The first use of olives in Africa around 100,000 years ago.

The olive tree was an iconic plant for most of the past Mediterranean civilizations, for which it had important economic value. Here we report the earliest use of fruits and wood from olive trees in Africa so far, around 100,000 years ago. These findings suggest the presence of olive trees on the Atlantic coast of Morocco during most of the last glacial period, and the use of olives by the early Homo sapiens for fuel management and most probably for consumption.

A DNA-binding mutant of TAL1 cooperates with LMO2 to cause T cell leukemia in mice.

The most common translocation in childhood T-cell acute lymphoblastic leukemia (T-ALL) involves the LMO2 locus, resulting in ectopic expression of the LMO2 gene in human thymocytes. The LMO2 gene was also activated in patients with X-linked Severe Combined Immune Deficiency treated with gene therapy because of retroviral insertion in the LMO2 locus. The LMO2 insertions predisposed these children to T-ALL, yet how LMO2 contributes to T cell transformation remains unclear. The LIM (Lin 11, Isl-1, Mec-3) domain containing LMO2 protein regulates erythropoiesis as part of a large transcriptional complex consisting of LMO2, TAL1, E47, GATA1 and LDB1 that recognizes bipartite E-box-GATA1 sites on target genes. Similarly, a TAL1/E47/LMO2/LDB1 complex is observed in human T-ALL and Tal1 and Lmo2 expression in mice results in disease acceleration. To address the mechanism(s) of Tal1/Lmo2 synergy in leukemia, we generated Lmo2 transgenic mice and mated them with mice that express wild-type Tal1 or a DNA-binding mutant of TAL1. Tal1/Lmo2 and MutTAL1/Lmo2 bitransgenic mice exhibit perturbations in thymocyte development due to reduced E47/HEB transcriptional activity and develop leukemia with identical kinetics. These data demonstrate that the DNA-binding activity of Tal1 is not required to cooperate with Lmo2 to cause leukemia in mice and suggest that Lmo2 may cooperate with Tal1 to interfere with E47/HEB function(s).

Impact of endovascular-assisted in situ saphenous vein bypass technique on hospital costs.

Our initial experience with endovascular-assisted in situ saphenous vein bypass (EISVB) showed patency rates to be comparable to those with conventional in situ bypass, and resulted in a significant reduction in wound-related complications and hospital length of stay (LOS). Here we evaluate the relative costs of these two approaches. Forty-four patients underwent 46 EISVB procedures using endovascular cannulation and coil occlusion of the saphenous vein side branches. Costs for each patient for the operation, the associated hospital stay, and any postoperative care were assessed. These costs were compared to those of the last 46 conventional open in situ bypass procedures as an historical comparison group. The two groups were statistically similar for all parameters except distal outflow target, with the comparison group having statistically more pedal bypasses (p = 0.004). Subset analysis was performed by subdividing each operative group, into those with popliteal and those with distal bypasses. The results of our analysis led us to conclude that the shorter LOS following EISVB more than compensates for the initial cost incurred by the side branch occlusion system. This shorter stay translates into an overall cost savings for EISVB compared to the cost of conventional in situ bypass. The reductions in wound-related morbidity and recovery time postoperatively with EISVB add an additional long-term cost benefit.

Endovascular in situ bypass decreases morbidity and hospital stay following infrainguinal arterial reconstruction.

PURPOSE: To report the early results of endovascular in situ saphenous vein bypass (EISVB) using side branch coil occlusion. METHODS: Between September 1997 and November 1998, 25 patients (15 men; mean age 70.9 years, range 53-85) with lower limb ischemia were treated with endovascular femorodistal bypass. The saphenous vein was prepared using retrograde valvulotomy and endoscopic cannulation with coil occlusion of the side branches. Duplex graft surveillance was performed at 1, 3, 6, and 12 months. RESULTS: The 25 EISVB procedures consisted of 15 femorodistal popliteal, 7 femorotibial, 2 femoroperoneal, and 1 femorodorsalis pedis in situ saphenous vein reconstructions. Mean operative time was 202 +/- 40 minutes, mean number of side branch coils per case was 5.1 +/- 1.3, and mean number of incisions per case was 2.9 +/- 0.6. Mean hospital length of stay (LOS) was 35 +/- 13 hours (1.4 +/- 0.6 days); 19 (76%) patients were discharged on the first postoperative day. Short-term follow-up (mean 6.2 months, range 2-15) was notable for 2 graft thromboses and 1 graft stenosis; primary and secondary patency rates were 88% and 92%, respectively. Three asymptomatic, persistent arteriovenous fistulas discovered on routine duplex were ligated in the outpatient setting. Only 1 (4%) minor wound complication was encountered. CONCLUSIONS: EISVB provides early patency comparable to conventional in situ infrainguinal bypass. Its distinct advantages, however, are the ability to minimize incision length with resultant reductions in wound-related complications, hospital LOS, and recovery time. EISVB promises to be a useful adjunct in the approach to peripheral vascular insufficiency.

