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Desmoid tumors are rare tumors accounting for only 0.03% of all neoplasms. Mainly occurring in the fourth and fifth decades of life, these tumors originate in musculoaponeurotic tissues of the limbs, neck, trunk, abdominal wall, and mesentery. We present a rare case of a chest wall desmoid tumor that was mistaken for breast cancer on both physical examination and mammography, which highlights the unique risk these tumors present for confusion with other malignant processes. Although past literature contains numerous reports of other misdiagnoses, this case is unique in reporting the potential for misdiagnosis between chest wall desmoid tumors and breast cancer. In cases where suspicious breast findings do not correlate to usual diagnostic measures, such as fine-needle aspiration or core needle biopsy, the possibility of another pathology such as a chest wall desmoid tumor mimicking breast cancer should be considered in the differential diagnosis. [ABSTRACT FROM AUTHOR]

The purpose of this study was to identify the presence of the anterior intermeniscal ligament of the knee and to study its attachment patterns and relationships to other anatomic structures within the knee. Fifty unpaired cadaveric knees were dissected. An identifiably distinct anterior intermeniscal ligament was found in 47 specimens (94%). The average length was 33 mm and the average midsubstance width was 3.3 mm. The average perpendicular distance from the anterior intermeniscal ligament to the anterior margin of the tibial insertion of the anterior cruciate ligament was 7.8 mm (range, 2.0 to 13.5). The anterior intermeniscal ligament was the primary attachment for the anterior horn of the medial meniscus in 12 knees (24%); 7 knees (14%) had no tibial insertion and 5 knees (10%) had only a fine fascial tibial connection. Successful arthroscopic evaluation, surgical repair, and meniscal allograft reconstruction can be enhanced by a precise knowledge of the anterior intermeniscal ligament anatomy, especially when identifying the various insertion patterns of the anterior horn of the medial meniscus. A correct understanding of these patterns is helpful for avoiding patient injury during surgical procedures (particularly arthroscopic ACL reconstructions) performed in close proximity to the anterior intermeniscal ligament of the knee. [ABSTRACT FROM AUTHOR]

Background: Mastectomy with immediate reconstruction is a high-risk cohort for postoperative nausea and vomiting (PONV). Known risk factors for PONV include female gender, prior PONV history, nonsmoker, age < 50, and postoperative opioid exposure. The objective of this observational, cohort analysis was to determine whether a standardized preoperative protocol with nonopioid and anti-nausea multimodal medications would reduce the odds of PONV., Methods: After IRB approval, retrospective data were collected for patients undergoing mastectomy with or without a nodal resection, and immediate subpectoral tissue expander or implant reconstruction. Patients were grouped based on treatment: those receiving the protocol - oral acetaminophen, pregabalin, celecoxib, and transdermal scopolamine (APCS); those receiving none (NONE), and those receiving partial protocol (OTHER). Logistic regression models were used to compare PONV among treatment groups, adjusting for patient and procedural variables., Main Findings: Among 305 cases, the mean age was 47 years (21-74), with 64% undergoing a bilateral procedure and 85% having had a concomitant nodal procedure. A total of 44.6% received APCS, 30.8% received OTHER, and 24.6% received NONE. The APCS group had the lowest rate of PONV (40%), followed by OTHER (47%), and NONE (59%). Adjusting for known preoperative variables, the odds of PONV were significantly lower in the APCS group versus the NONE group (OR=0.42, 95% CI: 0.20, 0.88 p = 0.016)., Conclusions: Premedication with a relatively inexpensive combination of oral non-opioids and an anti-nausea medication was associated with a significant reduction in PONV in a high-risk cohort. Use of a standardized protocol can lead to improved care while optimizing the patient experience., (Copyright © 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Models that recapitulate the complexity of human tumors are urgently needed to develop more effective cancer therapies. We report a bank of human patient-derived xenografts (PDXs) and matched organoid cultures from tumors that represent the greatest unmet need: endocrine-resistant, treatment-refractory and metastatic breast cancers. We leverage matched PDXs and PDX-derived organoids (PDxO) for drug screening that is feasible and cost-effective with in vivo validation. Moreover, we demonstrate the feasibility of using these models for precision oncology in real time with clinical care in a case of triple-negative breast cancer (TNBC) with early metastatic recurrence. Our results uncovered a Food and Drug Administration (FDA)-approved drug with high efficacy against the models. Treatment with this therapy resulted in a complete response for the individual and a progression-free survival (PFS) period more than three times longer than their previous therapies. This work provides valuable methods and resources for functional precision medicine and drug development for human breast cancer., (© 2022. The Author(s).)

