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Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting. In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010–2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics. In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9–3.1) to 4.1 (95% CI 3.5–4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6–3.1) to 9.9 (95% CI 4.9–14.9), while hospital volume increased from 3.5 (95% CI 2.3–4.6) to 15.4 (95% CI 6.9–24.0). Operative time was 34 (23–45) min faster in 2018–2019 compared with 2010–2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change. Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.

Lichen sclerosus is a chronic relapsing inflammatory dermatosis with a predilection for anogenital skin in 85%-98% of cases and is more prevalent in women (3%) than in men (0.07%).The purpose of this study was to investigate gender differences in clinical presentation and therapeutic response to treatment with platelet-rich plasma (PRP), an emerging innovative strategy for LS.Forty-three male and 51 female patients affected by LS were evaluated. Each patient was subjected to PRP treatment (1 infiltration every 15 days, for 3 times).The PRP procedure was well tolerated by all patients and an overall significant decrease in symptoms was reported 6 months after PRP infiltration. Reduction in pain and burning sensation was significant in both gender but more accentuated in women than in men, whereas reduction of itching was similar. On the contrary, dyspareunia evidenced sex-related difference since a significant diminution was observed only in male.This study demonstrates that PRP based therapy may exert a relevant role in LS patient management due to its effect on Quality of Life (QoL) and sexual function in both gender. In addition, the study underlined gender-related differences in severity of symptoms and disease age onset.

Introduction Lichen sclerosus (LS) is a chronic inflammatory disease affecting mainly the genital mucous membranes in both sexes. In the past, different terms were used to describe the disease, rendering a unique and specific clinical classification impossible. Aim New therapeutic approaches are being defined, which may contribute to a proper clinical management, however, a stage classification is essential to better define appropriate treatment for every stage of the disease. Material and methods One hundred and fifteen patients (50 women and 65 men) with a diagnosis of LS were enrolled between January 2014 and September 2016. All patients underwent cutaneous biopsy to confirm the clinical diagnosis of LS. Clinical and symptomatological parameters were used in order to put the patients into the correct stage of LS. The Dermatology Life Quality Index (DLQI) was used to classify patients based on subjective symptoms. Different cutaneous alterations and structural modifications of the genital mucosa were also taken into consideration in order to assign every patient to a specific stage. Conclusions Lichen sclerosus is clinically described differently in females and in males and every form of LS is put into one of two stages according to the degree of severity: early and late stages. Within the clinical practice, it is useful to screen patients for groups of early or late forms of the disease in order to obtain a uniform subdivision of patients: those who may benefit from localized treatments, require a systemic drug and must undergo physical treatments (surgical, stem cells infiltrations).

Mutations in the MBOAT7 gene have been described in 43 patients, belonging to 18 families, showing nonspecific clinical features (intellectual disability [ID], seizures, microcephaly or macrocephaly, and mild to moderate cerebellar atrophy) that make the clinical diagnosis difficult. Here we report the first Italian patient, a 22.5-year-old female, one of the oldest reported, born to apparently consanguineous parents. She shows severe ID, macrocephaly, seizures, aggressive outbursts, hyperphagia. We also documented progressive atrophy of the cerebellar vermis, that appeared not before the age of 7. The whole-exome sequencing of the trio identified a novel homozygous variant c.1057_1058delGCinsCA (p.Ala353His) in the MBOAT7 gene. The variant is considered to be likely pathogenic, since it is absent from population database and it lies in a highly conserved amino acid residue. This disorder has a neurometabolic pathogenesis, implicating a phospholipid remodeling abnormalities. A brain hydrogen-magnetic resonance spectroscopy (H-MRS) examination in our patient disclosed a peculiar neurometabolic profile in the cerebellar hemispheric region. This new finding could address the clinical suspicion of MBOAT7-related disorder, among the wide range of genetic conditions associated with ID and cerebellar atrophy. Moreover, the documented progression of cerebellar atrophy and the worsening of the disease only after some years open to the possibility of a therapeutic window after birth.

