Showing papers by "Lenox Hill Hospital published in 1998"

Microsatellite instability in human solid tumors

Abstract: BACKGROUND Microsatellite instability (MIN) has been identified in a wide variety of human tumors, both familial and sporadic. In this study the authors attempted to correlate MIN with other biologic parameters to assess the significance of MIN in cancer. METHODS The current literature up to May 1997 was reviewed critically. Comparative assessment and analysis of published MIN data in human solid tumors was addressed. RESULTS Based on review of the current medical literature, the following conclusions can be drawn: 1) MIN associated with inherited mutations of the DNA mismatch repair genes (predominantly hMSH2/hMLH1) appears to characterize only the hereditary nonpolyposis colon carcinoma (HNPCC)/Muir-Torre family cancer syndrome category, and a subset of young colorectal carcinoma patients. Constitutional hMSH2/hMLH1 mutations rarely are reported in other than colon MIN+ tumor types; 2) MIN in non-HNPCC tumors generally is not associated with somatic mutations in the mismatch DNA repair genes most commonly involved in HNPCC; 3) loci of individual chromosomes containing microsatellite markers demonstrating high MIN frequency may be linked to particular tumor types (tumor specific MIN hot spots); 4) the gel banding patterns of MIN observed in noncolon tumors differ significantly from those reported previously in HNPCC; 5) although overall no association between MIN and histopathology is observed in the literature, a statistically higher MIN frequency has been noted in certain tumor subtypes; and 6) MIN in tumors can be associated with early or late stages of tumor progression, and also has been found in nontumor tissues. CONCLUSIONS Molecular diagnosis using MIN analysis has been documented in at least two types of tumors (HNPCC and sporadic bladder carcinoma), suggesting a potential role of MIN in the diagnosis and/or prognosis of other solid human tumors as well. Cancer 1998;82:1808-20. © 1998 American Cancer Society.

Carcinoma arising in anorectal fistulas of Crohn's disease.

Abstract: PURPOSE: Anorectal fistulas are commonly associated with Crohn's disease. Carcinoma arising in an anal fistula in the absence of Crohn's disease occurs rarely. Carcinoma arising in an anorectal fistula of Crohn's disease is likewise rare and is the subject of this article. METHODS: We have seen eight cases in seven patients. Four of these were squamous carcinoma and three were adenocarcinoma. Details of these seven patients are presented. RESULTS: Two deaths in the four patients with squamous carcinoma and one in the two patients with adenocarcinoma with adequate follow-up suggest a poorer prognosis in both types of malignancy than when these lesions occur without Crohn's disease. CONCLUSION: Carcinoma does arise in the midst of the anorectal fistulas and abscesses of Crohn's disease. Carcinoma arising in a Crohn's disease fistula can be very difficult to diagnose. Examination may be limited by pain, stricture, or induration of the perianal and perineal tissues. Examination under anesthesia can also overlook the lesion. Diagnostic examination under anesthesia yields increases with biopsies or curettage of the fistulous tracts.

Association between coronary heart disease and cancers of the breast, prostate, and colon.

Abstract: Coronary heart disease (CHD) and cancers of the breast, prostate, and colon are more common in industrialized countries than in the developing world, and to some degree, these conditions appear to share risk factors. To investigate whether there is an association between these cancers and a prior history of CHD, a hospital-based case-control study was conducted at Columbia-Presbyterian Medical Center in New York. The study was based on 252 breast cancer cases, 256 colorectal cancer cases, and 322 benign surgical controls, all of whom underwent biopsy or surgery between January 1989 and December 1992, and on 319 prostate cancer cases and 189 benign prostatic hypertrophy controls diagnosed between January 1984 and December 1986 (prior to widespread use of prostate-specific antigen screening). Medical records were reviewed on each, focusing on the preoperative anesthesia and surgical clearances. No association was found between a history of CHD and breast or colorectal cancer, but an elevated risk was found for prostate cancer (odds ratio, 2.00; 95% confidence interval, 1.18-3.39), using unconditional logistic regression with adjustment for appropriate confounders. No association was found between cigarette smoking and any of the three cancers. Aspirin use was protective for colorectal cancer (odds ratio, 0.35; 95% confidence interval, 0.17-0.73) but had no association with breast or prostate cancer. The study suggests that individuals with CHD are at elevated risk for prostate cancer but not breast or colorectal cancer. Etiological risk factors associated with CHD should be investigated with regard to prostate cancer. Patients with CHD may represent a high-risk group for prostate cancer and potential future targets for prostate cancer screening interventions.