The clinical competency committee offers a fellowship program a structured approach to assess the clinical performance of each trainee in a comprehensive fashion This special article examines the structure and function of this important committee in detail. Furthermore, the strategies for the optimal functioning of this committee are also discussed as a way to enhance the overall quality of the fellowship program., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To quantify risk for CRI based on PABX use in CVAP placement for cancer patients., Summary Background Data: Central venous access ports (CVAP) are totally implanted devices used for chemotherapy. There is a temporal risk for catheter related infection (CRI) to insertion and perioperative prophylactic antibiotics (PABX) use is a contested issue among practitioners., Methods: Data was collected from a single center, academic oncology center. Treatment with a perioperative PABX was compared to non-treatment, to examine the incidence of 14-day CRI. Propensity scores with matched weights controlled for confounding, using 15 demographic, procedural and clinical variables., Results: From 2007 to 2012, 1,091 CVAP were placed, where 59.7 % received PABX. The 14-day CRI rate was 0.82%, with 78% of those not receiving PABX. While results did not achieve statistical significance, use of PABX was associated with a 58% reduction in the odds of a 14-day CRI (OR = 0.42, 95% CI: 0.08-2.24, p = 0.31)., Conclusion: The findings suggest a reduction in early CRI with the use of PABX. Since CRI treatment can range from a course of oral antibiotics, port removal, to hospital admission, we suggest clinicians consider these data when considering PABX in this high-risk population., (Copyright © 2018. Published by Elsevier Inc.)

Background: There has been a dramatic shift in recent years in anesthesia coverage for electrophysiology (EP) procedures. An anesthesiologist and electrophysiologist at our institution jointly developed a survey, which was distributed to the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society. Its goal was to document current practice patterns and examine perceived variability in coverage., Methods: On approval of the leadership from the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society, an online survey was administered to the membership. The survey included demographic data, anesthetic type, and perceptions of the respondents., Results: Four hundred seventy-nine surveys were completed. Thirty-eight percent were completed by electrophysiologists and 63% by anesthesiologists, giving a response rate of 8.24% for anesthesiologists and 13.6% for electrophysiologists. Of these, 57% of respondents worked in an academic setting. Over the past 2 years, 66.5% of respondents reported anesthesia involvement in EP cases increasing. These cases are reportedly covered by all anesthesiologists in a group 55% of the time, cardiac anesthesia 32.5%, and a designated team at the remainder of the institutions. Seventy-six percent of respondents reported having designated EP block time in the schedule. Ninety-two percent of respondents reported that patient satisfaction has increased with the involvement of anesthesia services., Conclusions: Anesthesia coverage for EP procedures has continued to increase with an increase in patient satisfaction. Anesthesiologists have had to adapt and provide designated block time to accommodate this increase and also, in some instances, form teams that go beyond simply cardiac anesthesiologists to care for these patients during their procedures.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

Objective: To evaluate the risk of neoadjuvant chemotherapy for surgical morbidity after mastectomy with or without reconstruction using 1:1 matching., Background: Postoperative surgical complications remain a potentially preventable event for breast cancer patients undergoing mastectomy. Neoadjuvant chemotherapy is among variables identified as contributory to risk, but it has not been rigorously evaluated as a principal causal influence., Methods: Data from American College of Surgeons National Surgical Quality Improvement Program (2006-2012) were used to identify females with invasive breast cancer undergoing planned mastectomy. Surgical cases categorized as clean and undergoing no secondary procedures unrelated to mastectomy were included. A 1:1 matched propensity analysis was performed using neoadjuvant chemotherapy within 30 days of surgery as treatment. A total of 12 preoperative variables were used with additional procedure matching: bilateral mastectomy, nodal surgery, tissue, and/or implant. Outcomes examined were 4 wound occurrences, sepsis, and unplanned return to the operating room., Results: We identified 31,130 patient procedures with 2488 (7.5%) receiving chemotherapy. We matched 2411 cases, with probability of treatment being 0.005 to 0.470 in both cohorts. Superficial wound complication was the most common wound event, 2.24% in neoadjuvant-treated versus 2.45% in those that were not (P = 0.627). The rate of return to the operating room was 5.7% in the neoadjuvant group versus 5.2% in those that were not (P = 0.445). The rate of sepsis was 0.37% in the neoadjuvant group versus 0.46% in those that were not (P = 0.654)., Conclusions: This large, matched cohort study, controlled for preoperative risk factors and most importantly for the surgical procedure performed, demonstrates that breast cancer patients receiving neoadjuvant chemotherapy have no increased risk for surgical morbidity.

