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Scientific evidence combined with new health insurance coverage now enable a chronic illness management approach to the treatment of alcohol use disorders (AUDs), including regular monitoring of blood alcohol content (BAC), as a useful indicator of disease control. Recent technical advances now permit many different types of remote, real-time monitoring of BAC. However, there is no body of research to empirically guide clinicians in how to maximize the clinical potential of remote BAC monitoring. As an initial step in guiding and supporting such research, the manufacturer of one remote BAC monitoring system sponsored a group of experienced clinicians and clinical researchers to discuss 8 issues that generally affect remote, clinical BAC monitoring of “adults in outpatient AUD treatment.” The expert panel unanimously agreed that remote BAC monitoring for at least 12 months during and after the outpatient treatment of AUD was a clinically viable deterrent to relapse. There was also consensus that positive test results (ie, recent alcohol use) should lead to intensified care and monitoring. However, there was no agreement on specific types of clinical intensification after a positive test. The panel agreed that sharing positive and negative test results with members of the patient support group was helpful in reinforcing abstinence, yet they noted many practical issues regarding information sharing that remain concerning. Significant differences within the panel on several important clinical issues underline the need for more clinical and implementation research to produce empirically-supported guidelines for the use of remote BAC monitoring in AUD treatment.

Dr Robert R. Shaw arrived in Dallas to practice Thoracic Surgery in 1937, as John Alexander's 7th Thoracic Surgical Resident from Michigan University Medical Center. Dr Shaw's modus operandi was, "You can accomplish almost anything, if you don't care who gets the credit." He was a remarkable individual who cared the most about the patient and very little about getting credit for himself. From 1937 to 1970, Dr Shaw established one of the largest lung cancer surgical centers in the world in Dallas, Texas. It was larger than M.D. Anderson and Memorial Sloan-Kettering Hospitals put together regarding the surgical treatment of lung cancer patients. To accomplish this, he had the help of Dr Donald L. Paulson, who trained at the Mayo Clinic and served as Chief of Thoracic Surgery at Brook Army Hospital during the Second World War. Following the War, because of his love for Texas, he ended up as a partner of Dr Shaw in Dallas. Together, they pursued the development of this very large surgical lung cancer center. Dr Shaw and his wife Ruth went to Afghanistan with Medico multiple times to teach men modern cardiac and thoracic surgery. They also served as consultants on Medico's Ship of Hope in Africa. Dr Shaw initiated multiple new operations including: 1) resection of Pancoast's cancer of the lung after preoperative irradiation; 2) upper lobe of the lung bronchoplasty, reattaching (and saving) the lower lobe to prevent the "disabling" pneumonectomy; and 3) resections of pulmonary mucoid impaction of the lung in asthmatics. Because of his humility and giving "the credit to others," Dr Shaw was never President of a major medical or surgical association.

Drug use has been associated with craving, which may be described as a powerful and sometimes overwhelming urge to use the drug. Patients seeking treatment for methylamphetamine dependence must cope with drug cravings as they engage in psychosocial treatments. Changes in brain GABAA receptors during substance use and withdrawal provide a neurobiological basis for craving and associated anxiety. Flumazenil (a benzodiazepine antagonist) plus gabapentin (an antiepileptic) were compared with placebo in a randomized, double-blind study to assess the effects on craving during initial treatment for methylamphetamine dependence. Evaluation was conducted over a 30-day period. Craving and drug use were found to be highly correlated. Craving was reduced significantly in the flumazenil plus gabapentin group compared with placebo following the initial treatment period and throughout the 30 days. Decreased methylamphetamine use was also observed, as measured by urine drug screens and self-reports.

Modafinil was tested for efficacy in facilitating abstinence in cocaine-dependent patients, compared to placebo.This was a double-blind placebo-controlled study, with 12 weeks of treatment and a 4-week follow-up. Six outpatient substance abuse treatment clinics participated in the study. There were 210 treatment-seekers randomized, having a diagnosis of cocaine dependence; 72 participants were randomized to placebo, 69 to modafinil 200mg, and 69 to modafinil 400mg, taken once daily on awakening. Participants came to the clinic three times per week for assessments and urine drug screens, and had one hour of individual psychotherapy weekly. The primary outcome measure was the weekly percentage of cocaine non-use days.The GEE regression analysis showed that for the total sample, there was no significant difference between either modafinil group and placebo in the change in average weekly percent of cocaine non-use days over the 12-week treatment period (p0.79). However, two secondary outcomes showed significant effects by modafinil 200mg: the maximum number of consecutive non-use days for cocaine (p=0.02), and a reduction in craving (p=0.04). Also, a post hoc analysis showed a significant effect of modafinil that increased the weekly percentage of non-use days in the subgroup of those cocaine patients who did not have a history of alcohol dependence (p0.02).These data suggest that modafinil, in combination with individual behavioral therapy, was effective for increasing cocaine non-use days in participants without co-morbid alcohol dependence, and in reducing cocaine craving.