Hand-assisted laparoscopic aortobifemoral bypass grafting.

OBJECTIVE: Aortobifemoral bypass grafting is a durable operation for arterial reconstruction in patients with symptomatic aortoiliac occlusive disease. In several small laparoscopic series technically demanding aortic operations have been described that have not gained widespread acceptance or applicability. To simplify the laparoscopic approach to the aorta, we have developed a technique of aortobifemoral bypass grafting that uses hand-assisted laparoscopic surgery (HALS) to minimize the complexity of aortic dissection and reconstruction. METHODS: Five patients with symptomatic aortoiliac occlusive disease underwent successful HALS aortobifemoral bypass grafting. With the use of a specialized sleeve device (Hand-Port), an operative hand was introduced into the laparoscopic field while pneumoperitoneum was maintained. Laparoscopic dissection of the infrarenal aorta was then performed with retraction provided by the operative hand. Proximal aortic anastomosis was performed with an open technique through the same 7.5-cm Hand-Port incision, and femoral anastomoses were performed in the standard fashion. RESULTS: Five hand-assisted laparoscopic aortobifemoral bypass grafts were performed (two end-to-end, three end-to-side proximal anastomoses). Mean operative time was 231 minutes. Mean blood loss was 440 mL. All patients underwent extubation immediately after surgery, were ambulatory on postoperative day (POD) 1, and were tolerating their diet by POD 3. The mean length of hospital stay was 3.8 days. One patient was discharged on POD 5 and started a clear liquid diet after a self-limiting postoperative ileus. All patients were asymptomatic and back to full activity/work by 14.6 days postoperatively, on average (range, 11-20 days). CONCLUSION: The HALS offers the advantages of tactile feedback, flexible retraction, and the introduction of conventional surgical instruments, all of which extend laparoscopic surgery and its established benefits to a wide array of more complex surgical problems, including major vascular surgery. Ease of performance, shorter hospital stays, and faster recovery times all suggest that HALS may become a valuable adjunct to conventional aortobifemoral bypass grafting.

Percutaneous induced thrombosis of iatrogenic femoral pseudoaneurysms following catheterization.

Femoral pseudoaneurysms are one of the common iatrogenic complications following catheterization procedures done via the femoral approach. Their treatment has evolved over the last decade from operative repair to ultrasound-guided compression (USGC) and more recently to thrombin injection of the pseudoaneurysm. We report our experience with that technique and compare the results of thromboobliteration to those of the compression method. All consecutive iatrogenic femoral pseudoaneurysms diagnosed in the vascular laboratory of two large community hospitals were referred for the study. Under ultrasound guidance, percutaneous thromboobliteration (PTO) of the pseudoaneurysms was done by injecting thrombin solution (500-unit increments) into the pseudoaneurysm. Time to thrombosis, dose of thrombin, patient's discomfort, and ease of procedure were recorded and analyzed. Comparison with results of USGC reported in the literature was made. Percutaneous thromboobliteration may be a simple and very effective treatment of femoral pseudoaneurysms. The high success rate, ease of procedure, and cost benefit over USGC are noteworthy. A larger trial is currently under way. If results are duplicated, PTO will emerge as the preferred treatment for iatrogenic femoral pseudoaneurysms.

Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients.