Objective: To describe the experience regarding the perioperative management of patients with left ventricular assist devices (LVADs) who require anesthesia while undergoing noncardiac surgery (NCS) at a single medical center., Design: Retrospective chart review, Setting: Academic medical center, Participants: Patients with LVADs, Interventions: Medical records from April 1, 2009 through January 31, 2014 were reviewed for patients who underwent Heartmate II LVAD placement at this facility. Individual records were reviewed for NCS after LVAD placement, specifically investigating perioperative and anesthetic management., Measurements and Main Results: Seventy-one patients underwent LVAD placement during this time period. Thirty-five patients (49%) underwent a total of 101 NCS procedures. Arterial catheters were placed in 19 patients (19%), and 33 patients (33%) were intubated for their procedure. No complications or perioperative mortality occurred related to the NCS., Conclusions: Noncardiac surgery is becoming more common in patients with LVADs. Anesthetic management of these patients outside of the cardiac operating room is limited. Patients with Heartmate II LVADs can safely undergo noncardiac surgery., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Incorporation of "lean" business philosophy within health care has the goal of adding value by reducing cost and improving quality. Applying these principles to the role of Advance Practice Clinicians (APCs) is relevant because they have become essential members of the healthcare team., Methods: An independent surgical breast care clinic directed by an APC was created with measurements of success to include the following: time to obtain an appointment, financial viability, and patient/APC/MD satisfaction., Results: During the study period, there was a trend toward a decreased median time to obtain an appointment. Monthly APC charges increased from $388 to $30,800. The mean provider satisfaction score by Press Ganey was 96% for the APC and 95.8% for the surgeon. Both clinicians expressed significant satisfaction with clinic development., Conclusions: Overall, initiation of an APC breast clinic met the proposed goals of success. The use of lean philosophy demonstrates that implementation of change can result in added value in patient care., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The goals of this study were to evaluate the complication rate for intraoperative placement of a long-term central venous catheter (CVC) using intraoperative ultrasound (US) and fluoroscopy and to examine the feasibility for eliminating routine postprocedure chest X-ray., Methods: Retrospective data pertaining to operative insertion of long-term CVC were collected and the rate of procedural complications was determined., Results: From January 2008 to August 2013, 351 CVCs were placed via the internal jugular vein using US. Of these, 93% had a single, successful internal jugular vein insertion. The complications included 4 arterial sticks (1.14%). Starting in October 2012, postprocedure chest radiography (CXR) was eliminated in 170 cases, with no complications. A total of $29,750 in charges were deferred by CXR elimination., Conclusions: This review supports the use of US for CVC placement with fluoroscopy in reducing the rate of procedural complications. Additionally, with fluoroscopic imaging, postprocedural CXR can be eliminated with associated healthcare savings., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Currently, there is no standard of care for prophylactic antibiotics (PABX) at the time of placement of fully implanted central venous access ports (CVAPs). A survey of fellows of the American College of Surgeons was undertaken to determine the current practice pattern of PABX in CVAP placement., Methods: A survey was mailed to 5,000 fellows of the American College of Surgeons., Results: The response rate was 21.7%, with 73.1% of respondents nonacademic surgeons. PABX were given by 88.2% of the respondents. Of those who did not use PABX, the primary reasons were "not justified" or "not standard of care." General comments regarding reasons for use of PABX included "medicolegal," "required by hospital," and "liability.", Conclusions: In this survey, the overwhelming majority of responding American College of Surgeons fellows indicated that they use preoperative antibiotic prophylaxis for CVAP placement, despite there being no accepted standard of care or definitive evidence regarding PABX use for fully implanted CVAPs., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: This study examined the changing demographics and age profile between living donors and their recipients. A 46-year review of living donor renal transplants in a single transplant center was performed., Patients: The study included 923 consecutive living donor renal transplants from January 1966 until December 2011., Results: These 923 living donor kidneys transplants represent 41% of all transplants performed during this 46-year review. The majority involved sibling donation (39.5%) followed by parent to child (32.5%). Dividing the 46-year timeframe into quartiles, the mean age of donors has remained stable at 39.3 ± 10.9 years. In contrast, the mean age of recipients has trended upwards, from 28 ± 10.7 years in the first quartile (1966-1978) to 37 ± 17.5 years in the latest quartile (2001-2011). This represents an increase every year of approximately 4 months (P < .001). Over the same period, the difference between a given donor's age and their recipient's has decreased every year by approximately 4 months (P < .001). In a linear regression model of donor-recipient categories and their age difference over time, we found that both the child-to-parent and grandchild-to-grandparent groups had the largest effect on the donor-recipient age difference when compared to the classic parent-to-child relationship., Conclusion: This review of center-specific