The Morgagni-type anterior diaphragmatic hernia is a congenital defect that is a very uncommon hernia presenting in an adult. Surgical repair is usually recommended upon diagnosis and often requires synthetic mesh for a durable, tension-free repair. The use of synthetic mesh concurrently with several of bariatric operations is controversial owing to the potential for mesh infection. In this report we describe a laparoscopic repair of a symptomatic Morgagni hernia with synthetic mesh, concurrently with sleeve gastrectomy, in a morbidly obese man. The patient was a 58-year-old man with a body mass index of 48 kg/m(2) and associated co-morbid conditions that included obstructive sleep apnea, hypertension, hyperlipidemia, impaired fasting glucose, and osteoarthritis. He was diagnosed with Morgagni hernia with exertional dyspnia. He underwent concurrent laparoscopic Morgagni hernia repair with mesh and sleeve gastrectomy. At 2 months after surgery the patient was doing well and tolerating solid foods, and his percentage excess weight loss was 35%. He was exercising regularly and had no exertional dyspnea. Laparoscopy is an attractive approach to performing multiple intra-abdominal procedures concurrently. The Morgagni hernia repair with mesh can be performed safely and effectively using a laparoscopic approach. This can be performed concurrently with bariatric surgery in the morbidly obese.

A high index of suspicion is necessary to diagnose portal vein thrombosis following laparoscopic bariatric procedures., Introduction: Portal vein thrombosis has been documented after laparoscopic general surgery and has been uncommonly observed after laparoscopic bariatric surgery. Among bariatric operations, the sleeve gastrectomy is being performed with ever-increasing frequency. Here we report the case of a man who presented with portal vein thrombosis after laparoscopic sleeve gastrectomy. Case Description: A 41-y-old man underwent an uneventful laparoscopic sleeve gastrectomy for the treatment of morbid obesity, and presented on postoperative day 10 with nonfocal abdominal pain, nausea, vomiting, and leukocytosis. Computed tomography revealed portal vein thrombosis, which was found in the setting of Clostridium difficile colitis. Discussion: Portal vein thrombosis may be identified with increasing frequency as the number of laparoscopic bariatric operations continues to increase. A high index of suspicion is necessary to diagnose this rare, but potentially lethal, complication.

Carotid artery stenting (CAS) with an embolic protection device (EPD) is a valid treatment alternative for experienced physicians to carotid endarterectomy (CEA) for patients with severe carotid artery stenosis, particularly high-risk patients.1,2 Despite absence of neurological symptoms, subclinical microemboli related to CAS procedures are common.3,4,5,6,7,8,9 Multiple studies have shown correlation of microemboli with cognitive decline in patients who underwent surgical procedures.10,11,12,13,14,15 Therefore, procedure-related microembolization is increasingly recognized as a promising outcome measure for carotid interventions. Studies have demonstrated that age, diabetes, and preoperative neurological events and open-cell stent design are predicative factors for CAS-associated 30-day strokes.5,8,16,17,18,19 However, these studies only evaluated clinically evident embolic events. There are very limited studies evaluating the risk factors for subclinical microemboli associated with CAS. The purpose of this study was to examine a relatively homogeneous group of CAS patients and to determine the risk factors predictive of subclinical microemboli associated with CAS procedures. Magnetic resonance imaging (MRI) offers extensive useful data by delineating the anatomy and presence of infarction. A diffusion-weighted magnetic resonance image (DWI) sequence in combination with an apparent diffusion coefficient (ADC) map has been shown to be a sensitive and reliable imaging modality to detect microembolic events following carotid interventions.3,4,5,6,8,9 Whereas conventional MRI may reveal positive findings within 8 to 12 hours of onset of acute infarction, DWI may be positive within minutes. Studies from our institution showed consistent and reliable readings of identifying carotid intervention-related lesions on DWI among experienced neuroradiologists with a low interobserver variability.8,9 In this study, MRI-evident procedure-related embolic lesions will be systemically examined.

