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Includes 11 sub-articles dealing with innovative recreational programs in Alaska, Michigan, Tennessee, Illinois, and California. Activities and facilities described include bus rides, artificial ice skating and skiing, rooftop playgrounds, wood structures, dam sites, and enclosed buildings. (NQ)

A newly-approved carotid patch, derived from porcine small intestinal submucosa (SIS), is thought to allow functional tissue regeneration by acting as a biologic scaffold of extracellular matrix. We report three cases of asymptomatic pseudoaneurysm after SIS patch closure. At exploration there were intact suture lines, no growth from cultures, and central patch herniation. Histopathologic examination showed postendarterectomy neointima in the artery and disorganized collagen in the pseudoaneurysm. SIS patch remnants adjacent to macrophage infiltration and neovascularization indicated ongoing processes of degradation and synthesis. Imbalances between degradation and host tissue synthesis are problems that may unpredictably affect SIS patch integrity.

Background: Germline mutation screening of BRCA1 and BRCA2 genes is performed in suspected familial breast cancer cases, but a causative mutation is found in only 30% of patients. The development of additional methods to identify good candidates for BRCA1 and BRCA2 analysis would therefore increase the efficacy of diagnostic mutation screening. With this in mind, we developed a study to determine molecular signatures of BRCA1—or BRCA2—mutated breast cancers. Materials and Methods: Array-cgh (comparative genomic hybridization) and transcriptomic analysis were performed on a series of 103 familial breast cancers. The series included 7 breast cancers with a BRCA1 mutation and 5 breast cancers with a BRCA2 mutation. The remaining 91 cases were obtained from 73 families selected on the basis of at least 3 affected first-degree relatives or at least 2 affected first-degree relatives with breast cancer at an average age of 45 years. Array-cgh analyses were performed on a 4407 BAC-array (CIT-V8) manufactured by IntegraGen. Transcriptomic analyses were performed using an Affymetrix Human Genome U133 Plus 2.0 chip. Results: Using supervised clustering analyses we identified two transcriptomic signatures: one for BRCA1-mutated breast cancers consisting of 600 probe sets and another for BRCA2-mutated breast cancers also consisting of 600 probes sets. We also defined cgh-array signatures, based on the presence of specific genomic rearrangements, one for BRCA1-mutated breast cancers and one for BRCA2-mutated breast cancers. Conclusions: This study identified molecular signatures of breast cancers with BRCA1 or BRCA2 germline mutations. Genes present in these signatures could be exploited to find new markers for such breast cancers. We also identified specific genomic rearrangements in these breast cancers, which could be screened for in a diagnostic setting using fluorescence in situ hybridization, thus improving patient selection for BRCA1 and BRCA2 molecular genetic analysis.

Background The efficacy of carotid endarterectomy in patients with asymptomatic carotid stenosis has not been confirmed in randomized clinical trials, despite the widespread use of operative intervention in such patients. Methods We conducted a multicenter clinical trial at 11 Veterans Affairs medical centers to determine the effect of carotid endarterectomy on the combined incidence of transient ischemic attack, transient monocular blindness, and stroke. We studied 444 men with asymptomatic carotid stenosis shown arteriographically to reduce the diameter of the arterial lumen by 50 percent or more. The patients were randomly assigned to optimal medical treatment including antiplatelet medication (aspirin) plus carotid endarterectomy (the surgical group; 211 patients) or optimal medical treatment alone (the medical group; 233 patients). All the patients at each center were followed independently by a vascular surgeon and a neurologist for a mean of 47.9 months. Results The combined incidence of ipsilatera...

The optimal solution for priming cardiopulmonary bypass machines and for postoperative resuscitation following myocardial revascularisation should be inexpensive, free of risk of transmitting disease, and free of other detrimental side effects. Colloid solutions are preferred over crystalloid solutions because of elevations in extracellular sodium and water that occur with cardiopulmonary bypass. Albumin, plasma protein solution, hetastarch (hydroxyethyl starch) and dextran are available for use if blood is not necessary and mediastinal blood is not available. Hetastarch is associated with a lower risk of bleeding and less risk of allergic reaction than dextran, and its cost is substantially less than that of albumin. However, high doses increase the risk of bleeding complications.

This paper reviews the authors' work with experimental silicone rubber and polyurethane replamineform small caliber vascular grafts. Description of the method of preparation of prostheses and in vivo implantation results is presented.

Sclerosing mediastinitis is an uncommon disease associated with a multiplicity of clinical syndromes. The cause of this disorder is probably an abnormal fibroproliferative response to an inflammatory stimulus, most commonly a granulomatous infection secondary to Histoplasma capsulatum . The pathophysiology of this disease is predicated on the encasement of mediastinal vital organ structures within a dense fibrotic mass. This mass appears to emanate from an invasive chronic inflammatory process causing erosion as well as external compression of these structures. The following case reports illustrate the diversity of this disease entity, representing a patient population from the Ohio River Valley, endemic for histoplasmosis. The purpose of this report is to elucidate the various clinical manifestations of sclerosing mediastinitis and to correlate the pathologic process with a rational approach to treatment. (Chest 1990: 97:338–46)