Comparison of molecular changes in lung cancers in HIV-positive and HIV- indeterminate subjects

Abstract: Context.— Human immunodeficiency virus (HIV) infection has been associated with an increasing incidence of malignancy, and HIV-infected persons have an increased incidence of primary lung carcinoma compared with the general population. Objective.— To investigate the molecular changes present in HIV-associated lung tumors and compare them with those present in lung carcinomas arising in HIV-indeterminate subjects ("sporadic tumors"). Design.—Convenience sample.Subjects.— Archival tissues from 11 HIV-positive persons and from 35 persons of indeterminate HIV status. Setting.—University-based medical centers and affiliated hospitals.Main Outcome Measures.— Analysis of frequency of loss of heterozygosity (LOH) and microsatellite alteration (MA) using polymerase chain reaction and 16 polymorphic microsatellite markers at 8 chromosomal regions frequently deleted in lung cancer. Presence of HIV and human papillomavirus (HPV) sequences. Results.— The overall frequency of LOH at all chromosomal regions tested and the frequencies at most of the individual regions were similar in the 2 groups. Frequency of MA present in the HIV-associated tumors (0.18) was 6-fold higher than in sporadic tumors (0.03) (P<.001). At least 1 MA was present in 10 (91%) of 11 HIV-associated tumors vs 17 (48%) of 35 sporadic tumors (P=.02). Molecular changes were independent of tumor stage and gender. HIV and HPV sequences were not detected in the HIV-associated lung carcinomas. Conclusions.— Microsatellite alterations, which reflect widespread genomic instability, occur at greatly increased frequency in HIV-associated lung carcinomas. Although the mechanism underlying the development of increased MAs is unknown, it may play a crucial role in the development of many HIV-associated tumors.

First metacarpal subsidence during pinch after ligament reconstruction and tendon interposition basal joint arthroplasty of the thumb

Abstract: Trapeziectomy, ligament reconstruction and tendon interposition arthroplasty is one of the most commonly performed procedures to address pain and instability due to osteoarthritis at the basal joint of the thumb. To determine the effect of stress on first metacarpal subsidence, 15 ligament reconstruction and tendon interposition basal joint arthroplasties were evaluated after a mean follow-up of 32 months. Radiographs were obtained of the arthroplasty at rest and then with maximal effort key pinch stress, which is known to subject the first carpometacarpal joint to considerable axial compression stress. Compared with the preoperative x-rays, the first metacarpal had subsided 21% of the arthroplasty space at rest. Under stress, the first metacarpal was found to subside another 10.5% in height. No subluxation of the metacarpal base could be detected. Key pinch strength improved 17% from the preoperative strength. Tip-to-tip pinch strength improved 17% from the preoperative measurement. Grip strength improved 17% from the preoperative measurement. Grip strength was 9% greater than the preoperative grip strength. There was no statistical association between the amount of first metacarpal subsidence and follow-up key pinch, tip pinch, or grip strength. With axial compressive loading of the arthroplasty, such as in lateral pinch, there is some further proximal migration of the first metacarpal, but this is minimal and does not correlate with functional outcome.

Stenting After Optimal Lesion Debulking (SOLD) Registry Angiographic and Clinical Outcome

Abstract: Background—Coronary stenting has reduced restenosis in focal de novo lesions, but its impact has been less pronounced in complex lesion subsets. Preliminary data suggest a role for plaque burden in promoting intimal hyperplasia after stent implantation. The aim of this study was to test the hypothesis that plaque removal with directional atherectomy before stent implantation may lower the intensity of late neointimal hyperplasia, reducing the incidence of in-stent restenosis. Methods and Results—Seventy-one patients with 90 lesions underwent directional atherectomy before coronary stenting. Intravascular ultrasound–guided stenting was performed in 73 lesions (81%). Clinical success was achieved in 96% of patients. Procedural complications were as follows: emergency bypass surgery in 1 patient (1.4%), who died 2 weeks later; Q-wave myocardial infarction in 2 patients (2.8%); and non–Q-wave myocardial infarction in 8 patients (11.3%). None of the patients had stent thrombosis at follow-up. Angiographic foll...