Poland syndrome is characterized by hypoplasia or absence of the breast or nipple, hypoplasia of subcutaneous tissue, absence of the costosternal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, and absence of costal cartilages or ribs 2, 3, and 4 or 3, 4, and 5. The chest wall defect is often associated with a lung hernia. Clinical manifestations are extremely variable and rarely are all the features recognized in 1 individual. Fortunately it is invariably unilateral, allowing for an easier reconstruction. Single-stage reconstruction of the chest wall combined with simultaneous augmentation mammoplasty and transfer of an island pedicle myocutaneous flap of latissimus dorsi muscle are major improvements over previous multiple-stage procedures that provide less satisfactory cosmetic results in management of patients with Poland syndrome.

Background Significant improvements were made in the diagnosis and management of Paget-Schroetter syndrome (thrombosis of the axillary–subclavian vein) secondary to thoracic outlet syndrome during the past 50 years. The diagnosis has often been extremely difficult. Methods Multiple approaches both in diagnosis and therapy have been tried during the years. After recognizing that the underlying pathologic process resulted from an abnormal insertion of the costoclavicular ligament laterally on the first rib, along with hypertrophy of the scalenus anticus muscle, 506 of 626 extremities have been managed by thrombolytic therapy followed by prompt transaxillary resection of the first rib. These patients have been followed up from 1 to 32 years (average of 7.2 years ± 1.0 standard deviation). Results Four hundred eighty-six patients (96%) improved. Because the pathophysiology is not well understood, many venograms suggest intraluminal disease rather than external compression. Therefore, attempts at opening the narrowed vein with intraarterial techniques do not work. Use of percutaneous venous angioplasty with stents have all occluded in our experience, making further management difficult. Venous bypass grafts fail because of low venous pressure. Conclusions Recognition that an abnormal congenital lateral insertion of the costoclavicular ligament on the first rib causes venous occlusion in Paget-Schroetter syndrome has led to acute thrombolysis, followed by prompt first rib resection, as the ideal management.

The term "thoracic outlet" is the area between the neck and shoulder, over the top of the thorax, and under the clavicle. Knowledge of thoracic outlet anatomy and the four major areas of compression is cardinal for the surgeon to perform thoracic outlet syndrome decompression without injuring major structures, having a minimal number of complications, and avoiding malpractice litigation.

Most patients with thoracic outlet syndrome can be treated conservatively without surgery in a successful fashion. In general, patients with neurogenic thoracic outlet syndrome should be given physiotherapy when the diagnosis is made. Proper physiotherapy includes heat massages, active neck exercises, stretching of the scalenus muscles, strengthening of the upper trapezius muscle, and posture instruction. Because sagging of the shoulder girdle, which is common among middle-aged people, is a major cause in this syndrome, many patients with less severe cases are improved by strengthening the shoulder girdle and by improving posture. Most patients with thoracic outlet syndrome who have ulnar nerve conduction velocities (UNCVs) of more than 60 meters per second (mps) improve with conservative management. 2 If the conduction velocity is below that level, most patients, despite physiotherapy, may remain symptomatic, and surgical resectionofthefirstribandcorrectionofotherbonyabnormalities may be needed to provide relief of symptoms. If symptoms of neurovascular compression continue after physiotherapy, and the conduction velocity shows slight or no improvement or regression, surgical resection of the first rib and cervical rib, when present, should be considered. The transaxillary route is an expedient approach for complete removal of the first rib with decompression of the seventhandeighthcervicalandfirstthoracicnerverootsandthe lower trunks of the brachial plexus. First rib resection can be performed without the need for major muscle division, the needforretractionofthebrachialplexus,andthedifficultyof removing the posterior segment of the rib. In addition, first rib resection shortens the postoperative disability and provides better cosmetic results than the anterior and posterior approaches, particularly because 80% of patients are female.