The external carotid artery (ECA) is an important collateral pathway for cerebral blood flow. Carotid artery stenting (CAS) typically crosses the ECA, while carotid endarterectomy (CEA) includes deliberate ECA plaque removal. The purpose of the present study was to compare the long-term patency of the ECA following CAS and CEA as determined by carotid duplex ultrasound.Duplex ultrasounds and hospital records were reviewed for consecutive patients undergoing CAS between February 2002 and April 2008, and were compared with those undergoing CEA in the same time period. Preoperative and postoperative ECA peak systolic velocities were normalized to the common carotid artery (CCA) as ECA/CCA ratios. A significant (80% or greater) ECA stenosis was defined as an ECA/CCA ratio of 4.0. A change of ratio by more than 1 was defined as significant. Data were analyzed using Student's t test and χ(2) analysis.A total of 86 CAS procedures in 83 patients were performed (81 men, mean age 69.9 years). Among them, 38.4% of patients had previous CEA, 9.6% of whom had contralateral internal carotid artery occlusion. Sixty-seven CAS and 65 CEA patients with complete duplex data in the same time period were included in the analyses. There was no difference in the incidence of severe ECA stenosis on preoperative ultrasound evaluations. During a mean follow-up of 34 months (range four to 78 months), three postprocedure ECA occlusions were found in the CAS group. The likelihood of severe stenosis or occlusion following CAS was 28.3%, compared with 11% following CEA (P0.025). However, 62% of CEA patients and 57% of CAS patients had no significant change in ECA status. Reduction in the patient's degree of ECA stenosis was observed in 9.4% of CAS versus 26.6% of CEA patients. Overall, immediate postoperative ratios of both groups were slightly improved, but there was a trend of more disease progression in the CAS group during follow-up.CAS is associated with a higher incidence of post-procedure ECA stenosis. Despite the absence of neurological symptoms, a trend toward late disease progression of ECA following CAS warrants long-term evaluation.

Objective— Mural inflammation and neovascularization are characteristic pathological features of abdominal aortic aneurysm (AAA) disease. Vascular endothelial growth factor receptor (VEGFR) expression may also mediate AAA growth and rupture. We examined VEGFR expression as a function of AAA disease progression in the Apolipoprotein E–deficient (Apo E −/− ) murine AAA model. Methods and Results— Apo E −/− mice maintained on a high-fat diet underwent continuous infusion with angiotensin II at 1000 ng/kg/min (Ang II) or vehicle (Control) via subcutaneous osmotic pump. Serial transabdominal ultrasound measurements of abdominal aortic diameter were recorded (n=16 mice, 3 to 4 time points per mouse) for up to 28 days. Near-infrared receptor fluorescent (NIRF) imaging was performed on Ang II mice (n=9) and Controls (n=5) with scVEGF/Cy, a single-chain VEGF homo-dimer labeled with Cy5.5 fluorescent tracer (7 to 18 μg/mouse IV). NIRF with inactivated single chain VEGF/Cy tracer (scVEGF/In, 18 μg/mouse IV) was performed on 2 additional Ang II mice to control for nonreceptor-mediated tracer binding and uptake. After image acquisition and sacrifice, aortae were harvested for analysis. An additional AAA mouse cohort received either an oral angiogenesis inhibitor or suitable negative or positive controls to clarify the significance of angiogenesis in experimental aneurysm progression. Aneurysms developed in the suprarenal aortic segment of all Ang II mice. Significantly greater fluorescent signal was obtained from aneurysmal aorta as compared to remote, uninvolved aortic segments in Ang II scVEGF/Cy mice or AAA in scVEGF/In mice or suprarenal aortic segments in Control mice. Signal intensity increased in a diameter-dependent fashion in aneurysmal segments. Immunostaining confirmed mural VEGFR-2 expression in medial smooth muscle cells. Treatment with an angiogenesis inhibitor attenuated AAA formation while decreasing mural macrophage infiltration and CD-31 + cell density. Conclusion— Mural VEGFR expression, as determined by scVEGF/Cy fluorescent imaging and VEGFR-2 immunostaining, increases in experimental AAAs in a diameter-dependent fashion. Angiogenesis inhibition limits AAA progression. Clinical VEGFR expression imaging strategies, if feasible, may improve real-time monitoring of AAA disease progression and response to suppressive strategies.

Apelin is a potent inodilator with recently described antiatherogenic properties. We hypothesized that apelin might also attenuate abdominal aortic aneurysm (AAA) formation by limiting disease-related vascular wall inflammation. C57BL/6 mice implanted with osmotic pumps filled with apelin or saline were treated with pancreatic elastase to create infrarenal AAAs. Mice were euthanized for aortic PCR analysis or followed ultrasonographically and then euthanized for histological analysis. The cellular expression of inflammatory cytokines and chemokines in response to apelin was also assessed in cultured macrophages, smooth muscle cells, and fibroblasts. Apelin treatment resulted in diminished AAA formation, with a 47% reduction in maximal cross-sectional area (0.74 vs. 1.39 mm2, P < 0.03) and a 57% reduction in macrophage infiltrate (113 vs. 261.3 cells/high-power field, P < 0.0001) relative to the saline-treated group. Apelin infusion was also associated with significantly reduced aortic macrophage colony-stimulating factor expression and decreased monocyte chemattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, interleukin (IL)-6, and tumor necrosis factor (TNF)-α mean mRNA levels. Apelin stimulation of cultured macrophages significantly reduced MCP-1 and TNF-α mRNA levels relative to baseline (2.03- and 1.89-fold reduction, P < 0.03, respectively) but did not affect intimal adhesion molecule expression or medial or adventitial cell cytokine production. Apelin significantly reduces aneurysm formation in the elastase model of human AAA disease. The mechanism appears to be decreased macrophage burden, perhaps related to an apelin-mediated decrease in proinflammatory cytokine and chemokine activation.