data shows that the difference in the age of the donor to their recipient has been narrowing over time. We have determined that this is primarily due to changes in donor-recipient demographics with an increasing number of younger donors to older recipients. Although the medical risks to donors living with a single kidney have yet to be shown different than that of the general population, the increasing volume of donors who are younger and those with no relation to the recipient should prompt closer follow-up within the transplantation medical community., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Müller-Weiss disease of the tarsal navicular is a rare condition, the etiology of which remains unclear. We present the case of a 28-year-old woman with classic radiographic findings consistent with Müller-Weiss disease. The patient was successfully treated with a talonavicular-cuneiform arthrodesis of her right foot. Radiographs at 6 months postoperatively demonstrated a successful medial arch fusion. At 38 months follow-up, the patient was asymptomatic. The American Academy of Orthopaedic Surgeons ankle hindfoot score was 97, compared with a preoperative score of 32., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the difference in post-renal transplant lymphocele rate based on the surgical dissection technique for control of lymphatics by examining the historical case group under the direction of a single, university-based surgeon in a retrospective, cohort study., Patients: Five hundred thirty-two consecutive renal transplant patients from January 1994 to December 2009., Findings: Of the 532 cases studied, 259 (48.7%) had suture ligation and 273 (51.3%) employed ultrasonic dissection (UD) for control of lymphatics during renal transplantation. There was no difference found in the rate of lymphocele formation, requiring either percutaneous or surgical drainage, when surgical ties (8.9%) were compared to UD (9.2%; P=.999). Logistic regression analysis showed that the odds ratio for developing a lymphocele was independent of surgical dissection technique. Within the logistic analysis, the prediction for lymphocele was increased 3.29 times for pediatric patients (P=.002) and increased 2.97 times for those who received a living donor graft (P=.001), and there was a trend for those with a history of more than one renal transplant of 2.01 times (P=.079)., Summary: Surgical dissection technique was not a factor in the development of post-renal transplant lymphocele. Younger age, living donor transplant, and repeat transplant status were found to be predictive variables for symptomatic lymphoceles requiring drainage, which may be considered when patients present for posttransplant evaluations for laboratory alterations., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Sentinel lymph node (SLN) biopsy for axillary staging in breast cancer is technically more demanding but of added benefit in obese patients. This retrospective review compares variables and outcomes of SLN staging in obese and nonobese women., Methods: From 235 total SLN cases, demographics and clinical and procedural variables were collected and compared in obese (body mass index [BMI] of ≥ 35, n = 28) and nonobese (BMI ≤ 25 [n = 84]) patients., Results: Overall, the intraoperative false-negative rate was 13.6% and failure to identify SLN occurred in 2 cases (.85%). Although no differences in patient or tumor characteristics were found, obese patients had significantly lower external hotspot counts, first sentinel node counts, and fewer sentinel nodes recovered when compared with the nonobese., Conclusions: SLN procedures are successful and accurate for axillary staging in obese women and avoid the added morbidity of axillary lymph node dissection in this higher risk population., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Antibiotic prophylaxis during placement of implanted central venous access ports (CVAP) has not been studied. This retrospective review compared the rate of catheter-related infections (CRIs) with and without perioperative antibiotics., Methods: This was a single-center study that compared patients treated with and without a single dose of antibiotics during CVAP placement. CRIs were defined as a patient treated with antibiotics for port site induration, positive blood cultures, or suspicion of infection that led to port removal within 30 days of placement., Results: CVAP were placed in 459 patients, 103 of whom (22.4%) received antibiotic prophylaxis. Surgical technique and patient demographics were similar to those patients not receiving antibiotics (356). All 9 (2%) CRIs occurred in the non-prophylactic antibiotic group (P = .218), with 5 infections resulting in port removal., Conclusions: Single-dose perioperative antibiotics may decrease CVAP infection rates and should be studied further in a prospective randomized trial., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: In breast cancer staging, the need for intraoperative sentinel lymph (SLN) evaluation is not well established. This study compares intraoperative use of touch preparation (TP), frozen section (FS), and factors that may influence the selective use of intraoperative SLN analysis., Methods: Breast cancer patients (1998-2007) undergoing SLN evaluation were retrospectively reviewed., Results: Of 205 SLN procedures, 157 cases underwent intraoperative evaluation, 43% (FS) and 57% (TP) with positive pathology in 21% and 20%, respectively. The false negative case rate was 16% for TP versus 12% for FS. Of T1, low-grade tumors, 9% were intraoperatively positive, versus 43% of T2-3, moderate- to high-grade tumors (P = .006). Additional positive axillary nodes were found in 43% of the higher risk patients versus 0% in the lower risk groups., Conclusions: Both TP and FS are accurate for intraoperative SLN evaluation and can be selectively applied to breast cancer staging in low- and high-risk groups.