Background Radial arteries are being used more often for coronary artery bypass grafting. A minimally invasive technique was devised for harvesting vessels and compared with the traditional harvesting technique. Methods In a prospective study of 200 consecutive patients undergoing coronary artery bypass grafting, 100 patients had traditional open radial artery harvesting and 100 underwent endoscopic radial artery harvesting. All patients had a preoperative modified Allen's test with Doppler imaging. The traditional technique involved a longitudinal incision over the radial aspect of the arm from the wrist to the antecubital fossa. The radial artery was dissected subfascially and removed. The endoscopic technique involved a 3-cm incision over the radial aspect of the arm. A vessel loop was placed around the artery and carbon dioxide was insufflated into the wound. The radial artery was dissected to the brachial artery and ligated with an Endo-loop ligature. The branches were divided with bipolar electrocautery and ligated with clips. Patients were evaluated for postoperative pain, bleeding, neuralgias, infection, and any adverse events. A p value of less than 0.05 was considered significant. Results All 200 radial arteries were successfully harvested and used as grafts. Patients who had undergone endoscopic radial artery harvesting had significantly fewer major complications than patients who underwent the open technique: hematomas (five versus no complications) or wound infections requiring antibiotics (seven versus one complication). The occurrence of major neuralgias that restricted function were also significantly lower postoperatively and 1, 3, and 6 months later (ten versus one, eight versus one, five versus zero, and one versus zero, respectively). Conclusions Endoscopic radial artery harvesting results in good cosmetic results, useable grafts, and minimal neuralgias. Endoscopic radial artery harvesting is better than traditional open radial artery harvesting.

Background The accumulation of activated leukocytes in the pulmonary circulation plays an important role in the pathogenesis of lung dysfunction associated with cardiopulmonary bypass (CPB). Patients undergoing valve surgery have prolonged CPB owing to the complexity of the surgery. The goal of this study is to determine if arterial leukocyte filters during CPB improve clinical outcomes after valve surgery. Methods A prospective analysis of all patients receiving only valve surgery with leukocyte arterial filters from June 1999 to June 2002 was compared with a case matched cohort during the same time period. Two hundred fifty patients were identified and compared with a cohort who did not have leukocyte filters used during CPB. The following study points were evaluated preoperatively and postoperatively: white blood cell count, platelet count, arterial blood gas, time to extubation, intensive care unit stay, and total length of hospital stay. Results There were 500 patients in the study. The following valve operations were performed: 92 mitral valve replacements, 168 aortic valve replacements, 152 mitral valve repairs, 80 combined valve repair/replacements, and 8 tricuspid valve repairs, all evenly divided between the two treatment limbs. Patients with leukocyte filters had the following findings compared with nonfilter patients: The time to extubation 10.3 versus 16.2 hours ( P = 0.009), postoperative respiratory quotient 407 versus 320 ( P = 0.02), total length of stay 5.4 versus 7.2 days ( P = 0.04). Conclusions The use of arterial leukocyte filters in patients undergoing valve surgery leads to earlier extubation, improved oxygenation, and a decreased length of stay. Leukocyte filters should be used during CPB for patients having valve surgery.

Adenocarcinoma, typically in the distal third of the esopha- gus, and squamous cell carcinoma, typically in the proximal two thirds of the esophagus, each make up 49% of cases of esophageal cancer. The remaining cancers in this area include sarcoma (1%), lymphoma (0.5%), cylindroma (0.25%), and primary melanoma (0.25%) (1). The incidence of adenocarcinoma is clearly increas- ing; it will soon become the most prevalent type of cancer of the esophagus. No malignant tumor in the past 25 years has increased in incidence as much as adenocarcinoma of the esophagus. The primary risk of adenocarcinoma is related to the duration and se- verity of gastric-esophageal reflux and the progression of mucosal changes from Barrett's esophagus to dysplasia to adenocarcinoma. Early detection is the most important factor in determining sur- vival. Most patients present with stage IIB to stage IV disease, and most disease occurs at the gastroesophageal junction. Among patients with Barrett's esophagus, the risk of devel- oping adenocarcinoma is 0.2% to 2.1% each year; 77% of patients with adenocarcinoma have had Barrett's esophagus. Endoscopy with systematic biopsy cannot reliably exclude the presence of occult adenocarcinoma, since it could miss adenocarcinoma lo- cated somewhere else in that region. Forty percent of patients with Barrett's esophagus and dysplasia have invasive carcinoma in the resected specimen. The incidence of squamous cell carcinoma, which used to be the major cause of esophageal cancer, has significantly decreased. The decrease may be related to reductions in risk factors, which include smoking, excessive alcohol use, caustic lye injury or ther- mal injury, diet, obesity, achalasia, and tylosis. Typical symptoms of esophageal cancer include difficulty swallowing, with a feeling of fullness, pressure, burning, or cough- ing; a feeling of both liquids and solids becoming stuck behind the sternum; indigestion; emesis; and weight loss. Many patients attribute their symptoms to heartburn and do not seek the medi- cal care they need.