Primitive neuroectodermal tumor (PNET) of the kidney is a rare and aggressive tumor, often presenting in advanced stages and progressing rapidly. Renal PNET (rPNET) may affect a wide age spectrum, but the majority of cases are in young adults. We present a case of advanced rPNET in a 78-year-old woman. To our knowledge, this is the most advanced age of presentation of this neoplasm to date. We report on her presentation and management, and discuss the current clinical management of this tumor.

Purpose: To determine risk factors predictive of microemboli found on diffusion-weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS) with distal protection and carotid endarterectomy (CEA). Methods: A retrospective review was conducted of all carotid interventions at a single institution between 2004 and 2006. In that time frame, 64 carotid interventions (34 CAS, 30 CEA) were performed in 63 male patients (mean age 69.5 years, range 52 to 91) with DW-MRI scans available for review. Patient characteristics, including age, gender, smoking history, diabetes mellitus, hypertension, hyperlipidemia, obesity (body mass index >30), coronary artery disease (CAD), chronic obstructive pulmonary disease, peripheral vascular disease, and atrial fibrillation, were documented. For the CAS patients, anatomical and procedural characteristics, including fluoroscopy time, contrast volume, performance of an arch angiogram, and lesion anatomy, were recorded. Bivariate analyses were performed to determine which parameters were associated with the occurrence of acute postprocedural microemboli found on DW-MRI by 2 blinded neuroradiologists. Results: Twenty-four (71%) of the 34 CAS patients and 1 (3%) of the 30 CEA patients demonstrated new cerebral microemboli postoperatively. In the bivariate analyses of all patient, anatomical, and procedural characteristics, only a history of CAD was associated with an increased risk of microemboli; 20 (80%) of the 25 patients who had postprocedure microemboli had CAD compared to 18 (46%) of 39 patients without microemboli (p=0.007). Twenty (53%) of the 38 (59%) patients with CAD developed microemboli compared to 5 (19%) of the 26 patients without CAD (p=0.007). All other patient, procedural, and anatomical characteristics were not found to be independent risk factors predictive of postprocedure microemboli. Conclusion: CAS with distal protection carries a significantly greater risk for developing new microemboli compared to CEA. Of all the risk factors analyzed, only a history of CAD emerged as an independent risk factor for the development of microemboli following carotid intervention. This finding may influence the decision to perform CAS in patients deemed high risk solely due to the presence of CAD.

Abdominal aortic aneurysm (AAA) is a common and frequently lethal disease of older Americans. No medical therapy has been proven effective in retarding progression of small AAAs prior to surgical repair. With the emerging ability of magnetic resonance (MR) flow imaging and MR-based computational analysis to define aortic hemodynamic conditions, and bio-imaging strategies to monitor aortic inflammation real time in vivo, the opportunity now exists to confirm the potential value of medical interventions such as supervised exercise training as first line therapy for small AAA disease.

An operating room's condition is rarely directly implicated in dis-ease transmission. Even so, to prevent such rare transmissions,hospitals must be thoughtful in designing operating rooms as important adjuncts to infection control. Proper ventilation in and near the operating room is the single most important component in establishing an environment that stops the spread of infection. Other considerations include attention to traffic control, equipment maintenance and storage, and construction materials that enhance the ability to maintain clean rooms. Hospitals can avert potential infectious problems through preventive maintenance and the use of infection control risk assessments (ICRAs) for preemptive consideration of infectious risks before renovations, repairs and new construction. Guidelines should be consulted and incorporated into each operating room's policies and procedures.