Plasma cell neoplasms are generally categorized into four groups; multiple myeloma (MM), solitary plasmacytoma of the bone (SPB), plasma cell leukemias, and extramedullary plasmacytomas (EMP). A plasmacytoma is defined as any discrete, usually solitary mass of neoplastic plasma cells, either in the bone marrow or in various soft tissue sites. Each manifestation of a plasma cell neoplasm differs in terms of tumor recurrence and progression to MM. A gastric plasmacytoma (GP) is a rare presentation of extramedullary plasmacytoma and has not been previously reported as a site of recurrence for a SPB. This pattern of tumor recurrence is unique and the management of gastric plasmacytoma as part of this complex disease is discussed. The continuum of progression between various sites and manifestations of plasma cell manifestations is reviewed including a previously undiscovered sequence of bone disease, gastric disease, and finally multiple myeloma.

Background: Traditionally, a post transplant lymphocele (PTL) is drained by widely opening the wall connecting the lymphocele cavity to the intraperitoneal space via laparotomy. We hypothesize that laparoscopic techniques can be effectively used for the treatment of PTL., Methods: Patients requiring intervention for PTL between 1993 and 2002 were identified via a retrospective review. Results of drainage via laparotomy and laparoscopy were compared., Results: During the study period 685 renal transplants (391 cadaveric, 294 living) were performed. The incidence of lymphocele was 5% [34/685 (36 cases)]. The indications for surgical drainage were local symptoms (69%), graft dysfunction (14%), or both (17%). The mean time to surgical therapy was 4.9 months. Laparoscopic drainage was performed in 25 patients (74%) and open drainage in 9 patients (26%). Open procedures were performed in cases for: previous abdominal surgery (5), undesirable lymphocele characteristics or location (2), or with concomitant open procedures (3). There were no conversions or operative complications in either group. There was no difference in operative time for the laparoscopic group vs the open group (108 +/- 6 vs 123 +/- 18 min, p = 0.8). Hospital stay was significantly shorter for the laparoscopic group (1.7 +/- 0.8 vs 3.8 +/- 1.0, p = 0.0007), with 88% of laparoscopic patients being either overnight admissions or same day surgery. Two patients (5%) developed symptomatic recurrences requiring reoperation [1 laparoscopic (4%), 1 open (10%)]., Conclusions: Laparoscopic fenestration of a peritransplant lymphocele is a safe and effective treatment. The large majority of patients treated with laparoscopic fenestration were discharged within one day of surgery. Unless contraindications exist, laparoscopy should be considered first-line therapy for the surgical treatment of posttransplant lymphocele.

Background: Crossed renal ectopia is a rare (1 in 1000 live births) congenital anomaly in which both renal masses are located on one side of the abdomen and in 90% of cases are fused. Although this condition is not typically associated with underlying renal pathology or symptoms, complex vascular anatomy is commonly encountered., Study Design: A report of the successful transplantation of crossed fused ectopic kidneys as a single allograft., Results: With careful attention to the complex anatomy presented by this anomaly, the course of the patient's transplantation and postoperative convalescence were uncomplicated and resulted in excellent longterm graft function. We report the first successful transplantation and longterm function of crossed fused ectopic kidneys as a single allograft., Conclusions: Given the shortage of cadaveric renal allografts, patients with this anomalous condition should not be excluded as potential organ donors. Transplant surgeons should have an understanding of this anomaly and its anatomic variants to ensure proper utilization of this limited but valuable resource.

The purpose of this study was to establish the relationship between force at the distal radius and power grip force of the hand, a common functional and rehabilitation maneuver. This information will provide limits of allowable grip forces during postfixation rehabilitation and guide design requirements for fixation systems. By designing a model of power grip using the extrinsic hand musculotendinous units, we were able to compare grip force with force at the distal radius. Our results show that to obtain 10 N of grip force, approximately 26.3 N of force is transmitted through the distal radius, 52.4 N is transmitted through the radius and ulna combined, and 30.0 N needs to be applied to the flexor tendons. Fifty-one percent of the total forearm force was transmitted through the distal radius in this model. If all forearm forces were transmitted through the radius, 52 N of force would be transmitted through the distal radius to obtain 10 N of grip force. The clinical application of this model suggests that since failure forces of tested distal radius fixation systems range from 55 to 825 N, rehabilitation grip force should not exceed 10 to 159 N, depending on the type of fixation.

Background: Splenectomy in patients with massive splenomegaly and hematologic malignancy results in higher morbidity and mortality with primarily palliative benefit., Methods: From a 14-year experience with 172 splenectomies, the perioperative course of 39 high-risk patients with splenomegaly was reviewed for comorbidities, indications, complications, and mortality., Results: Twenty-three males and 16 females with a mean age of 54.2 years and a mean 12.8-day postoperative length of stay were reviewed. Sixteen patients (41%) had 23 major complications related to age (P = 0.047) and operative time (P = 0.01). Intraoperative transfusion was related to splenic size (P = 0.04), and estimated blood loss (P = 0.02) was inversely related to use of splenic artery preligation. Three perioperative deaths were secondary to sepsis and multi-organ system failure., Conclusion: Splenomegaly and comorbidities of the primary disease result in higher morbidity and mortality. Splenic artery preligation is valuable to limit intraoperative blood loss and facilitate splenectomy.