Coronal and sagittal balance in surgically treated adolescent idiopathic scoliosis with the King II curve pattern: A review of 67 consecutive cases having selective thoracic arthrodesis

Abstract: STUDY DESIGN A retrospective study by an independent observer of a consecutive series of 67 cases of adolescent idiopathic scoliosis presenting with a King II curve pattern. OBJECTIVES To demonstrate the validity of a selective thoracic fusion as a treatment of King II curves with special attention to immediate postoperative and long-term trunk balance in the coronal and sagittal planes. SUMMARY OF THE BACKGROUND DATA The literature has been fairly controversial in terms of the recommended treatment of King II curve patterns in adolescent idiopathic scoliosis. The main confusion appears to be whether the thoracic curve alone or both curves should be instrumented and fused. METHODS Sixty-seven patients were identified as having had a selective posterior thoracic spine fusion with instrumentation between 1961 and 1994. None of these cases had a fusion of the lumbar spine. Preoperative radiographs were analyzed for determination of the appropriate fusion level using the criteria of the stable and neutral vertebra. Follow-up radiographs were evaluated for balance in the coronal and sagittal planes using the central sacral line on posteroanterior radiograph and the C7 sacral promontory line on lateral film. RESULTS At 2-year or greater follow-up, the unfused lumbar curve remained equal to or less than the corrected thoracic curve in 63 patients (94%). No patient required extension of fusion. Frontal plane balance analysis showed that 47 of the 67 patients had the T1 plumb line within 2 cm of the midline for an average decompensation of 8.7 mm. In no patient was the loss of balance greater than 3.8 cm. Sagittal plane balance analysis showed that only one patient had inferior junctional kyphosis greater than 10 degrees. This did not require extension of fusion. There were no cases of superior junctional kyphosis. CONCLUSIONS The concept of selective thoracic fusion in the King II curve pattern appears to be valid. These findings suggest that arthrodesis of the lumbar spine can be avoided when this pattern is properly diagnosed and appropriately treated. Proper identification of the stable and neutral vertebra and of the appropriate level of fusion are important to achieve good postoperative balance. Successful preservation of lumbar motion segments is important to long-term satisfactory outcome in adolescent idiopathic scoliosis.

The Effect of Immediate Weightbearing After Anterior Cruciate Ligament Reconstruction

Abstract: Immediate weightbearing has been advocated after anterior cruciate ligament reconstruction and is thought to enhance the return of quadriceps muscle activity and knee extension range of motion without jeopardizing graft integrity. This study examined the effect of immediate weightbearing after anterior cruciate ligament reconstruction on the return of vastus medialis oblique electromyography activity, knee extension range of motion, knee stability, physical examination, Lysholm score, and anterior knee pain. Forty-nine patients (24 men and 25 women) undergoing endoscopic central third patella tendon autograft reconstruction were randomized prospectively into two groups. Group 1 patients underwent immediate weightbearing as tolerated. Group 2 patients were kept nonweightbearing for 2 weeks. All measurements were taken before surgery, 2 weeks after surgery, and between 6 and 14 months (average, 7.3 months) followup. There was no effect of weightbearing on knee extension range of motion or vastus medialis oblique function at followup. In addition, knee stability was not compromised after surgery. Seven of 20 (35%) nonweightbearing patients and only two of 25 (8%) immediate weightbearing patients reported anterior knee pain at followup. Overall, immediate weightbearing did not compromise knee joint stability and resulted in a better outcome with a decreased incidence of anterior knee pain.

Diagnosis, management, and follow-up of congenital head and neck teratomas

Abstract: Objective : To describe our clinical experience with congenital teratomas of the head and neck. Study Design: A retrospective review of the six patients as well as a review of the literature in the setting of academic referral centers. Methods: In six infants with teratomas, four in the cervical region and two arising from the nasopharynx, surgical excision of all tumors was performed. Outcome measures were clinical and radiographic follow-up and the use of α-fetoprotein (AFP) for postoperative monitoring. Results: There was no recurrence of teratomas. Conclusions: Surgical excision is the treatment for congenital teratomas. Postoperative monitoring for recurrences should include AFP levels in difficult cases.