In the present study, several doses of lithium chloride were tested for their ability to induce the expression of tyrosine hydroxylase (TH) in neurons derived from a human teratocarcinoma cell line (hNT) after 5 and 10 days in vitro (DIV). Following immunocytochemical staining for tyrosine hydroxylase, the percentage of TH-positive neurons was determined and morphometric analysis, including mean soma profile area and neuritic length, was performed. hNT neurons responded to lithium treatment in a dose-dependent manner. In 5 DIV, the most effective dose of lithium chloride (1.0 mM) increased the number of TH-positive neurons approximately sixfold. In addition, both TH-positive hNT neuron mean soma profile area and neurite length were significantly larger than controls by 60 and 70%, respectively. Moreover, even after withdrawal of lithium chloride on day 5, the number of TH-positive neurons in 10 DIV cultures remained significantly increased. These data suggest that hNT cells are indeed responsive to lithium exposure and may serve as a continual source of TH-expressing neurons in new therapeutic approaches to degenerative brain disease.

Background. The rates of obesity and substance abuse are high among US veterans. Objective. To examine weight loss and substance abuse rates following bariatric surgery in veterans with a history of substance abuse (SA). Methods. A prospective database of consecutive bariatric operations was reviewed. Data for SA patients were compared to patients without a substance abuse history (NA). Behavioral medicine staff followed patients throughout the pre- and postoperative courses. Results. Of 205 bariatric surgery patients, there were 74 (36.1%) SA patients. The mean preoperative body mass index (BMI) was 46.2 ± 8.1 kg/m2, and percent excess weight loss at 12 months was 71.8%, 58.0%, and 33.5% for Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic gastric banding, respectively, not significantly different than the NA group (P = 0.15, 0.75, 0.96). Postoperative substance abuse in SA and NA patients was 8.1% and 1.5%, respectively (P = 0.234). Conclusion. A prior history of substance abuse is common in veterans undergoing bariatric surgery; weight loss results are comparable to the general veteran bariatric cohort. Rates of substance abuse are low postoperatively, but higher in patients without a prior history of substance abuse. Close multidisciplinary followup throughout the postoperative course is likely to be integral to the patient's success.

Objective: To evaluate the quality of sexual life in patients with genital lichen sclerosus (LS) recruited in a trial aimed to assess the efficacy of innovative surgical treatments. Design and Method: The Index of Sexual Satisfaction (ISS) questionnaire was used. The Brief Pain Inventory (BPI) was also used to assess the level of pain/discomfort and the grade of interference of LS in daily activities, social relationships, happiness, mood and sleeping. Patients were evaluated at baseline, 4,12, and 24 weeks after treatment. Results: From May 2014 to December 2015, 74 heterosexual patients (52 men, 70.3%, median age 52, IQR: 37-68; 22 women, 29.7%, median age 59.2, IQR: 42-73) with genital LS were evaluated. Fifty-nine patients (79.7%) were sexually active; among these, 45 (76.3%) were in a stable sexual partnership. Overall, 56 patients (75.7%) reported a high degree of genital pain/discomfort, particularly the female patients (18/22, 81.8%), and measurable interferences in selected wellbeing dimensions, such as mood balancing and social relationships. Overall, 49 patients (66.2%) had a current/history of secondary sexual disorders after the onset of LS; dyspareunia (32/49, 59.1%) and desire disorders (8/49, 16.3%) were reported; vulvodinia (5/22, 22.7%), and erectile dysfunction (4/32, 12.5%) were also experienced. Over two-thirds of the sexually active patients who were in a stable partnership (31/45, 68.9%) declared a decrease in the number and quality of sexual intercourses per month. Conclusions: LS affects dramatically the quality of sexual life and secondary sexual disorders are very frequent among LS patients. Thus, a sexological support is needed for this population.

Objective—To determine whether procarboxypeptidase B (pCPB)−/−mice are susceptible to accelerated abdominal aortic aneurysm (AAA) development secondary to unregulated OPN-mediated mural inflammation in the absence of CPB inhibition.Methods and Results—Thrombin/thrombomodulin cleaves thrombin-activatable pCPB or thrombin-activatable fibrinolysis inhibitor, activating CPB, which inhibits the generation of plasmin and inactivates proinflammatory mediators (complement C5a and thrombin-cleaved osteopontin [OPN]). Apolipoprotein E−/−OPN−/−mice are protected from experimental AAA formation. Murine AAAs were created via intra-aortic porcine pancreatic elastase (PPE) infusion. Increased mortality secondary to AAA rupture was observed in pCPB−/−mice at the standard PPE dose. At reduced doses of PPE, pCPB−/−mice developed larger AAAs than wild-type controls (1.01±0.27 versus 0.68±0.05 mm;P=0.02 [mean±SD]). C5−/−and OPN−/−mice were not protected against AAA development. Treatment with tranexamic acid inhibited plasmin generation and abrogated enhanced AAA progression in pCPB−/−mice.Conclusion—This study establishes the role of CPB in experimental AAA disease, indicating that CPB has a broad anti-inflammatory role in vivo. Enhanced AAA formation in the PPE model is the result of increased plasmin generation, not unregulated C5a- or OPN-mediated mural inflammation.