Hal Urschel (Figure ​(Figure11) was born in Toledo, Ohio, and he grew up primarily in Bowling Green, 20 miles away. After public schools, he went to Princeton University on a football scholarship and graduated cum laude in 1951. The Princeton team was undefeated during his freshman and senior years. He also had a scholarship to Harvard University School of Medicine, where he again graduated cum laude in 1955. His internship, residency, and chief residency in general, vascular, cardiac, and thoracic surgery were at the Massachusetts General Hospital (MGH) in Boston. After serving in the US Navy as chief of experimental surgery at the National Naval Medical Research Center in Bethesda, Maryland, he and his young family moved to Dallas and have been here ever since.

Background The purpose of this study is to show that intravenous stents (IS) are contraindicated in patients with thrombosis of the axillary-subclavian vein (Paget-Schroetter syndrome). Methods Twenty-two patients had IS placed after balloon dilatation of the venous compression in the thoracic outlet. Each of the patients receiving IS had the diagnosis made less than 6 weeks after vein occlusion, previous thrombolytic therapy, and poststent anticoagulants. (All were performed in outside hospitals. In no case was surgical decompression of the "externally constricted venous tunnel" performed.) The 22 patients receiving IS were compared with a similar group of 384 patients seen less than 6 weeks after thrombosis who were treated with "optimal therapy," ie, thrombolysis and prompt transaxillary resection of the first rib with venous tunnel decompression. Results All 22 patients with IS reoccluded their axillary-subclavian vein from 1 day to 6 weeks after insertion. All were retreated with thrombolytic therapy and first rib resection. Ten remained patent and 7 remained occluded but developed adequate collateral circulation. All 17 were asymptomatic. Five remained occluded with minimal collateral circulation. Attempts were made to reopen them a third time. All 5 are receiving long-term anticoagulants. In contrast the 384 patients managed with optimal therapy were significantly improved without retreatment or anticoagulants. Conclusions From our study, there is no indication for use of IS in patients with Paget-Schroetter syndrome; in fact, from our experience it is contraindicated when compared with the optimal therapy group. Other authors corroborate this conclusion in recent review articles.

The clinical presentation of thoracic outlet syndrome depends on which anatomic structure is compressed in the area of the thoracic outlet (eg, the axillary-subclavian artery, vein [Paget-Schroetter syndrome, or effort thrombosis], brachial plexus, or the sympathetic nerves). The clinical syndrome may be isolated to one or a mixture of these compressed anatomic structures. Although there are multiple compressive forces, the first rib is the common denominator, and extirpation of this structure is the “gold” standard for therapy. The various syndromes are discussed in their clinical order of frequency. For severe nerve compression, whether upper or lower brachial plexus, the best surgical procedure is the transaxillary first rib resection, anterior scalenectomy, and neurovascular decompression. Axillary-subclavian vein occlusion (ie, Paget-Schroetter syndrome) is best treated with early diagnosis, intravenous thrombolysis of the clot, transaxillary first rib resection anterior scalenectomy, and resection of the costoclavicular ligament. Arterial compression, occlusion, or aneurysm may occur with or without peripheral emboli and require a supraclavicular approach with arterial ligation, endarterectomy, or bypass grafts from the supraclavicular subclavian to the infraclavicular brachial artery. Compression of the sympathetic nerves produces vasospasm, Raynaud’s phenomenon, or Raynaud’s disease, requiring dorsal sympathectomy as well as first rib extirpation occasionally. This may be performed through the transaxillary, supraclavicular posterior, or thoracoscopic approach. Recurrent thoracic outlet syndrome may involve any or all of the above anatomic syndromes. The surgical approach is best from the posterior, high thoracoplasty, muscle-splitting incision, performing neurolysis of the C7, C8, and T1 nerve roots and the brachial plexus as well as release of any vascular constriction.

Background . The evaluation of 312 extremities in 294 patients with Paget-Schroetter syndrome (effort thrombosis of the axillary-subclavian vein) over 30 years provides the basis for optimal management determination. Methods and Results . Group I (35 extremities) was initially treated with anticoagulants only. Twenty-one developed recurrent symptoms after returning to work, requiring transaxillary resection of the first rib. Thrombectomy was necessary in eight. Group II (36 extremities) was treated with thrombolytic agents initially, with 20 requiring subsequent rib resection after returning to work. Thrombectomy was necessary only in four. Of the most recent 241 extremities (group III), excellent results accrued using thrombolysis plus prompt first rib resection for those evaluated during the first month after occlusion (199). The results were only fair for those if seen later than 1 month (42). Conclusions . An early diagnosis (less than 1 month), expeditious thrombolytic therapy, and prompt first rib resection are critical for the best results.