Influence of Size and Etiology of Glottal Gap in Glottic Incompetence Dysphonia

Abstract: This study investigates the relationship between glottal gap and vocal function in patients with glottic incompetence dysphonia. Twenty patients with vocal fold paralysis (VFP), 17 patients with vocal fold atrophy (VFA), and five patients with sulcus vocalis (SV) were examined. Glottal gap area at the most closed point of vibration was measured using digitized videostroboscopic images. Glottal gap area was correlated with acoustic and aerodynamic measures of vocal function. Patients with VFP had the largest glottal gaps and had significantly worse vocal function than did the patients with VFA or SV. Regardless of groups, however, where glottal gap size was similar, there was no difference in vocal function. Therefore vocal function was mainly influenced by glottal gap size, not by whether glottic incompetence was the result of VFP, VFA, or SV.

Polyethylene wear and periprosthetic osteolysis in metal-backed acetabular components with cylindrical liners

Abstract: A retrospective clinical and radiographic analysis was performed in 27 hips (23 patients), in which a threaded, porous-coated acetabular component with cylindrical liner was implanted (Sintered T-Tab-ST cup, Biomet, Warsaw, IN). Sixteen hips had cemented stems; 11 had cementless, circumferentially porous-coated stems. The mean clinical and radiographic follow-up period was 68 months. The mean patient age was 49 years; the mean patient weight was 68 kg. The mean rates of linear and volumetric wear were 0.25 mm/y and 149 mm3/y, respectively. Osteolysis occurred in 51.8% (14 hips). Wear rate and young age correlated with osteolysis (P = .0002 and P = .01, respectively). There were no cases of distal femoral osteolysis.

Intravenous Corticotrophin vs. Hydrocortisone in the Treatment of Hospitalized Patients with Crohn's Disease: A Randomized Double-Blind Study and Follow-Up

Abstract: Adrenocorticotrophic hormone (ACTH) and corticosteroids have no maintenance values for inflammatory bowel disease but serve to reduce the severity of disease. The effectiveness of intravenous corticotrophin versus hydrocortisone in ulcerative colitis has been determined including whether previous steroid therapy influenced the better response to one rather than the other, but no such studies have ever been done in Crohn's disease. Eighty-eight patients hospitalized with moderate-to-severe Crohn's disease (Present-Korelitz [P-K] Index -3 to -2 and the International Organisation for the Study of Inflammatory Bowel Disease-Crohn's & Colitis Foundation of America [IOIBD-CCFA] Index, mean 14, range 5-23) were treated in a prospective, randomized, double-blind clinical trial to receive either continuous intravenous infusion of 120 U/day of ACTH (44 patients) or hydrocortisone 300 mg/day (44 patients). Patients were also subdivided into those who received oral steroids during the 30 days prior to intravenous therapy and those who had not. Response was followed on a daily basis and tabulated at 3, 5, and 10 days. Patients were followed from 1-3 years to determine the later status. After 10 days of intravenous therapy 36 of 44 patients (82%) who received ACTH and 41 of 44 patients (93%) who received hydrocortisone fully responded (P-K index +3 and IOIBD-CCFA Index mean of 3). At the end of the study, response to intravenous ACTH and hydrocortisone was not statistically different whether or not patients received oral steroids during the 30 days prior to admission, although the response to IV ACTH tended to be faster at 3 days in those who had received previous steroid therapy. Intravenous ACTH and hydrocortisone are equally effective in achieving therapeutic goals in patients with Crohn's disease who have not achieved results with oral medications. Moreover the response rate was high (mean 88%), serving to buy time for establishment of successful maintenance programs of treatment with oral 5-ASA and immunosuppressive drugs for 69% of patients at 1-3 years.

Cardiac hemangioma. A case report and discussion.

Abstract: A cardiac hemangioma is a rare form of primary cardiac tumor. To our knowledge, only 34 cases of cardiac hemangioma have been discussed in the literature at the time of this writing. We report the case of a patient who presented with 1 episode of exertional dyspnea. The medical history, physical exam, work-up, surgical approach, and outcome are discussed. Other published reports on this topic are also reviewed.