Abdominal aortic aneurysms (AAAs) are a common and lethal disease of the elderly. ‘Atherosclerotic’ aneurysms occur far more frequently in the caudal or infrarenal segment, a localization influenced at least in part by site-specific hemodynamic conditions. Alterations in aortic flow and wall shear stress modify AAA disease progression in small animal models and may explain increased prevalence in certain at-risk patient populations. If a specific hemodynamic risk profile can be established, anti-aneurysmal lower extremity exercise protocols or the development of molecular interventions that mimic the benefits induced by exercise may prove effective in reducing progression of small AAAs or limiting continued remodeling or expansion following endovascular exclusion.

The aim of this preliminary, prospective, longitudinal study was to evaluate the effects on graft function and viral loads of modulation of immunosuppressive therapy based upon serial noninvasive monitoring of urine and serum viral loads with real-time polymerase chain reaction among unselected renal transplant recipients. Thirty-nine renal transplant recipients with follow-up times of 7.8 +/- 4.3 months were monitored monthly with urine and serum samples to measure BK viral load. Interventions such as gradual reductions of mycophenolate mofetil and/or tacrolimus were performed when repeated urine and serum viral loads were10(5) and10(3) copies/mL, respectively. Among 271 samples, the patients were divided into 6 groups: negative urine (group = 1; n = 10) and negative serum (group 2; n = 25) versus BK viral loads that were intermittent (urine: group 3; n = 24 and serum: group 4; n = 11) versus persistent (urine: group 5; n = 5 and serum: group 6; n = 3). In groups 3-4 we observed the higher viral loads in the urine than in the serum (10(3): 21; 10(4): 1; 10(5): 1; 10(6): 1 vs 10(2): 8; 10(3): 2; 10(4): 1). The timing of resolution of viremia was more rapid than viruria. In groups 5-6 we observed the greatest viral load and greater number in urine. The overall incidences of viruria and viremia were 74.3% and 35.9%, respectively. The overall rates of clearance of viruria were 26/29 recipients (89%) and viremia, 11/14 recipients (78%). Only 10 patients (25.6%) needed extensive reduction of immunosuppression. No modifications of serum creatinine levels and no rejection episodes were observed. In conclusion this preliminary analysis suggested that serial, noninvasive monitoring of viral load allows gradual premptive reduction of immunosuppression with consequent strong reduction in viral load.

Objective New training paradigms in vascular surgery allow for early specialization out of medical school. Surgical simulation has emerged as an educational tool for trainees to practice procedures in a controlled environment allowing interested medical students to perform procedures without compromising patient safety. The purpose of this study is to assess the ability of a simulation-based curriculum to improve the technical performance and interest level of medical students in vascular surgery. Design Prospective observational cohort study of medical student performance. Setting Academic medical center. Participants Forty-one medical students (23 first year, 15 second year, 3 other) enrolled in a vascular surgery elective course. Students completed a survey of their interests and performed a renal stent procedure on an endovascular simulator (pretest). The curriculum consisted of didactic teaching and weekly mentored simulator sessions and concluded with a final renal stent procedure on the simulator (posttest). Objective procedural measures were determined during the pre- and posttest by the simulator, and subjective performance was graded by expert observers utilizing a structured global assessment scale. After the course, the students were surveyed as to their opinions about vascular surgery as a career option. Finally, 1 year after the course, all students were again surveyed to determine continued interest in vascular surgery. Results The objective and subjective criteria measured on the simulator and structured global assessment scale significantly improved from pre- to posttest in terms of performer technical skill, patient safety measures, and structured global assessments. Before beginning the course, 8.5% of the students expressed high interest in vascular surgery, and after completing the course 70% were seriously considering vascular surgery as a career option (p = 0.0001). More than 95% of the students responded that endovascular simulation increased their knowledge and interest in vascular surgery. In the 1-year follow-up survey (n = 23 medical students), 35% had already entered their clinical years. Seventy percent of the students were still considering vascular surgery, while several other career options were still popular including the surgical subspecialties (70%), interventional cardiology (57%), and interventional radiology (48%). Most respondents indicated the major reasons for continued interest in vascular surgery were the ability to practice endovascular procedures on the simulator (100%) and mentorship from vascular surgery faculty (78%). Conclusions The use of high fidelity endovascular simulation within an introductory vascular surgery course improves medical student performance with respect to technical skill, patient safety parameters, and global performance assessment. Mentored exposure to endovascular procedures on the simulator positively impacts long term medical student attitudes towards vascular surgery. Simulator-based courses may have the potential to be an important component in the assessment and recruitment of medical students for future surgical training programs.