SUMMARY BACKGROUND DATA: During the past five decades, significant improvements have been made in the diagnosis and treatment of thoracic outlet syndrome (TOS) secondary to sports activities, breast implants, or median sternotomy. METHODS, RESULTS, AND CONCLUSIONS: Of more than 15,000 patients evaluated for TOS, 3914 underwent primary neurovascular decompression procedures and 1221 underwent second surgical procedures for recurrent symptoms. Of 2210 consecutive patients, 250 had symptoms of upper plexus compression only (median nerve), 1508 had symptoms of lower plexus compression only (ulnar nerve), and 452 patients had symptoms of both. Ulnar and median nerve conduction velocities confirmed the clinical diagnosis. Transaxillary first rib removal alone for neurovascular decompression relieved both upper and lower plexus symptoms (without a combined transaxillary and supraclavicular approach). There are two reasons for this: most upper compression mechanisms attach to the first rib, and the median nerve is also supplied by C8 and T1 as well as C5, C6, and C7 nerve roots. Axillary subclavian artery aneurysm or occlusion was treated successfully in 240 patients. Dorsal sympathectomy was performed concomitantly in 71 patients for occlusion or embolectomy. It was combined with first rib resection in 1974 patients for sympathetic maintained pain syndrome and causalgia that did not improve with conservative therapy. Of 264 patients with effort thrombosis (Paget-Schroetter syndrome), 211 were treated by urokinase thrombolysis and prompt first rib resection with excellent long-term results. Recurrent TOS symptoms required a second procedure using the posterior approach in 1221 patients with brachial plexus neurolysis and dorsal sympathectomy. The use of hyaluronic acid significantly reduced recurrent scarring.

Background . Previously, transaxillary first rib resection alone was not considered adequate therapy for "upper plexus" (median nerve) thoracic outlet syndrome. It was thought that the "combined" approach with upper plexus dissection through a supraclavicular incision in addition to the transaxillary approach was necessary. However, with better understanding of anatomy—that the median nerve receives fibers from C8 and T1 as well as the upper plexus and that muscles that compress the upper plexus attach to the first rib—it is now recognized that first rib removal alone will relieve upper plexus compression. Methods . Assessment of 2,210 operations for thoracic outlet syndrome revealed 250 patients (11%) had symptoms and nerve conduction velocity slowing of the median nerve only (upper plexus), whereas 452 (20%) patients had both median and ulnar nerve compression (upper and lower), and 1,508 patients exhibited compression symptoms and nerve conduction velocity slowing of the ulnar nerve alone (lower plexus). Results . Transaxillary first rib resection relieved symptoms of median nerve (upper plexus) compression as well as it did for ulnar nerve (lower plexus) compression. Treatment outcome comparisons of patients with median and ulnar compression show no significant differences. Conclusions . These data refute the need for supraclavicular or combined supraclavicular and transaxillary approaches to treat patients with upper plexus (median) thoracic outlet syndrome compression as previously recommended. The transaxillary approach alone is satisfactory. (Ann Thorac Surg 1997;63:935–9)

Acute axillosubclavian vein thrombosis is a disorder of the anterior thoracic outlet, and is always associated with an abnormally lateral insertion of the costoclavicular ligament. This is a low pressure system associated with extrinsic compressive forces, and conventional intraluminal therapy designed to treat atherosclerotic arterial lesions is not appropriate in this situation. In our experience of over 600 extremities with this condition, prompt thrombolysis followed by thoracic outlet decompression leads to excellent results in over 95 % of patients, especially if treatment is instituted soon after thrombosis occurs.

The topic of this chapter is to address the rhetorical question, “Is neurogenic thoracic outlet syndrome (TOS) overdiagnosed or underdiagnosed,” and the answer depends a great deal on the experience of a given physician, medical center, or geographic location. The necessity of a multi-disciplinary team to improve the diagnosis and treatment of this difficult condition renders a variety of situations with regard to the question at-hand. For example, if a physician is in solitary practice or isolated geographically, it is very unlikely that they will “overdiagnose” neurogenic TOS unless they happen to know a great deal about it (from some form of unique previous exposure in training or practice), have it themselves, or something similar. On the other hand, if he or she is a member of a large primary care or ­multidisciplinary group, or one of several referring ­specialties (such as thoracic surgery, cardiovascular surgery, neurology or neurological ­surgery, orthopedic surgery or sports medicine, physical medicine and rehabilitation, pain management medicine, psychiatry, cardiology, internal medicine or general practice), the diagnosis of neurogenic TOS may well have been regularly considered in a differential diagnosis and this condition may even have been even “overdiagnosed.”

