked immunosorbent assay for thrombin-antithrombin complex. Histological samples were taken to analyze vessel lumen area, vessel diameter, intimal thickness, and medial thickness. Pathological examinations were made to compare rates of intimal hyperplasia, aneurysm, patency, and thrombus formation. The Permacol group showed equivalent rates of thrombus, aneurysm, and patency compared with PTFE. Increased lumen area was seen in the Permacol group, 0.344 mm2 (p = 0.02) compared with the PTFE group, 0.204 mm2. Permacol also had decreased incidence of intimal hyperplasia compared with PTFE, 50.0% versus 92% (p < 0.05). Alloderm had increased rates of aneurysm formation, 63.6% (p = 0.004) compared with PTFE, 0.0%, and Permacol groups, 8.3%. Alloderm also had increased intimal thickness through the patch, 0.076 mm (p = 0.18), compared with PTFE, 0.026 mm, and Permacol groups, 0.024 mm. Vessel diameter through the patch showed the Alloderm group, 1.87 mm (p = 0.004), was significantly larger than both the Permacol, 1.41 mm, and PTFE groups, 1.28 mm. Furthermore, Alloderm showed leukocyte migration around the patch. Enzyme-linked immunosorbent assay for thrombin-antithrombin complex was only elevated for PTFE in the 7-day postoperative measurement but was not statistically different from the other groups. Permacol has characteristics to be an effective alternative for PTFE for patch arteriotomy repair in our rabbit model. Futher studies need to be conducted to investigate the potential of Permacol in vascular trauma. Alloderm is not a suitable alternative to PTFE for patch arteriotomy repair.

Objectives: To describe the leadership and management challenges of creating and maintaining a comprehensive hematopoietic stem cell transplant program., Data Sources: Research studies, review articles, databases, and web sites., Conclusion: Nurses at all levels of practice must conceptualize and execute expert specialized care through all phases of transplantation. Attention must be paid to specialized functions such as care coordination and case management, as well as scope of practice. Focus must be given to quality assessment and improvement., Implications for Nursing Practice: As the field of transplant grows and evolves, expert nursing leadership will be required to manage the continuum of care as patients move between health care settings. The increased emphasis on outpatient care, cost containment, and consumer and regulatory demand for quality will continue to challenge nurse leaders to manage creative enterprises.

Purpose/objectives: To review neutrophil physiology, consequences of chemotherapy-induced neutropenia (CIN), CIN risk assessment models, national practice guidelines, the impact of febrile neutropenia and infection, and what is known and unknown about CIN., Data Sources: Extensive review and summary of published neutropenia literature, guidelines, meta-analyses, currently funded National Institutes of Health and Oncology Nursing Society studies, and invited expert panel symposium presentations., Data Synthesis: A comprehensive review of current literature regarding CIN risk assessment, practice guidelines, management, impact on dose-dense and dose-intense cancer treatment, complications, costs related to hospitalizations, and treatment strategies has been compiled., Conclusions: CIN is the most common dose-limiting toxicity of cancer therapy. Medical practice guidelines and risk assessment models for appropriate use of myeloid growth factors and management of febrile neutropenia have been developed to assess patients for CIN complications prechemotherapy and during CIN episodes. CIN affects patients, families, practitioners, and the healthcare system. Although much is known about this common chemotherapy complication, a great deal remains to be learned., Implications for Nursing: CIN is a serious and global problem in patients receiving cancer therapy. Oncology nurses need to critically analyze their own practices when assessing, managing, and educating patients and families about CIN.

Traumatic hemorrhage and vascular injury management have been concerns for both civilian and military physicians. During the 20th century, advances in technique allowed surgeons to focus on vascular repair, restoration of perfusion, limb salvage, and life preservation. Military surgeons such as Makins, DeBakey, Hughes, Rich, and others made significant contributions to the field of surgery in general and vascular surgery in particular. Casualties from combat in Afghanistan and Iraq confront physicians and surgeons with devastating injuries. The current generation of providers is challenged with applying contemporary care while expanding upon the lessons taught by our predecessors. The objective of this report is to review the historical experience with managing military upper extremity arterial injuries and compare that experience with current management.

