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Objective: Mitral valve (MV) repair with premeasured Gore-Tex loops (the 'loop technique') was introduced in 1999. We assessed the early- and mid-term outcomes for the loop technique in patients with MV prolapse., Methods: A total of 632 patients (447 male, 185 female) underwent MV repair with Gore-Tex loops for MV prolapse. A mini-thoracotomy was performed in 522 patients (mean age 58+/-12.4 years) and 110 patients received a full sternotomy (mean age 66.5+/-11.9 years). Early postoperative echo was performed in all patients and clinical follow-up was obtained in 95% of patients., Results: Loops were used to correct prolapse of the posterior leaflet in 308 patients, the anterior leaflet in 150 patients, and both leaflets in 174 patients. The mean length of Gore-Tex loops was 20.8+/-3.4 mm for the A2 segment and 14.3+/-3.0mm for the P2 segment. Concomitant procedures consisted of atrial fibrillation ablation in 123 patients, tricuspid valve repair in 30 patients, coronary bypass surgery in 73 patients, and aortic valve surgery in 21 patients. Mean aortic cross-clamp and cardiopulmonary bypass times were 89+/-32 and 137+/-43 min, respectively. Predischarge echocardiography revealed no residual mitral regurgitation (MR) in 75%, trace or mild MR in 21% and mild-to-moderate MR in 4% of patients. Thirty-day survival was 98.6%, and one-year survival was 97.1%. Freedom from reoperation was 97.4+/-1.4%, 3 years postoperatively., Conclusion: MV repair with premeasured Gore-Tex loops results in excellent early- and mid-term outcomes for all types of leaflet prolapse. The loop technique facilitates minimal invasive MV repair without compromising surgical outcomes.

As alternatives to standard sternotomy, surgeons have developed innovative, minimally invasive approaches to conducting valve surgery. Through very small skin incisions and partial upper sternal division for aortic valve surgery and right minithoracotomy for mitral surgery, surgeons have become adept at performing complex valve procedures. Beyond cosmetic appeal, apparent benefits range from decreased pain and bleeding to improved respiratory function and recovery time. The large retrospective studies and few small prospective randomized studies are herein briefly summarized. The focus is then directed toward describing specific intraoperative technical details in current clinical use, covering anesthetic preparation, incision, mediastinal access, cardiovascular cannulation, valve exposure, and valve reconstruction. Finally, unique situations such as pulmonic valve surgery, reoperations, beating heart surgery, and robotics are discussed.

Mitral valve repair with Gore-Tex (W.L. Gore & Assoc, Inc, Flagstaff, AZ) neochordae is of increasing interest. In 2000, the loop technique using premeasured Gore-Tex neochordae was introduced by our group. Herein, we report our experience with this technique in minimally invasive mitral valve repair (MVR) for degenerative disease. Between 1999 and 2006, 468 patients (328 men and 140 women) underwent elective MVR using neochordae at our institution. The mean age of the patients was 58 +/- 12.3 years. All patients had significant mitral valve regurgitation, and the mean severity was 3.5 +/- 0.6. Prolapse of the posterior leaflet was diagnosed in 393 patients (84%), and prolapse of the anterior leaflet was diagnosed in 250 patients (53.4%). Mean left ventricular function was 64.8 +/- 12.3%. All patients were operated on with the minimally invasive approach via a right lateral mini-thoracotomy, femoral cannulation for cardiopulmonary bypass, and the transthoracic direct clamp technique. Mean duration of cardiopulmonary bypass was 136 +/- 40 minutes, and mean aortic clamp time was 87 +/- 31 minutes. Gore-Tex neochordae were used in 149 patients (32%) on both leaflets, in 224 patients (47.7%) on the posterior leaflet only, and in 95 patients (20.3%) on the anterior leaflet only. A mean number of 2.7 +/- 1 loops at a mean length of 21 +/- 3.3 mm were used on the A2 segment. On the P2 segment, a mean number of 3.2 +/- 1 loops at a mean length of 14.3 +/- 3.1 mm were applied. The intraoperative course was uneventful in all patients. Early reoperation for bleeding had to be performed in 18 patients (3.9%). Mean duration of hospital stay was 11.9 +/- 13 days. The 30-day mortality rate was 1.5% (7 patients), and 1-year mortality rate was 2.6% (12 patients). MVR with neochordae and the loop technique is an easy and effective treatment for degenerative mitral valve disease. The procedure is reliable and reproducible, leading to low morbidity and mortality. Thus, use of Gore-Tex neochordae has become the standard technique for MVR at our institution.