The treatment of recurrent neurogenic thoracic outlet syndrome (TOS) is an exceptional challenge. We believe that in patients with symptoms suggesting recurrent neurogenic TOS, the clinical diagnosis should be confirmed by objective nerve conduction velocity (NCV) testing, and that when NCVs are depressed in a patient whose symptoms are unrelieved by prolonged conservative therapy, a posterior reoperative procedure should be considered. Removal of any cervical or first rib remnants or regenerated fibrocartilage, along with neurolysis of C7, C8, and T1 nerve roots and the brachial plexus, is performed. Dorsal sympathectomy is typically included to minimize any contribution to symptoms that might be attributable to causalgia and sympathetic-maintained pain syndrome, and topical agents are employed to minimize formation of recurrent perineural scar tissue. In this chapter, we summarize results with this approach in a large number of patients.

In honor of Ronald C. Jones, MD, I offer some thoughts on leadership and review Bay lor University Medical Center (BUMC) surgeons' contributions in thoracic surgery and cardiac stem cell therapy for heart failure. First, I must comment: Ron Jones pretended to be from the backwoods of the Ozarks, but he was really a “city slicker” from Harrison, Arkansas (population 12,000) (Figure ​(Figure1a1a) (1). I was the real hillbilly from Rush Creek, Arkansas, on the Buffalo River 52 miles from an indoor toilet (Figure ​(Figure1b1b). Figure 1 Two boys from Arkansas: (a) Dr. Ron Jones at age 8; (b) Dr. Hal Urschel at age 6.

Operative transluminal coronary artery balloon angioplasty has been used for over 3000 lesions in 1000 patients since 1980. Initially it was only used for distal stenoses not accessible to coronary bypass grafting in 200 patients. Recatheterization of patients who had intraoperative transluminal balloon angioplasty of the proximal left anterior descending, right, and circumflex coronary arteries 3 years previously revealed excellent patency of both the bypass grafts and the dilated native coronary arteries. This observation supports the thesis that with properly constructed bypass anastomoses competitive flow does not significantly mandate graft thrombosis. Subsequently, intraoperative balloon angioplasty has been performed for both proximal and distal stenoses in 800 patients to improve native coronary artery perfusion and maximize revascularization. Follow-up from 1 to 7 years revealed perioperative myocardial infarction in 21 patients (2.1%) and death in 19 patients (1.9%). Recatheterization from 1 to 7 years after the operation in 51 patients (41 with symptoms) revealed that patency was almost as prevalent in arteries subjected to angioplasty (82%; 137/167) as in bypass grafts (84%; 102/122). Intraoperative balloon angioplasty appears to improve coronary artery perfusion without detrimental competitive flow when used with bypass grafts.

To evaluate the safety and efficacy of the pharmacological component of a proprietary medical treatment program targeting type A gamma-aminobutyric acid receptor dysregulation in adults who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for methamphetamine dependence.A prospective, open-label, single-group study of the medication portion of a proprietary treatment program for methamphetamine dependence was conducted from July 1, 2005, to May 10, 2006, at Research Across America, an outpatient private, for-profit, clinical research company in Dallas, TX. In the study, flumazenil, hydroxyzine, and gabapentin, all of which were approved by the US Food and Drug Administration for indications other than drug dependence, were used off-label for the treatment of methamphetamine dependence. Fifty persons who had used methamphetamine within 7 days of study entry were enrolled and received the treatment. Treatment lasted 4 weeks, followed by 8 weeks of weekly follow-up visits to monitor for methamphetamine use via urine drug tests and self-reporting.Participant retention was higher than expected, with 85% of participants completing the program. Significant decrease in methamphetamine use (P.001) was noted at 84 days after vs 90 days before treatment. If missing data are counted as days of methamphetamine use, a 47% reduction in use was observed for the entire sample (P.001) and a 65% reduction for the 36 who completed the 8-week evaluation phase (P.001). Urine test results and self-reported use were positively correlated (Pearson r=0.72, P.001). The frequency of cravings was reduced on average by 66% (P.001), with 30 of 31 (97%) of the 36 who completed the study reporting reduction in cravings.Substantial reductions in methamphetamine cravings and use were observed in all phases of treatment, and the retention rate of participants was high. These findings suggest that the efficacy of the medications and of the entire program in treating methamphetamine dependence should be examined in controlled trials.