Although the argon laser is used successfully to weld a number of different tissues, the underlying chemical and cellular mechanisms for this process are not precisely defined. Consequently, a biochemical model has been developed in vitro using the welldefined extracellular matrix from the murine Engelbreth-Holm-Swarm (EHS) sarcoma. Control and experimental samples of EHS basement membranes were irradiated with a Trimedyne argon laser at 500–3,000 Joules/cm2 at 0°C. The samples were diluted into cold phosphate-buffered saline and allowed to gel at 35°C. The time course of the gelation reaction was followed in a spectrophotometer at 360 nm. Irradiation reduced the absorbance 7.5–15% compared to controls and was independent of the dilution over a 10-fold range. Gelation was also measured by determining the amount of protein by the Bradford assay that could be collected by centrifugation at 10,000g for 10 minutes. Argonirradiated samples had 30–40% less protein in the precipitate than the controls. The addition of 5 mM beta-mercaptoethanol to the EHS extract blocked the effect of the laser on the gelation reaction. In addition, when gelation was carried out in the absence of calcium and magnesium, there were no differences between laser-treated samples and controls. The basement membrane proteins were separated by electrophoresis through polyacrylamide gels under denaturing plus reducing or denaturing and non-reducing conditions. No differences in the polypeptide composition were noted between irradiated and control samples using either Coomassie- or silver-staining techniques. The irradiated and control samples were also analyzed on 1.5% agarose gels in 10 mm Tris-HCl, pH 8 containing 0.1% SDS. Both samples produced a single Coomassie-positive band, but the control migrated at 0.5 and the irradiated sample at 0.6. In sum, the conformation of extracellular matrix proteins can be altered by the argon laser at welding energies at low temperatures, even though no new covalent interactions were observed.

Background The episode of care for colorectal surgery in 8 outlier Veterans Affairs Hospitals with high mortality and the volume outcome relationship in 118 Hospitals are examined. Methods A total of 103 deaths were reviewed. Mean age was 74 with 63% of the patients undergoing emergency surgery; 54% of the patients had malignant disease and 21% had metastatic disease. Results Nineteen percent of the patients had a delay in diagnosis, 22% had delay in surgery and 14% should have received a different surgery usually less radical. In addition, system related issues were identified in 19% of the cases and practitioner related issues in 20% of the cases. The Spearman rank correlation between colorectal surgery volume and unadjusted mortality was 0.114 ( P = 0.22). Conclusion Colorectal surgery death is prevalent in elderly patients undergoing emergency surgery for malignancy or metastatic disease and is not related to hospital volume. Timely diagnosis, less radical surgery while optimizing system based pathways might improve outcome.

F 34-year-old woman was referred for evaluation of a chest roentgenogram abnormality. The patient, a nonsmoker, as immunocompetent with no risk behavior for HIV. She eported a sudden cough that developed, followed by pain in er left anterior chest radiating to the shoulder. The cough was ccompanied by subsequent development of bloody mucus. er symptoms persisted for 1 week with no prior history of imilar episodes. On physical examination, diminished breath sounds were uscultated over the left chest. Chest roentgenogram (Fig 1) emonstrated a large left upper lobe opacification with poserior displacement of the major fissure. Subsequent workup ncluded computed tomographic imaging of the thorax (Fig 2) nd a bronchoscopy, which did not provide the diagnosis. Due o the large size of the mass, a tissue biopsy was not pursued ecause it would not impact the plan for thoracotomy and esection. The patient underwent a left thoracotomy, revealing a large, olid mass filling the hemithorax from hilum to apex. An ntraoperative frozen section evaluation of the specimen sugested lymphoma. A pneumonectomy was performed. Sevral factors were judged to prohibit completion of a lesser peration (lobectomy and wedge resection). Calcific granuloatous disease involved the hilum and fissure, causing fusion f the two lobes. In addition, the primary lesion was considrable in size and was accompanied by a satellite nodule. In act, resection of portions of the pericardium and left phrenic erve were required in conjunction with resection of the pecimen. Individual nodes from the inferior pulmonary ligig 1.

This study was designed to determine the prevalence of Chlamydia pneumoniae in carotid artery plaques. Although there have been numerous studies evaluating coronary plaques for this bacterium fewer studies have assessed noncoronary vasculature. In addition we wished to evaluate whether correlation exists between the presence of C. pneumoniae in carotid plaques and established risk factors for atherosclerosis. Sixty intact carotid artery plaques removed during surgery (carotid endarterectomy) were formalin-fixed and paraffin-embedded according to conventional techniques. These samples were evaluated by polymerase chain reaction analysis to detect presence of C. pneumoniae DNA. Results were tabulated and compared against established risk factors for atherosclerosis: diabetes, hypertension, hyperlipidemia, age, and smoking. Forty-two (70.0%) of the 60 plaques that were evaluated tested positive for the presence of C. pneumoniae DNA by polymerase chain reaction analysis. In the sample defined as being from heavy smokers (greater than 15-pack-year history) 33 (94.3%) of 35 plaques tested positive whereas two (5.7%) tested negative. This correlation demonstrated statistical significance ( P = 1.36 x 10–6, two-tailed Fisher exact test). Presence of C. pneumoniae in carotid plaques demonstrated no statistically significant correlation with diabetes, hypertension, or hyperlipidemia. Age as a risk factor was examined but not statistically evaluated because of the narrow range within our patient sample. Analysis of the data reveals that C. pneumoniae is present in large numbers of atheromatous plaques as is consistent with emerging data. What is interesting though is that 33 (94.3%) of the 35 smokers had plaques that tested positive for the bacterium as opposed to only nine (36.0%) of the 25 nonsmokers. Identification of specific populations exhibiting a high prevalence of C. pneumoniae may serve to focus future studies. Ongoing investigation will seek to determine whether C. pneumoniae plays an active role in the pathogenesis of atherosclerosis.