A 29-year-old Marfan patient at 17 weeks of gestation was diagnosed with acute type A aortic dissection and severe aortic regurgitation. Aortic valve and aortic arch replacement was successfully performed under circulatory arrest with deep hypothermia. At 34 weeks of gestation, the patient underwent a cesarean section and delivered a healthy baby.

The most recently characterized genetic defect contributing to venous thrombophilia is the 20210 A prothrombin gene mutation. We describe a patient with this defect who had arterial thrombosis resulting in considerable mesenteric ischemia. Several environmental factors, which might otherwise be considered of low thrombotic risk, may also have contributed to her condition. The recognition of the potential for novel presentations of hypercoagulable states may contribute to a reduction in the morbidity associated with acute mesenteric ischemia.

Transgenic mice expressing a mutated (G93A) human Cu/Zn superoxide dismutase (SOD1) develop motor neuron pathology and clinical symptoms similar to those seen in patients with amyotrophic lateral sclerosis. Loss of motor neurons is most prominent in lumbar, followed by cervical cord and then brainstem. No significant cell death has been reported in motor cortex. The integrity of the cortical glutamate reuptake systems was evaluated using intracerebral microdialysis and western immunoblot assays for the glutamate transporters GLT-1, GLAST, and EAAC1. The basal extracellular fluid levels of aspartate, glutamate, glutamine, 3,4-dihydroxyphenylacetic acid, and 5-hydroxyindole-3-acetic acid were evaluated by HPLC. The extraction fraction of L-3H]glutamate, corrected with [14C]mannitol, was also evaluated. GLT-1, EAAC1, and GLAST protein levels were determined by semiquantitative chemiluminescence immunoblot of proteins from membrane-enriched fractions. The relative optical density of film was translated into relative protein level by comparison with a standard control mouse. The SOD1 mutant mice demonstrated a significant (p < 0.05) increase in basal levels of extracellular aspartate and glutamate. In addition, when the glutamate extraction fraction was challenged with exogenous unlabeled glutamate (500 microM) by reversed microdialysis, the glutamate extraction fraction in the mutant SOD1 mice was decreased significantly from control levels. The SOD1 mutant mice demonstrated no difference in the cortical protein levels of the glutamate transporter subtypes. This study demonstrates that in areas of no visible pathology and no loss of glutamate transporter proteins, SOD1 mutant mice have elevated extracellular fluid aspartate and glutamate levels and a decreased capacity to clear glutamate from the extracellular space.