Clinical and Pathologic Findings in Hemochromatosis Hip Arthropathy

Abstract: During a 9-year period, 15 patients with hemochromatosis hip arthropathy required 19 total hip arthroplasties for disabling hip pain. Preoperative presentation, hip function, pathologic evaluation of the femoral head, and radiographic findings were reviewed. Postoperative followup averaging 5.7 years (range, 2-11 years) was performed to assess hip pain and function after total hip arthroplasty. The average preoperative Hospital for Special Surgery hip score was 15 points (range, 4-24 points), and this improved to 30 points (range, 4-38 points) after total hip arthroplasty. Only one of 15 patients required revision surgery at 10 years for acetabular loosening. All other patients were pain free, with improved function at latest followup. Histologic evaluation of the resected femoral heads revealed evidence of primary or secondary osteonecrosis in seven of 19 (37%) specimens. Articular cartilage avulsion at the level of the tidemark was identified in eight of 19 (42%) specimens, and calcium pyrophosphate deposition was identified in five of 19 (26%) specimens. These pathologic findings suggest a predictable progression of the arthritic process in patients with hemochromatosis.

Cystic lymphangioma of the pancreas: CT and pathologic findings

Abstract: A case of pancreatic cystic lymphangioma is presented with CT and pathologic findings. CT demonstrated a large septated cystic mass in the left abdomen in an otherwise healthy young female. A diagnosis of lymphangioma was made after excision and pathologic examination.

Rheumatoid arthritis of the forefoot

Abstract: Severe and often debilitating involvement of the forefoot is seen frequently in patients with rheumatoid arthritis (RA). The combination of destructive synovitis and weight bearing leads to a spectrum of disorders causing pain, deformity, and eventual loss of function. In addition, advances in total knee and total hip arthroplasty have placed added importance on preserving the ability of the foot and ankle to bear weight and allow functional ambulation. In this article, the authors discuss the diagnosis and treatment of rheumatoid arthritis of the forefoot.

Carotid Stenting in 350 Vessels: Problems Faced and Solved.

Abstract: at Birmingham to New York, where we established, with participation of Dr. Jeffrey Moses, New York Cardiac and Vascular Institute at Lenox Hill Hospital. Since 1994, simultaneously with other centers, we set up our goal to develop alternative revascularization technique for extracranial stenotic atherosclerotic disease on brachiocephalic arteries with special attention to lesions in vicinity of the bifurcation of the carotid artery. The word “alternative” is very important, because we did not want to treat only lesions vascular surgeons turned down for variety of reasons, such as post radiation stenoses, post endarterectomy restenosis, high internal carotid artery lesions or stenoses on old, e . g . debilitated patients with multiple risk factors, but to develop real and viable alternative to endarterectomy. This approach of course stimulated passionate criticism and created significant interdisciplinary tension, at least at the UAB. Our present material consists of 345 patients who underwent carotid angioplasty with stenting (CAS). On these patients we stented 392 carotid arteries, i . e . 4 7 patients (13%) underwent bilateral CAS, some of them as one intervention, occasionally in two separate procedures. Thirty-eight patients (11%) presented with contralateral internal carotid artery occlusion. Sixty-six vessels (17%) were treated because of post endarterectomy (EAC) restenosis. Eighty percent of our patients were ineligible for NASCET. The study includes both symptomatic (42%) and asymptomatic patients with 60% carotid stenosis. The only exclusions have been severely tortuous, diseased aortic arch and vessels and presence of a mobile thrombus at the lesion site. Over the past 12 months the clinical protocol has been simplified. Neurological status at baseline, post-procedure and at follow-up is assessed by an independent neurologist using NIH Stroke Scale. Complete cerebral angiography is done on all patients prior to stenting as a separate examination or immediately before stenting. The knowledge of overall brain blood supply, conditions of other brachiocephalic arteries, status of circle of Willis and absence of other intracranial vascular pathology (stenosis, aneurysm, arterio-venous malformation) is very important to avoid certain complications of CAS. Duplex ultrasound is required preand post-stenting and used as a base line for follow-up at six months and thereafter. Only symptomatic patients, especially those with history of stroke undergo CT or MRI scanning. For 48 hours before the procedure, patients are treated with aspirin 325 mg and ticlopidine 250 mg bid. Same day admissions and 23hour discharges are done when possible. The technique of CAS was simplified as well. If the intervention follows cerebral angiography, 5 Fr diagnostic catheter (if needed) is advanced into the external carotid artery over 0.038 glide wire. This glide wire is replaced with 0.038 exchange wire (glide or Amplatz), diagnostic catheter is withdrawn and 7 Fr 90 cm sheath is advanced into the common carotid artery, just below the carotid bifurcation. If CAS is done separately from Carotid Stenting in 350 Vessels: Problems Faced and Solved