During the past 5 decades, the recognition and management of thoracic outlet syndrome (TOS) have evolved. This article elucidates these changes and improvements in the diagnosis and management of TOS at Baylor University Medical Center. The most remarkable change over the past 50 years is the use of nerve conduction velocity to diagnose and monitor patients with nerve compression. Recognition that procedures such as breast implantation and median sternotomy may produce TOS has been revealing. Prompt thrombolysis followed by surgical venous decompression for Paget-Schroetter syndrome has markedly improved results compared with the conservative anticoagulation approach; thrombolysis and prompt first rib resection is the optimal treatment for most patients with Paget-Schroetter syndrome. Complete first rib extirpation at the initial procedure markedly reduces the incidence of recurrent neurologic symptoms or the need for a second procedure. Chest pain or pseudoangina can be caused by TOS. Dorsal sympathectomy is helpful for patients with sympathetic maintained pain syndrome or causalgia and patients with recurrent TOS symptoms who need a second procedure.

Respiration Motion and Tumor Tracking Techniques.- Tumor Motion Ranges Due to Respiration and Respiratory Motion Characteristics.- Respiratory Motion Tracking for Robotic Radiosurgery.- Patient Alignment and Target Tracking in Radiosurgery of Soft-Tissue Tumors Using Combined Fiducial and Skeletal Structures Tracking Techniques.- Thoraco-Abdominal Dosimetry, Radiobiology, and Imaging.- The Radiobiological Rationale for Hypofractionation of Lung and Liver Tumors.- 18FDG-PET/CT for Treatment Planning and Follow-Up.- Treatment Planning of Abdominal Lesions.- Use of a Target Complexity Index in Radiosurgical Plan Evaluation.- Dose Escalation with the Frameless Respiratory Tumor Tracking System of the CyberKnife for Early Stage Non-Small-Cell Lung Cancer.- Thoraco-Abdominal Fiducial Placement Strategies.- Percutaneous Placement of Fiducial Markers for Thoracic Malignancies.- Use of a Blood Patch Technique to Prevent Pneumothorax During Insertion of Lung Fiducials.- Thoracic Fiducial Placement via Flexible Bronchoscopy.- Endoscopic Ultrasound-Guided Fiducial Placement for CyberKnife Radiosurgery.- Lung Tumor Treatment - Techniques and Experiment.- Stereotactic Body Radiation Therapy in the Treatment of Early Stage Non-Small Cell Lung Cancer.- Dosimetric Considerations for Stereotactic Body Radiotherapy Delivery in the Lung.- Selection of Treatment for Patients with Early Stage Non-Small Cell Lung Cancer in a Multidisciplinary Thoracic Oncology Program.- CyberKnife Frameless Image-Guided High-Dose Fractionated Stereotactic Radiosurgery with the Synchrony Motion Tracking Module in the Treatment of Single Small Peripheral Lung Tumors.- Initial Experience Treating Lung Tumors with the CyberKnife.- Stereotactic Radiosurgery for Early Stage Non-Small Cell Lung Cancer: Rationale, Patient Selection, Results and Complications.- Toxicity and Efficacy of Treating Mediastinal and Hilar Lesions.- Liver and Pancreas Treatment - Techniques and Experiment.- A Review of Stereotactic Body Radiotherapy for Liver and Pancreas.- Multidisciplinary Overview of Local-Regional Therapies for Liver Malignancies.- Stereotactic Radiosurgery for Liver Malignancies Using the CyberKnife.- CyberKnife Radiosurgery for Pancreatic Cancer.- Stereotactic Radiosurgery for Unresectable Adenocarcinoma of the Pancreas: Initial Experience at Sinai Hospital of Baltimore.- Emerging Thoraco-Abdominal Radiosurgery Concepts.- 4D Treatment Optimization and Planning for Radiosurgery with Respiratory Motion Tracking.- Xsight Lung Tracking System: A Fiducial-Less Method for Respiratory Motion Tracking.- CyberKnife Radiosurgery: Quality of Life and Cost Considerations.

Background Atrial fibrillation is the most common complication after cardiac surgery. Current medical treatment using antiarrhythmics and anticoagulants has a significant morbidity. The goal of this study was to determine if epicardial atrial defibrillation can be safely performed and return patients to sinus rhythm. Methods A prospective analysis of patients undergoing cardiac surgery was performed. Patients with a prior pacemaker/defibrillator, history of arrhythmia, preoperative antiarrhythmic, age greater than 85 years, history of stroke, or intraaortic balloon pump were excluded. Temporary epicardial atrial cardioversion wires were placed on the right and left atrium. Bipolar atrial and ventricular pacing wires were also placed. The wires were tested in the operating room. Patients who went into postoperative arial fibrillation were cardioverted with 3 J, 6 J, or 9 J. Results There were 45 patients enrolled. Sixteen patients (35%) went into postoperative arial fibrillation during their hospital stay. Mean time to onset of arial fibrillation was 2.6 ± 1.4 days after surgery. Fifteen patients were successfully cardioverted to sinus rhythm on the primary cardioversion, with mean of 5.7 ± 2.4 J. One patient was cardioverted at 6 hours after onset of arial fibrillation, at 6 J. Recurrent arial fibrillation occurred in 4 patients during their hospital stay. All 4 of these patients were cardioverted with a mean of 6.4 ± 2.6 J. All wires were removed the day before patients were discharged. There were no complications with wire insertion or removal. There were no adverse neurologic events. The mean hospital stay was 5.1 ± 2.2 days. All patients were in sinus rhythm at 1 month follow-up. Conclusions The use of a temporary atrial defibrillator to resynchronize patients in postoperative arial fibrillation is safe and effective.