Purpose: To evaluate the utility of gadolinium-enhanced three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) of the renal arteries in the evaluation of potential renal donors., Materials and Methods: Fifty consecutive patients underwent gadolinium-enhanced 3D-TOF MRA of the renal arteries as part of their evaluation as possible renal donors. All imaging was performed on a 1.5-T system with use of a torso phased-array coil. Conventional T1-weighted axial spin-echo and T2-weighted axial fast spin-echo imaging was performed to evaluate the renal parenchyma. Coronal dynamic MRA was performed during bolus injection of 40 mL of gadolinium with use of a 3D-TOF sequence requiring a breathhold of approximately 30 seconds. Maximum-intensity-projection reconstructions were obtained of the renal arterial and venous anatomy. All studies were prospectively evaluated by a single radiologist experienced with body MRA. Intraoperative findings were used as the reference standard in 35 patients. To evaluate interobserver variability, each examination was evaluated for image quality, renal artery number, and anatomy by two radiologists experienced with MRA and blinded to the other's interpretations and surgical results., Results: Ninety-eight percent of all MRAs were graded as diagnostic quality (Kappa value = 0.38; P < .05). Multiple renal arteries were identified in 29 (29%) of 100 kidneys. Four of 50 patients studied (8%) had renal parenchymal abnormalities identified with MR imaging. Sensitivity and specificity for accessory renal artery detection was 71% and 95%, respectively. Overall, accuracy for MRA in determining renal artery number was 90%., Conclusion: Gadolinium-enhanced breathhold 3D-TOF renal MRA is sufficient to assess the renal arteries in potential donors.

Background: Allogeneic blood transfusion is associated with an increased risk of infection and higher cancer recurrence rates. Previous research has shown that blood transfusion results in multiple immune effects, including cytokine alterations. The purpose of this study was to measure the long term kinetics of splenocyte cytokine production in transfused mice., Methods: Balb/c mice received either syngeneic transfusion (Syn-BT) or allogeneic transfusion (Allo-BT) from C3H-HeN mice. Splenocyte production of IL-2, IL-6, IL-10, and IFN-gamma was quantitated by ELISA on post-transfusion days 5, 10, 21, and 30., Results: Both Allo-BT and Syn-BT produced significant alterations in cytokine production, but Allo-BT produced the most dramatic and enduring effects as summarized: IL-2: Production of IL-2 was suppressed at day 5, (p < 0.0001), but then rose, peaking at day 21, 30% greater than control values (p < 0.05). IL-6: Allo-BT mice showed suppression of IL-6 throughout the study period (p < 0.005 vs controls, each time point). IL-10: A 5-fold increase in IL-10 production was seen at day 5 after Allo-BT (p < 0.0001 vs control). Production of IL-10 was suppressed at days 10 and 21 (p < 0.001), but returned to control levels by day 30, gamma-IFN: At day 5 post Allo-BT, gamma-IFN was 4 x greater than controls (p < 0.0001). Gamma-IFN production was suppressed at day 10, but then rose at days 21 and 30 to nearly 3 x control levels (p < 0.0001)., Conclusion: Allo-BT produced multiple cytokine alterations that were of prolonged duration. These results provide a theoretic explanation for the multiple, long-term immunomodulating effects seen in patients who have received transfusions.

Unlabelled: Allogeneic blood transfusion is known to be immunosuppressive in the settings of cancer and transplantation, but the contribution of blood transfusion to immunomodulation after hemorrhage is unknown. Our purpose was to determine the influence of allogeneic blood transfusion upon cytokine profiles following hemorrhagic shock, using a model which approximates the clinical setting., Methods: Male C3H/HeN mice were hemorrhaged via femoral arterial catheters to a mean arterial pressure (MAP) of 35 +/- 5 mm Hg, which was maintained for 1 h. Mice were resuscitated with autologous blood (auto BT) or allogeneic blood (allo BT) from Balb/c mice (both equivalent to volume of shed blood), and crystalloid (2X the volume of shed blood)-infused at 0.05 ml/min. Animals were sacrificed at 1, 2, and 5 days postshock, and splenocytes were cultured for 24 h with anti-CD3 antibody. Supernatants were assayed for IL-2, IL-6, IL-10, and gamma-IFN by ELISA., Results: Regardless of transfusion status, hemorrhagic shock resulted in increased IL-6 and gamma-IFN by Day 2 postshock. Distinct cytokine alterations after allogeneic transfusion were as follows. IL-2: transient elevation of splenocyte IL-2 production in the shock + allo BT group (P < 0.005 vs. shock + auto BT) at Postshock Day 2. IL-6: suppression in IL-6 production in the shock + allo BT group by Postshock Day 5 (P < 0.05 vs. shock + auto BT). IL-10: persistently elevated IL-10 production following shock + allo BT (Day 1, P < 0.001 vs. shock + auto BT; Day 5; P < 0.05 vs. shock + auto BT). gamma-IFN: elevation in gamma-IFN production by Day 5 in the shock + allo BT group (P < 0.0005 vs. shock + auto BT)., Conclusions: Allogeneic blood transfusion results in distinct alterations in splenocyte production of IL-2, IL-6, IL-10, and gamma-IFN after hemorrhagic shock. This model reflects the clinical usage of blood products and demonstrates some of the immune alterations after transfusion.