Abdominal aortic aneurysms (AAAs) affect 5-7% of older Americans. We hypothesize that exercise may slow AAA growth by decreasing inflammatory burden, peripheral resistance, and adverse hemodynamic conditions such as low, oscillatory shear stress. In this study, we use magnetic resonance imaging and computational fluid dynamics to describe hemodynamics in eight AAAs during rest and exercise using patient-specific geometric models, flow waveforms, and pressures as well as appropriately resolved finite-element meshes. We report mean wall shear stress (MWSS) and oscillatory shear index (OSI) at four aortic locations (supraceliac, infrarenal, mid-aneurysm, and suprabifurcation) and turbulent kinetic energy over the entire computational domain on meshes containing more than an order of magnitude more elements than previously reported results (mean: 9.0-million elements; SD: 2.3 M; range: 5.7-12.0 M). MWSS was lowest in the aneurysm during rest 2.5 dyn/cm(2) (SD: 2.1; range: 0.9-6.5), and MWSS increased and OSI decreased at all four locations during exercise. Mild turbulence existed at rest, while moderate aneurysmal turbulence was present during exercise. During both rest and exercise, aortic turbulence was virtually zero superior to the AAA for seven out of eight patients. We postulate that the increased MWSS, decreased OSI, and moderate turbulence present during exercise may attenuate AAA growth.

Objective We have previously demonstrated a 70% incidence of microemboli on diffusion weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS). The purpose of this study is to compare the incidence of microemboli in two distinct time periods when procedural modifications were implemented into a CAS program. Methods Following a retrospective quality review of our CAS cohort (n = 27) from November 2004 through April 2006 (period 1), we enrolled patients (n = 20) from May 2006 through February 2008 (period 2) undergoing CAS into a prospective cohort that included obtaining pre- and postprocedure DW-MRI exams. Procedural modifications during period 2 included the preferential use of closed-cell systems (60% vs 0% in period 1), early heparinization at the initiation of arterial access, and elimination of an arch angiogram. The hospital records of these 47 patients were reviewed; symptoms, comorbidities, lesion characteristics, periprocedural information, and postoperative outcomes were collected. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs. Results Twenty (74%) CAS patients from period 1 and seven (35%) patients from period 2 demonstrated acute microemboli on postprocedural DW-MRI ( P = .02). The mean number of microemboli in period 1 was 4.1 ± 5.3 vs 1.5 ± 2.7 during period 2 ( P = .04). Two of the 27 patients (7.4%) during period 1 experienced temporary neurologic changes that resolved within 36 hours. None of the patients during period 2 exhibited any neurologic changes. Patient demographics, comorbidities, and presenting symptoms were similar between the two groups except for smoking prevalence, female presence, and obesity (BMI > 30). Period 2 patients when compared with period 1 had more technically challenging anatomy with more calcified lesions (68% vs 27%), longer lesions (15.9 mm vs 8.2 mm), and higher incidence of ulceration (55% vs 27%) (all P Conclusion Despite successful performance of 47 consecutive CAS procedures without permanent neurologic sequelae, significant reductions in periprocedural embolic events as identified via DW-MRI lesions may be achieved through implementation of quality improvement measures identified through continuous outcome analysis. The long-term neurologic benefits associated with reduced subclinical neurologic events remains to be determined.