OBJECTIVE: To evaluate the feasibility and potential benefits of hand-assisted laparoscopic surgery with the HandPort System, a new device. SUMMARY BACKGROUND DATA: In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic cases. METHODS: A prospective nonrandomized study was initiated with the participation of 10 laparoscopic surgical centers. Surgeons were free to test the device in any situation where they expected a potential advantage over conventional laparoscopy. RESULTS: Sixty-eight patients were entered in the study. Operations included colorectal procedures (sigmoidectomy, right colectomy, resection rectopexy), splenectomy for splenomegaly, living-related donor nephrectomy, gastric banding for morbid obesity, partial gastrectomy, and various other procedures. Mean incision size for the HandPort was 7.4 cm. Most surgeons (78%) preferred to insert their nondominant hand into the abdomen. Pneumoperitoneum was generally maintained at 14 mmHg, and only one patient required conversion to open surgery as a result of an unmanageable air leak. Hand fatigue during surgery was noted in 20.6%. CONCLUSIONS: The hand-assisted technique appeared to be useful in minimally invasive colorectal surgery, splenectomy for splenomegaly, living-related donor nephrectomy, and procedures considered too complex for a laparoscopic approach. This approach provides excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. Although the data presented here reflect the authors' initial experience, they compare favorably with series of similar procedures performed purely laparoscopically.

Endovascular-assisted versus conventional in situ saphenous vein bypass grafting: cumulative patency, limb salvage, and cost results in a 39-month multicenter study.

OBJECTIVE: In this retrospective multicenter study, the results of a minimally invasive method of endovascular-assisted in situ bypass grafting (EISB) versus "open" conventional in situ bypass grafting (CISB) were evaluated with a comparison of primary and secondary patency, limb salvage, and cost. METHODS: Enrolled in this study were 273 patients: 117 underwent CISB (42 femoropopliteal, 75 femorocrural) and 156 underwent EISB (41 femoropopliteal, 115 femorocrural). EISB was performed with an angioscopic Side Branch Occlusion system and an angioscopically guided valvulotome. All the patients underwent follow-up examination with serial color-flow ultrasound scanning. RESULTS: Both groups had similar comorbid risk factors for diabetes mellitus, coronary artery heart disease, hypertension, and cigarette smoking. The primary patency rates (CISB, 78.2% +/- 5% [SE]; EISB, 70.5% +/- 5%; P =.156), the secondary patency rates (CISB, 84.1% +/- 4%; EISB, 82.9% +/- 5%; P =.26), and the limb salvage rates (CISB, 85.8%; EISB, 88.4%; P =.127) were statistically similar, with a follow-up period that extended to 39 months (mean, 16.6 months; range, 1 to 40 months). In veins that were less than 2.5 to 3.0 mm in diameter, the EISB grafts fared poorly, with an increased incidence of early (12-month) graft thromboses (CISB, 10 grafts, 8.5%; EISB, 24 grafts, 15.3%). However, wound complications (CISB, 23%; EISB, 4%; P =.003), mean hospital length of stay (CISB, 6.5 days +/- 4.83; EISB, 3.2 days +/- 3.19; P =.001), and mean hospital charges (CISB, $25,349 +/- $19,476; EISB, $18,096 +/- $14,573; P =.001) were all significantly reduced in the EISB group. CONCLUSION: The CISB and EISB midterm primary and secondary patency and limb salvage rates were statistically similar. In smaller veins (< 2.5 to 3.0 mm in diameter), however, EISB is not appropriate because overly aggressive instrumentation may cause intimal trauma, with resultant early graft failure. With the avoidance of a long leg incision in the EISB group, wound complications and hospital length of stay were significantly reduced, which lowered hospital charges and justified the additional cost of the endovascular instruments. When in situ bypass grafting is contemplated, EISB in appropriate patients is a safe, minimally invasive, and cost-effective alternative to CISB.

Thrombolytic therapy: the treatment of choice for iliac vein thrombosis in the presence of kidney transplant.

A 49-year-old kidney transplant recipient was admitted with the diagnosis of acute iliofemoral deep venous thrombosis (DVT) extending into the external iliac vein in close proximity to the renal vein anastomosis. Thrombolytic therapy with urokinase was used and complete lysis of the thrombus was achieved within 36 hr. We feel that this method of therapy, rather than standard anticoagulation, represents the treatment of choice for acute DVT in the presence of a renal graft. Using this method we were able to salvage the kidney and avoid the complications of postphlebitic syndrome and pulmonary embolus.

Double clostridial mycotic aneurysms of the aorta.