Objective: To evaluate the influence of stereotactic core needle biopsy (SCNB) as an alternative to wire localization biopsy (WLB) on the evaluation and workup of nonpalpable mammographic lesions., Design: A 4-year retrospective clinical review., Setting: University hospital and clinics., Patients: All patients evaluated for nonpalpable mammographic lesions after screening, diagnostic mammography, or both during the 4-year period of the study were included., Outcome Parameters: Changes in the number and types of mammograms and diagnostic biopsies and the histologic findings using each technique (SCNB vs WLB), including total number of cancers diagnosed., Results: The number of screening mammograms and WLBs performed remained constant compared with a marked increase in the number of diagnostic mammograms and SCNBs. The rates of positive findings for each biopsy technique were consistent while the total number of cancers diagnosed increased dramatically. The percentage of biopsy specimens with positive results (ductal carcinoma in situ and invasive cancers) for SCNB was 13.3% compared with 26.2% for WLB specimens. There has also been an increase in the number of cancers found, from 22 in the first year to 54 in the fourth year. In the first year, 45% of these cancers were diagnosed by SCNB; in the fourth year, 83% of the cancers were diagnosed by SCNB., Conclusion: Stereotactic core needle biopsy has replaced WLB as the standard for the diagnostic biopsy of suspicious, nonpalpable mammographic lesions. Since adopting this technique, more patients have been examined and their conditions diagnosed as breast cancer in an efficient, cost-effective manner.

Foreign body detection and removal from the hand can present a challenging problem for the hand surgeon. Imaging studies often are of little help and may even be misleading regarding the size and location of the object. This article reports imaging techniques used in the detection of foreign bodies and presents a case in which magnetic resonance imaging was used to localize a lead-pencil foreign body in the hand prior to surgical removal. We also present the results of magnetic resonance imaging analysis of several lead pencils, showing a similar signal that indicates that iron and magnesium were responsible for the artifact seen on the magnetic resonance image.

Background: Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder of unknown pathophysiology. The role of splenectomy in the multimodality therapy of TTP is controversial., Materials and Methods: All charts of patients with TTP at the University of Utah between 1984 and 1994 were reviewed to evaluate various treatment regimens, and specifically, the impact of splenectomy on morbidity and survival., Results: Of the 15 patients identified, 14 underwent initial treatment with plasmapheresis and steroids. Nine patients were treated with medical therapy only, 6 of whom completely recovered, while 3 patients died. Six patients failed plasmapheresis and underwent splenectomy. There were no operative complications or postoperative deaths. All surgical patients had no active disease at last follow-up., Conclusion: Plasmapheresis and steroid administration remain the first-line therapy for TTP. This series documents that splenectomy offers excellent results with minimal morbidity and mortality in patients who do not respond to or who relapse after plasmapheresis.

Objective: We examined the accuracy and cost-effectiveness of large-core needle breast biopsy in a selected group of patients with mammographically detected lesions., Materials and Methods: We selectively used large-core needle biopsy to sample breast lesions that were intermediate (neither clearly benign nor clearly malignant) and wire localization biopsy to sample breast lesions that were strongly suggestive of cancer. We compared 2 years' experience using this protocol with the preceding 2 years at the University of Utah Health Sciences Center during which we did only a few large-core needle biopsies on a nonselective basis., Results: Our biopsy rate increased from one biopsy per 36 mammographic screening examinations to one per 26 (p = .001) when the protocol was used. The cost of biopsy per cancer detected decreased from $11,555 to $8356. The specificity of large-core needle biopsy was 98%; the sensitivity based on limited follow-up was 100%., Conclusion: Large-core needle biopsy is an accurate and cost-effective method for sampling breast lesions when used in a selective fashion.