Background: Administration of chemotherapeutic agents in the immediate postoperative period may have beneficial effects by decreasing local cancer recurrence rates, but this must be weighed against possible impairment of wound healing. Since local expression of transforming growth factor-beta1 (TGF-beta1) is normally upreglated following creation of experimental colonic anastomoses, this study examines the effects of 5-fluorouracil (5-FU) on colonic healing and on the local expression of TGF-beta1., Materials and Methods: Forty-eight male Sprague-Dawley rats underwent transection of the descending colon with primary anastomosis and were then randomly assigned to receive either intraperitoneal 5-FU (20 mg/kg/day) or saline (SAL). On Postoperative Days (PODs) 3, 5, and 7, bursting pressure (BP, mm Hg) and bursting energy (BE, mm Hg xs) were determined in situ. Anastomotic and nonoperated segments of colon were harvested and analyzed using the semiquantitative reverse transcriptase-polymerase chain reaction to determine the relative expression of TGF-beta1 normalized to that of a constitutive gene., Results: Progressive increases in BP and BE were observed in both the 5-FU and the SAL groups, across the time course examined. Overall, these measures were decreased in the 5-FU groups compared to SAL, significantly so on PODs 5 and 7; BP, 127.8 +/- 7.6 vs 161.1 +/- 7.2 and 139.9 +/- 10.9 vs 186.0 +/- 8.6; BE, 1093.6 +/- 190.0 vs 2207.9 +/- 308.2, and 1518.5 +/- 326.5 vs 3279.3 +/- 225.7, respectively. Anastomotic TGF-beta1 expression also increased progressively in both groups over the postoperative time course. Expression in the 5-FU group, however, was significantly decreased compared to that in the SAL group on POD 3; 0.42 +/- 0.05 vs 0.84 +/- 0.04. Interestingly, this preceded the reduction in BP and BE in the 5-FU group on PODs 5 and 7. TGF-beta1 expression in nonoperated colonic segments did not change during the time points studied or in response to 5-FU administration., Conclusions: Wound healing following a colonic anastomosis is associated with local increases in TGF-beta1 expression, which in turn is diminished by the administration of 5-FU. If this deleterious effect on wound healing could be counteracted, then chemotherapy administration in the immediate postoperative period may become safer., (Copyright 1999 Academic Press.)

Purpose: Dehiscence of colonic anastomoses is prevalent and potentially fatal. In an attempt to reduce the likelihood of anastomotic dehiscence, the colon is cleansed before surgery and fiber-free diets are prescribed postoperatively. However, fiber-free diets induce colonic atrophy and impair healing. This study was designed to investigate the effect of bowel preparation and postoperative fiber-free diet on the local gene expression of transforming growth factor-beta 1 and procollagen type I., Methods: Four Sprague-Dawley rats underwent bowel preparation with a fiber-free liquid diet and polyethylene glycol in a balanced electrolyte solution for two days (fiber-free preoperative diet group), whereas four rats received standard chow with fiber (preoperative diet with fiber group). On the third day tissue was obtained from the descending colon of each rat to assess the effect of bowel preparation. Forty additional rats had their bowels prepared and underwent transection of the descending colon and anastomosis. These rats were then randomly assigned to continue on the liquid diet (fiber-free postoperative diet group) or rat chow (postoperative diet with fiber group). On postoperative days 3, 5, 6, 7, and 14, colonic tissue was obtained from the anastomosis and analyzed with the use of semiquantitative reverse transcriptase-polymerase chain reaction to examine the relative expression of transforming growth factor-beta 1 and procollagen type I genes normalized to that of a constitutive gene., Results: There was a decrease in the expression of the transforming growth factor-beta 1 and the procollagen type I genes in the fiber-free preoperative diet group compared with the preoperative diet with fiber group; however, this difference only reached statistical significance for procollagen type I. Postoperatively, significant increases in the expression of the transforming growth factor-beta 1 and procollagen type I genes over baseline levels were observed around postoperative day 7 in both groups, which temporally correlates with active phases of collagen deposition in the wounded colon. Expression of the procollagen type I gene, however, was significantly decreased at this time in the fiber-free postoperative diet group compared with the postoperative diet with fiber group., Conclusion: Although necessary to reduce septic complications, preoperative bowel preparation has a detrimental effect on the expression of transforming growth factor-beta 1 and procollagen type I. A postoperative fiber-free liquid diet also may be detrimental to the expression of these transcripts in the bowel. Alternative methods for delivery of colonic fuels are needed to create a better environment for colonic healing while eliminating bacteria and bulk.