Child homicide caused by commotio cordis

Abstract: Cardiac concussion, previously known as commotio cordis, occurs in structurally normal hearts without gross or microscopic injury to the myocardium, cardiac valves, or coronary arteries, as opposed to other sports-related deaths known to occur more frequently in structural or congenital heart disease. We describe the sudden cardiac death of a 2-year-old child, who died as a result of a blunt force impact to the chest. A thorough medicolegal investigation was necessary to determine that the child died as a result of foul play.

EBV-associated primary lymphomas in salivary glands of HIV-infected patients.

Abstract: The lymph nodes within and around salivary glands are commonly involved in inflammatory processes, but rarely the site of primary lymphomas. We observed six cases of primary salivary gland lymphoma in HIV-infected patients and studied them in parallel with three cases of primary salivary gland lymphoma unrelated to HIV and three cases of HIV-related salivary gland lymphadenopathies in order to characterize this new entity. We found that all salivary gland lymphomas in HIV-infected patients were of high histologic grade while salivary gland lymphomas unrelated to HIV were predominantly of low grade MALT type. All lymphomas in both categories expressed the B-cell phenotype. Just as HIV-unrelated lymphomas frequently arise on the background of chronic inflammatory lymphoid processes, lesions characteristic of HIV-lymphadenopathy were still present in some lymphomas of HIV-infected patients. EBV RNA transcripts (EBER) were demonstrated in three, and latent membrane protein (LMP) in two of the six HIV-related and in none of the three HIV-unrelated lymphomas. The three EBER-positive lymphomas were of the histologic types known to express the virus in most cases. The presence of HIV in the form of the core protein p24 and envelope glycoprotein gp41 on the dendritic reticular cells of germinal centers was ascertained in the cases of HIV-related lymphadenopathies but also in the coexistent lymphadenopathies of lymphomas. The practical importance of diagnosing the salivary lymphadenopathies and lymphomas associated with the HIV-infection resides in avoiding their misdiagnosis and surgical removal as tumors of salivary glands.

Comparison of angiographic and clinical outcomes of coronary stenting of chronic total occlusions versus subtotal occlusions.

Abstract: The objective of this study was to assess the short- and long-term outcome of patients undergoing coronary stenting for chronic total occlusions compared with a control patient population with nonocclusive stenoses. A total of 789 consecutive patients (1,043 lesions) underwent coronary stenting using a high-pressure stent optimization technique. The study population was divided into total occlusion group (94 consecutive patients [95 lesions] with chronic total occlusions) and subtotal occlusion group (695 consecutive patients [948 lesions] with nonocclusive stenoses). There was no difference in postprocedure angiographic minimum lumen diameter (3.13 ± 0.48 vs 3.15 ± 0.57 mm, p=0.72) and minimum intrastent cross-sectional area by intravascular ultrasound (7.31 ± 2.06 vs 7.64 ± 2.53 mm 2 , p=0.26) between the total and subtotal groups, respectively. Subacute thrombosis occurred in 2 patients (2.1%) in the total group compared with 9 patients (1.3%) in the subtotal group (p = 0.63). Angiographic restenosis occurred in 27% vs 22% (p = 0.40) and repeat angioplasty in 15% vs 13% (p = 0.62) in the total and subtotal groups, respectively. Thus, coronary stenting of chronic total occlusions after successful recanalization could be performed with a high success rate. In addition, the incidence of stent thrombosis, angiographic restenosis, and the need for target lesion revascularization is comparable to that of an unselected cohort of patients with nonocclusive stenoses.