The cytokine release syndrome (CRS) accompanying OKT3 therapy is a major cause of posttransplant morbidity. The pathogenesis of this syndrome has been attributed to the synthesis of tumor necrosis factor, interleukin 2 (IL-2), interleukin 6 (IL-6), and gamma-interferon in response on T lymphocyte stimulation by OKT3. The hemorrheologic agent pentoxifylline (PTX) inhibits the synthesis of TNF alpha in vitro in response to a variety of stimuli, including OKT3. We performed a randomized, double-blinded trial of PTX during OKT3 induction in recipients of cadaveric renal allografts. Patients received either PTX 800 mg or placebo 2 hr before the initial dose of OKT3 and every 8 hr thereafter during the first 3 posttransplant days. Serum TNF alpha and IL-6 concentrations were measured pre-OKT3 and at 2 and 6 hr post-OKT3 on the first 3 posttransplant days. Despite the achievement of apparently adequate plasma levels of PTX and its active metabolites, no difference was observed in the incidence or severity of clinical manifestations of CRS. Serious manifestations of CRS--including acute pulmonary edema, encephalopathy, and aseptic meningitis--were not seen in either group. Serum TNF alpha and IL-6 concentrations were similar in PTX and control patients throughout the course of the study. Plasma levels of PTX and its active metabolites did not correlate with serum TNF alpha levels, serum IL-6 levels, or the incidence and severity of clinical manifestations of CRS.

The amount of torque required to loosen screws from three different antirotational screw-retained abutment/implant combinations was compared (with and without adhesive sealant applied) after 6 kg of force was applied during simulated intraoral movements. Movements were generated over two simulated time periods, representing 1 and 6 months. There was no significant decrease (alpha < .05) in the torque required to loosen the screws after either time period when using Calcitek Omnilock or Stryker Minimatic. The Core-Vent Bio-Vent specimens, however, exhibited a significant decrease (alpha < .05) in the amount of torque required to loosen the screws at the 1-month test period only. The addition of adhesive sealant significantly increased (alpha < .05) the amount of torque necessary to loosen the screws only in the Core-Vent specimens.

The present public health strategy to encourage the adoption of "safe sex" practices to contain the AIDS epidemic in America is incomplete. Current policy is responsive to and appropriate for control of homosexual, but not heterosexual transmission. Powerful societal forces restrict a woman's perception of risk. Consequently, the adoption of safe sex (condom use/insistence on use) by women at risk has not matched safe sex practice by homosexual men. Predictably, pattern two (heterosexual, maternal-fetal) HIV transmission is now rapidly increasing in the United States, particularly among minority women. In anticipation of an intensified pattern two subepidemic, AIDS containment policy should be reoriented to develop the role of women in AIDS prevention. An initiative, termed "sexual self-defense" (SSD), combines the technology of double-barrier (female irrespective of male) protection with a "universal precautions" approach to long-term sexual risk management. The initiative addresses both per-contact infectiousness and new partner acquisition, the principal determinants of HIV spread. As a female-targeted strategy, SSD is a timely supplement to existing programs, consistent with the direction of contemporary women's movements in the United States. A "street smart" approach, SSD bridges ethnic and socioeconomic individual differences. As a unifying philosophy of risk management in health promotion, SSD may avert the threatened fragmentation of AIDS control from existing programs of sexually transmitted disease control and teenage pregnancy prevention.

Objective: To test the hypothesis that the appropriateness of parents' use of early follow-up care after emergency department (ED) visits can be improved by postvisit support from a nurse practitioner., Design: Randomized controlled trial, single blinded., Setting: Urban university hospital ED linked to hospital's primary care center., Participants: Parents of 190 children younger than 8 years who sought care in the ED for acute illnesses and who were treated as outpatients with primary care center follow-up at the discretion of ED clinicians., Intervention: Parents in the experimental group were called by a nurse practitioner who offered both individualized guidance regarding follow-up and access to a nurse practitioner for further help as needed. The control group received "usual" follow-up advice during ED visits., Measurements/main Results: In the week after the ED visits, parents in the experimental group, compared with parents in the control group, were more compliant with instructions regarding follow-up (79% vs 61%), less apt to miss appointments (15% vs 31%), and less apt to "shop" elsewhere for care (2% vs 9%). Appropriateness of follow-up was assessed in "blinded" fashion using preestablished guidelines. Inappropriate use of follow-up care was significantly reduced among experimental group subjects (10% vs 20%)., Conclusion: The nurse practitioner's intervention improved parents' use of follow-up care in our sample. Overall care for episodic ED users might be improved by similar interventions.

A case is reported in which a comprehensive program of hyperbaric oxygen (HBO), surgical debridement and reconstruction, and continuing medical management resulted in complete and sustained closure of an extensive perineal Crohn's lesion refractory to conventional medical and surgical management. It is emphasized that in this case healing occurred in the setting of previous removal of all diseased intestinal tissue and only with the combined use of all three treatment modalities. HBO may be a useful adjunct in the therapy of large nonhealing perineal lesions post-proctocolectomy in patients who are unresponsive to metronidazole or to immunosuppressant therapy or who experience limiting side effects from continued medical therapy.