Background Patients with penetrating cardiac injuries have a high mortality. The utilization of sonography in these patients may lead to earlier diagnosis and definitive surgical intervention. Methods A retrospective review of all patients admitted to a level I trauma center were examined from March 1996 to March 2001 (17,241 patients). Patients were identified with penetrating thoracic injuries and were evaluated for mechanism of injury, sonographic findings (subxiphoid and parasternal windows), injury severity score, length of stay, and mortality. Surgeons performed all sonography. Results There were 478 patients who underwent sonography for penetrating thoracic injuries. Twenty-three patients were identified with positive sonographic findings. Subsequently 20 patients had a cardiac injury at surgery. There were no missed injuries. The 3 patients with false positive findings had congestive heart failure (2 patients) and morbid obesity (1 patient). Mean time to operation was 13 minutes. Mean injury severity score was 33. Mean intensive care unit and hospital stay was 3.1 days and 7.2 days respectively. Sonography had a specificity of 99.3% and sensitivity of 100% for identifying penetrating cardiac injury and a positive predictive value of 87% and negative predictive value of 100%. There were no hospital deaths. Conclusions Early diagnosis and management using surgeon performed sonography may reduce the high mortality associated with penetrating cardiac injury.

Many patients with thoracic outlet syndrome develop a chronic pain syndrome (1). Some of these patients require surgical decompression of the thoracic outlet to alleviate their symptoms. Surgical decompression is accomplished by performing a first rib resection with cervical sympathectomy. There are 2 approaches to first rib resection, supraclavicular and transaxillary. The preferred surgical technique at Baylor University Medical Center is transaxillary (2–4). Postoperative pain management for patients with thoracic outlet syndrome is compounded by the fact that most of these patients are on long-term potent analgesics at home before the operation.

Reassessment of the managed care environment and restructuring of our practice will be accomplished by transitional short-term actions while we institute our long-range plan. In the short term we must develop appropriate relationships with hospitals and medical groups that interrelate to our specialty, and develop a "love our enemy" philosophy. We must establish operating organizational units that will be competitive. Reassessment of our own practice, our unique skills, our inadequacies, our competition, and our performance through outcome studies is essential to retake positions weakened by loss of contract inclusion. Long-term strategy must develop insurance coverage in conjunction with our patients in such a way that the middleman is eliminated and the profit currently extracted by managed care is reinvested in patient care, research, and education. Whoever controls payment determines the quality of medicine and how it is delivered.

Dorsal sympathectomy and the management of the thoracic outlet syndrome have been considerably improved with the use of video assistance because it affords both magnification and an improved light system. Two techniques of video assistance were employed in the group of patients described here. One involved the sympathectomy done through three ports using standard video-assisted thoracic surgical methods. The second technique involved a transaxillary incision with removal of the first rib using video-assistance magnification and light, operating either directly or secondarily while visualizing the image on the television set. (The vast majority of cases have been performed using this latter technique.) Major indications for performing dorsal sympathectomy include (1) hyperhidrosis, (2) Raynaud's phenomenon, (3) Raynaud's disease, (4) causalgia, (5) reflex sympathetic dystrophy, and (6) vascular insufficiency of the upper extremity. Except for hyperhidrosis, all of the other indications require the usual diagnostic techniques, including cervical sympathetic blockade to assess whether the symptoms are relieved by temporary blockade of the sympathetic ganglia. In 326 patients, sympathectomy, performed either alone or in conjunction with first-rib removal for relief of the thoracic outlet syndrome, has been successful. In only 6 patients has sympathetic activity recurred in less than 6 months. Initially all of them were treated conservatively. Three of the 6 required a repeat sympathectomy. Postsympathectomy neuralgia occurred in only 2 of more than 326 patients. Both cases were managed successfully in a conservative fashion. Among the patients in whom a Horner's syndrome was not deliberately induced, the syndrome developed in 2. In both, the syndrome resolved spontaneously within several months.