Mycotic aortic aneurysm continues to present challenging and difficult management issues with a significant morbidity and mortality. The offending organism in the etiology of this aneurysm can be variable and unusual. The first report of two mycotic aortic aneurysms caused by Clostridium septicum in the same patient is described here. Presentation and management as well as conditions commonly associated with Clostridium septicum infection and a review of all clostridial mycotic aortic aneurysms in the English literature are discussed.

Femoral vein aneurysm: a case report and review of the literature.

Primary venous aneurysms are rarely encountered lesions. Case reports have been described throughout the venous system. The lesions are usually symptom-free being found as a subcutaneous mass, an incidental finding on an imaging study, or during the work-up for deep venous thrombosis. However, embolism and rupture have been rarely described. A femoral vein aneurysm is reported, along with a current review of the literature of venous aneurysms.

Comparison of the safety and efficacy of parenteral ticarcillin/clavulanate and clindamycin/gentamicin in serious intra-abdominal infections.

One hundred and twelve patients with proven or suspected serious intra-abdominal infections were randomized for treatment with either ticarcillin/clavulanate (3.1 g every 4 h) or gentamicin (dosage schedule adjusted according to serum concentrations) plus clindamycin (in most cases 900 mg every 8 h). Positive intraperitoneal and/or blood cultures were available in 47 cases. Considering only fully evaluable cases, 15/20 (75%) were clinically cured or improved in the ticarcillin/clavulanate group and 16/25 (64%) in the gentamicin/clindamycin group, the difference not being significant (P greater than 0.05). Bacteraemia was documented in nine of 45 fully evaluable cases. During the course of the study, the serum creatinine concentration increased by more than 5 mg/l in only one patient (ticarcillin/clavulanate group). Two patients (one in each group) had apparent allergic reactions. No other drug-related adverse effects were noted. In-vitro sensitivity testing of anaerobic isolates revealed that, of those tested, 5/38, 1/38 and 2/37 were resistant to ticarcillin, ticarcillin/clavulanate and clindamycin, respectively. Among aerobic Gram-negative isolates, 34/78, 6/78 and 4/78 were resistant to ticarcillin, ticarcillin/clavulanate, and gentamicin, respectively. Among aerobic Gram-positive isolates, 2/32, 2/32, and 5/14 were resistant to ticarcillin, ticarcillin/clavulanate, and clindamycin, respectively. We conclude that ticarcillin/clavulanate is a safe and efficacious preparation for treating serious intra-abdominal infections.

Prediction of the development of sigmoid ischemia on the day of aortic operations. Indirect measurements of intramural pH in the colon.

A deviation in an indirect measurement of intramural pH below the limits of normality (6.86) was used as a diagnostic test for sigmoid ischemia in 25 high-risk patients undergoing abdominal aortic operations. The clinical diagnosis of ischemic colitis was made by the attending physicians in only two of the 25, on the day after operation in one and three months after operation in another. In neither was the ischemic colitis considered to have been a causative factor in their subsequent deaths. In contrast, six patients developed pH evidence of ischemia on the day of operation. All six subsequently developed a transient episode of guaiac-positive diarrhea, four developed physical signs consistent with ischemic colitis, and four died. Of 19 who did not develop pH evidence of ischemia, none developed guaiac-positive diarrhea, none developed any signs of ischemic colitis, and none died. Stepwise logistic regression showed the duration of pH evidence of ischemia on the day of operation to be the best predictor for the symptoms and signs of ischemic colitis and for death after operation.

The ischemic exercise test in patients with peripheral vascular disease. Implications for management.

We observed myocardial ischemia in 135 of 808 patients undergoing routine ECG-monitored treadmill tests before vascular reconstructive operations. Postoperative infarction incidence was 27% among 56 patients who had operations regardless of test results. When patients had a lesser procedure, such as extra-anatomic bypass, infarction incidence decreased to 17% (not statistically significant). Ten patients having staged aortocoronary and peripheral reconstruction had no myocardial infarctions postoperatively or during follow-up of up to five years. Of 37 patients asymptomatic for coronary artery disease who had normal ECGs at rest, 24% of those undergoing a standard intra-abdominal operation suffered myocardial infarctions. At present, such asymptomatic but high-risk patients can be identified only by routine ECG stress testing or coronary angiography. Patients with an ischemic response to exercise have the best chance for long-term survival through staged coronary and vascular reconstruction.