Two feet-one hand syndrome is also defined as bilateral plantar tinea pedis with coexistent unilateral tinea manuum. Toenails and fingernails may also be affected and the dermatophyte Trichophyton rubrum is the usual cause. When there is nail involvement, especially of the toenails, treatment with an oral antifungal agent should be considered because topical therapy alone is usually not effective. However, relapses are common. With the advent of new, more effective antifungal drugs such as itraconazole, terbinafine, and fluconazole, it is hoped that this troublesome and recalcitrant disorder may be better controlled.

Total RNA from rat Schwann cells grown in culture and adult rat skeletal muscle was reverse transcribed, amplified for glial cell line-derived neurotrophic factor (GDNF) messenger RNA (mRNA) using the polymerase chain reaction (PCR), and the PCR products sequenced. Two forms of GDNF were detected in the PCR step, one of a predicted size (GDNF633) and a second smaller form missing a 78-base pair sequence (GDNF555). Sequence analysis demonstrated that GDNF633 is similar to the published sequence of GDNF differing only at three nucleotides. Southern and Northern blot analyses reveal that the two forms are probably derived from a single RNA species that is alternatively spliced. Interestingly, GDNF633 mRNA was found to be selectively upregulated in denervated rat skeletal muscle at 1-2 weeks following axotomy, providing evidence that the innervation status of the muscle may determine the expression profile of the two alternatively spliced forms. Given these findings, we suggest that GDNF may function as a target-derived trophic factor for neuronal populations innervating skeletal muscle, including sensory neurons and spinal cord motoneurons.

Current therapeutic efforts to treat chronic and progressive neurodegenerative disease include, for the first time, attempts to regenerate affected nervous tissue using neurotrophic factors. The rationale for using trophic factors includes the understanding that they support neuronal survival and regrowth processes. The potential benefits of trophic factor therapy will be no more realized in the near future than in the treatment of amyotrophic lateral sclerosis (ALS). ALS is pathologically characterized by the selective degeneration of specific populations of cranial and spinal motoneurons. Evidence for the existence of factors that support motoneurons has come from studies demonstrating that motoneurons receive trophic influences from various tissues, both central and peripheral, within their local environment. Although the identity of these putative tissue-derived factors has remained enigmatic, recent studies have demonstrated that several previously characterized trophic factors exhibit trophic influences on motoneurons. Among these are several members of the neurotrophin family, most notably brain-derived neurotrophic factor. These neurotrophins meet most of the criteria to be considered motoneuron trophic factors: they are locally available to motoneurons in vivo; motoneurons express specific receptors for these factors; and exogenous application of these factors mimicks the effects of the uncharacterized endogenous agents. The clinical use of these factors for the treatment of ALS, therefore, appears to be scientifically justified.

Lennert's lymphoma is a peripheral T-cell lymphoma that only rarely involves the skin. We present the case of a forty-two-year-old man who experienced severe pruritus for ten months. He was repeatedly diagnosed as having neurodermatitis and prurigo nodularis before subtle hematologic clues suggested, and subsequent examination of bone and lymph node biopsy specimens confirmed, the diagnosis of Lennert's lymphoma. This report describes the case and presents a brief review of Lennert's lymphoma.

Background: Often after biopsy a skin cancer appears to resolve clinically and a repeat biopsy may be done on the area in question before proceeding with further treatment., Objective: Our purpose was to assess the value of a subsequent biopsy in the treatment of skin cancers previously diagnosed by biopsy results., Methods: The results of a subsequent biopsy were compared with the results of Mohs micrographic surgery in 291 patients with biopsy-established basal cell carcinoma and squamous cell carcinoma. Pre-Mohs surgery curettings were examined in 60 of these patients to evaluate whether these could have caused false-negative Mohs results., Results: One hundred nineteen patients had a negative second biopsy, of which 75 (63%) had residual tumor at surgery. Eight of 60 patients in whom the curettings were examined had negative results from both biopsy and Mohs surgery; tumor in the curettings was shown in six of these eight patients (75%)., Conclusion: This study suggests that 63% or more of subsequent biopsy specimens for skin cancer may yield false-negative results and casts doubt on the usefulness of a subsequent biopsy before surgery.