ObjectiveThe relative safety of percutaneous carotid interventions remains controversial. Few studies have used diffusion-weighted magnetic resonance imaging (DW-MRI) to evaluate the safety of these interventions. We compared the incidence and distribution of cerebral microembolic events after carotid angioplasty and stenting (CAS) with distal protection to standard open carotid endarterectomy (CEA) using DW-MRI.MethodsFrom November 2004 through August 2006, 69 carotid interventions (27 CAS, and 42 CEA) were performed in 68 males at a single institution. Pre- and postprocedure DW-MRI exams were obtained on each patient undergoing CAS and the 20 most recent CEA operations. These 46 patients (47 procedures as one patient underwent bilateral CEAs in a staged fashion) constitute our study sample, and the hospital records of these patients (27 CAS and 20 CEA) were retrospectively reviewed. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs and assessed independently by two neuroradiologists without knowledge of the subjects’ specific procedure.ResultsNineteen CAS patients (70%, 95% confidence interval [CI]: 42%-81%) demonstrated evidence of postoperative, acute, cerebral microemboli by DW-MRI vs none of the CEA patients (0%, 95% CI: 0%-17%) (P < .0001). Of the 19 CAS patients with postoperative emboli, nine (47%) were ipsilateral to the index carotid lesion, three (16%) contralateral, and seven (36%) bilateral. The median number of ipsilateral microemboli identified in the CAS group was 1 (interquartile ranges [IQR]: 0-2, range 0-21). The median number of contralateral microemboli identified in the CAS group was 0 (IQR: 0-1, range 0-5). Three (11%) CAS patients experienced temporary neurologic sequelae lasting less than 36 hours. These patients suffered 12 (six ipsilateral and six contralateral), 20 (19 ipsilateral and one contralateral), and zero microemboli, respectively. By univariate analysis, performing an arch angiogram prior to CAS was associated with a higher risk of microemboli (median microemboli 5 vs none, P =.04)ConclusionsAlthough our early experience suggests that CAS may be performed safely (no permanent neurologic deficits following 27 consecutive procedures), cerebral microembolic events occurred in over two-thirds of the procedures despite the uniform use of distal protection. Open carotid surgery in this series seems to offer a lower risk of periprocedural microembolic events detected by DW-MRI.

We review the status of the hypothesis that interventions that increase the resistance to stress offer the potential for effective life prolongation and increased health. The work focuses on research in the nematode worm Caenorhabditis elegans and describes both published and unpublished results consistent with this hypothesis. Correlation between stress resistance and longevity among many gerontogene mutants is provided.

Nine obese children were referred to our liver disease unit because of asymptomatic, long-standing (range, 4 to 49 months) hyperaminotransferasemia of unknown origin. Ultrasonography showed a "bright" liver in most patients. A hypocaloric diet was prescribed, and the hepatic abnormalities of the complaint patients showed a prompt and persistent improvement that paralleled the loss of excess weight.

Twenty-three children, aged 3 to 15 years, with chronic delta hepatitis have been followed for 5 to 12 years to evaluate long-term outcome. Although 83% of patients had chronic active hepatitis when first seen, with cirrhosis in 26%, the clinical and biochemical features of the disease remained reasonably stable during observation; liver histologic findings, obtained in 14 patients, worsened in only two.

Aortic valve prosthesis determine a transvalvular gradient (Δp) with changes in aortic flow that can affect left ventricular geometry and function, implanted prosthesis and aortic route. In order to improve prognosis a new prosthesis has been proposed, the so called 'stentless valve' (SV), whose main characteristic is the absence of the supporting ring. Aim of our study was to evaluate if such valve could influence early postoperative course in ICU.

Remifentanil (R) a new short-acting opioid, has been introduced in cardiac total intravenous anesthesia to solve the problems connected with the adminstration of long-acting opioids. Aim of our study was to evaluate the efficacy of R in optimizing mechanical ventilation and ICU stay after cardiac surgery.

ObjectivesSimulator-based endovascular skills training measurably improves performance in catheter-based image-guided interventions. The purpose of this study was to determine whether structured global performance assessment during endovascular simulation correlated well with trainee-reported procedural skill and prior experience level.MethodsFourth-year and fifth-year general surgery residents interviewing for vascular fellowship training provided detailed information regarding prior open vascular and endovascular operative experience. The pretest questionnaire responses were used to separate subjects into low ( .05).ConclusionStructured endovascular skills assessment correlates well with prior procedural experience within a high-fidelity simulation environment. In addition to improving endovascular training, simulators may prove useful in determining procedural competency and credentialing standards for endovascular surgeons.