Objective: This study described the occurrence and expression of pharyngeal and laryngeal anomalies in a population of patients with oculo-auriculo-vertebral spectrum (OAVS)., Design: Cross-sectional study using chart review, physical examination, and endoscopic evaluation of the pharynx and larynx, and perceptual and aerodynamic evaluation of speech for assessment of vocal tract function., Setting: Academic tertiary referral center., Patients: Chart review of 41 patients with a diagnosis of OAVS and clinical evaluation of 23 of the patients identified in the initial chart review, ranging in age from 9 months to 17 years., Main Outcome Measures: Data from chart review pertaining to airway and speech symptoms. Physical examination and endoscopic studies of pharyngeal and laryngeal structure and function and perceptual and aerodynamic evaluation of speech, resonance, and voice., Results: Chart review showed a high occurrence of indicators of pharyngeal and laryngeal abnormalities such as velopharyngeal inadequacy and airway obstruction. Clinical evaluations documented a variety of abnormalities in pharyngeal and laryngeal structure and function as well as impairment in speech articulation, resonance, and voice. Presence and severity of pharyngeal and laryngeal abnormalities were not correlated with the severity of expression of the spectrum based on mandibular morphology., Conclusions: Oculo-auriculo-vertebral spectrum appears to be associated with a high occurrence of structural and functional abnormalities of the pharynx and larynx that may contribute to increased risk of airway obstruction, communication impairment, and morbidity.

Objective: To determine whether the argon tunable dye laser, used in a noncutting, hemocoagulative mode, improves skin flap survival as effectively as a surgical delay procedure., Design: A physiologic, controlled trial was completed with three groups: acute control skin flaps, surgical delay skin flaps, and experimental laser delay skin flaps. The outcome variable was percentage of skin flap survival., Subjects: Forty-four male Sprague-Dawley rats., Interventions: McFarlane skin flaps were raised in all groups. The first group had no delay procedure, the second had the standard surgical delay, and the third group was lased at the periphery of the flap 2 weeks before raising the acute flap., Results: The acute control group had survival of 85.7% +/- 1.5% (mean +/- SE) of skin flaps; surgical control group, 94.4% +/- 0.7%; laser delay group, 96.5% +/- 0.1%. The survival of the experimental group was better than the acute control group and was not different from the surgical delay group by the Scheffé multiple comparison test., Conclusions: This research may lead to a technique to reproduce the benefits of the delay phenomenon without the risks and cost of a surgical procedure.

Problem: Reproducing the benefits of the delay phenomenon without the risks and costs of a surgical procedure has long been a goal of skin flap physiologists. After the success of the suture-delay technique and argon tunable dye laser in improving survival in McFarlane skin flaps, important questions remained: (1) will laser delay be effective in dermal flaps, (2) can induction of collateral blood flow be documented, and (3) is the KTP laser, which is generally more available to otolaryngologists, more effective than the argon tunable dye laser., Methods: The KTP and argon tunable dye lasers were compared by use of the laser-delay technique, with two outcome measures - blood flow and survival. The laser-delay procedure was accomplished with the laser in a noncutting mode in an attempt to coagulate cutaneous vessels at the periphery of a planned skin flap. The objective was to induce collateralization and improve skin flap survival. Patterns of blood flow were tested by use of the base occlusion test. Flap survival of an acute control flap group was compared with that of the laser delay groups., Results: Blood flowing to the distal flap area originated from the base of the flap area after laser delay. Flap survival of the laser delay groups was significantly improved over that of the control group., Conclusion: Both lasers were able to effectively induce collateralization and improve flap survival.

Merkel cell carcinoma (MCC) of the skin is an uncommon, but highly aggressive neoplasm with a marked propensity for local and distant metastasis. Despite the fact that more than half of the 600 cases of MCC reported in the literature involved primary sites in the head and neck, MCC has rarely been discussed in otolaryngology publications. We present five new cases of MCC of the head and neck and summarize 89 additional cases from the literature in which detailed treatment and survival data were given. Our findings again emphasize the difficulty in making the initial histopathologic diagnosis of MCC and demonstrate the necessity of early diagnosis and multimodality treatment.

The Rice Infant Sensorimotor Stimulation (RISS) treatment was given to 15 premature infants to determine effects on neurophysiological development. The mothers of the infants were trained to administer the treatment for 15 minutes, 4 times a day, for 1 month, beginning the day the infant arrived home from the hospital. When each infant in the study (15 experimental and 14 control) was 4 months postnatal age, he/she was examined by a pediatrician, a psychologist, and a pediatric nurse who had no knowledge of which infant was experimental or control. The results indicated the experimental infants made significant gains in neurological development (p less than .001), weight gain (p less than .04), and mental development (p less than .05). The findings of this research indicate that early and systematic stimulation of the nerve pathways of the skin and of the vestibular nerve cells can accelerate growth and development of premature infants.