Surgical management of the rheumatoid hip

Abstract: Total hip arthroplasty (THA) has improved significantly in the last 30 years since the popularization of the procedure by John Charnley in the late 1960s. The significant advances in THA in the last 20 years have been that it is highly reproducible and durable, has high quality of function and low morbidity, patient satisfaction is high, and salvage is possible when necessary. The main object of this article is to discuss the surgical management of patients who have RA of the hip joint, dealing with indications, surgical techniques, results, and complications.

Long-term follow-up after subtotal parathyroidectomy in patients with renal failure.

Abstract: Objectives/Hypothesis: The most appropriate type of surgery for hyperparathyroidism secondary to renal failure remains controversial. We report a 5-year experience of patients with hyperparathyroidism secondary to end-stage renal disease who underwent subtotal parathyroidectomy. We believe that this is the procedure of choice, offering several advantages over total parathyroidectomy with and without reimplantation. Study Design: Retrospective review. Methods: Review of 14 consecutive renal failure patients who underwent subtotal parathyroidectomy by one surgeon (A.K.) was performed. Follow-up ranged from 4 to 54 months. All patients were receiving chronic maintenance dialysis. All patients came to surgery with clinical symptoms of parathyroid bone disease, elevated serum calcium levels (10.1-12.4 mg/dL), and intact parathyroid hormone levels (619-4160 pg/mL), despite maximal medical therapy. At exploration four glands were identified in all patients and three and a half were removed. Results: All patients experienced symptomatic relief postoperatively with normalization or near-normalization of serum calcium concentration and intact parathyroid hormone concentrations. One patient developed recurrent disease 4 months after surgery, and on re-exploration a supernumerary substernal gland was identified. A second patient developed recurrent symptoms 4 years after surgery and at the time of this writing was awaiting re-exploration. Conclusions: All patients had either resolution of or marked improvement in their subjective complaints. There have been no cases of permanent hypoparathyroidism. We believe that subtotal parathyroidectomy is the best procedure for patients with refractory symptoms of secondary hyperparathyroidism.

Laser wire for crossing chronic total occlusions : Learning phase results from the U.S. TOTAL Trial

Abstract: The Prima laser guidewire system (Spectranectics Corp., Colorado Springs, CO) consists of an 0.018" hypotube containing a bundle of 45-microm optical fibers coupled to a pulsed excimer laser operating at a tip fluence of 60 ml/mm2 and a repetition rate ranging from 25-40 Hz. This laser guidewire was specifically designed to cross total occlusions refractory to passage with conventional wires. The Prima wire was evaluated in a feasibility study at 15 U.S. centers. Following failure to cross a total occlusion with approved guidewires, the Prima wire was utilized in 179 patients. Average age of subjects was 61 yr. Lesion locations included left anterior descending (36%), right (45%), and circumflex (19%) coronary arteries. Mean angiographic age of total occlusions was 70 wk (range, 2-1,020 wk, median, 14 wk). The use of the Prima wire either solely or in combination with conventional guidewires resulted in successful crossing in 61% of these previously impenetrable occlusions. Failure of the device was commonly related to length of the occlusion and tortuosity along the occluded pathway. Major complications included myocardial infarction in 7 patients (3.9%), tamponade in 3 (1.7%), and death in 2 (1.1%). This "learning phase" pilot study confirmed the feasibility of a laser guidewire in chronic total occlusions that are resistant to passage of conventional guidewires. An extended registry at these investigative sites is planned.

Low restenosis rate in lesions of the left anterior descending coronary artery with stenting following directional coronary atherectomy.

Abstract: The present study evaluated acute and late results with stenting following directional coronary atherectomy (DCA) for the lesions in the left anterior descending coronary artery (LAD). Between April 1995 and January 1997, 200 LAD lesions with > or =3 mm reference vessel diameter were treated with coronary stents. The lesions were divided as to whether or not DCA was performed before stenting; 1) stenting alone (n = 163) and 2) debulking and stenting (n = 37). There were no significant differences in the incidences of complications except for non-Q-wave myocardial infarction that was more frequent in patients with debulking and stenting than in those with stenting alone (13.5% vs. 2.4%, P or =3 mm reference vessel diameter.