Thoracic aortic transection resulting in a type B dissection following blunt trauma.

A 39-year-old man sustained an acute grade III aortic injury resulting in a type B aortic dissection in the setting of severe traumatic brain injury, cervical spine injury and multiple orthopaedic injuries following a motorcycle crash. The patient underwent an emergent thoracic endovascular aortic repair, complicated by a thoracic pseudoaneurysm rupture and ongoing exsanguination from a persistent type 1 endoleak. Additional stent grafts were required to gain control of the endoleak. The patient ultimately progressed to brain death post procedure in the intensive care unit. This case reviews treatment considerations in the context of a blunt thoracic aortic transection and distal dissection with concomitant polytrauma.

Diagnosis and management of enterovesical fistulas in patients with Crohn's disease.

The objective of this study was to investigate the clinical manifestations and diagnostic studies used to evaluate Crohn's patients with enterovesical fistulas (EVFs) and to assess outcome after surgical intervention. This is a ten year multi-institutional retrospective chart review of patients with Crohn's disease. Of 400 patients identified with Crohn's disease eight (2%) were diagnosed with EVF. The mean age at diagnosis was 27 years. No patients had prior surgeries for Crohn's. Duration of symptoms ranged from 6 months to 15 years. There were seven ileovesical and one colovesical fistula identified. One patient had associated perianal disease. Three had concomitant enteroenteral fistulae. Clinical features included pneumaturia in seven patients (88%), fecaluria in three (38%), hematuria in five (63%), and urinary tract infection symptoms in seven (88%). Diagnostic studies included CT scan in six, barium or gastrografin enema in four, and cystoscopy in four. Surgical therapy involved resection of the affected bowel. The bladder defect was closed primarily in two layers in all patients using absorbable suture, with omental patch in four. Two patients underwent ileostomy and one underwent colostomy, all taken down within 6 months. There were no bladder leaks and no anastamotic leaks. There were no perioperative deaths. The mean postoperative stay was nine days. The mean follow-up was 39 months. We conclude that pneumaturia is a strong clinical indicator of EVF. CT has been valuable in identifying gas within the bladder in these patients. Cystoscopy has proven useful in identifying the fistulous tract and in evaluation of the ureters. The presence of an EVF should heighten suspicion as to the presence of concomitant enteroenteral fistulae. Barium or gastrografin studies are useful in this capacity. Surgical treatment of EVFs should include resection of affected bowel. The bladder defect can safely be closed using absorbable suture.

Prospective study of eukaryotic initiation factor 4E protein elevation and breast cancer outcome.

OBJECTIVE: To validate the authors' initial hypothesis-generating observation that eukaryotic initiation factor 4E (eIF4E) protein elevation predicts a higher cancer recurrence rate in patients with stage 1 to 3 breast cancer. SUMMARY BACKGROUND DATA: Tumor size and nodal status continue to be the two most important independent prognostic markers in breast cancer, despite well-documented limitations. In a previous smaller retrospective study, eIF4E, important in the regulation of protein synthesis of mRNAs with long or complex 5' untranslated regions, appeared promising as an independent predictor of breast cancer recurrence. METHODS: Specimens and clinical data from 191 patients with stage 1 to 3 breast cancer were accrued prospectively. Data collected include stage of disease, tumor grade, age at diagnosis, and menopausal status. Endpoints measured were disease recurrence and cancer-related death. eIF4E protein level was quantified using Western blot analysis. Immunohistochemical staining was used to determine estrogen receptor, progesterone receptor, and HER-2/neu receptor status. Statistical analysis include Cox proportional hazards model, log-rank test, Kaplan-Meier survival curve, Fisher exact test, and t test. RESULTS: Patients were divided into three groups based on tertile distribution of eIF4E: low, defined as less than 7.5-fold elevation (n = 64); intermediate, defined as 7.5- to 14-fold elevation (n = 61); and high, defined as more than 14-fold elevation (n = 66). The relative risk for cancer recurrence with intermediate elevation was 4.1 times that of patients with low elevation. For patients with high elevation, the relative risk for recurrence was higher, at 7.2 times that of the low group. The relative risk for cancer-related death for high elevation was 7.3 times that of patients with low eIF4E. Using multivariate analysis, high eIF4E remained an independent predictor of cancer recurrence after adjusting for tumor size, tumor grade, nodal disease, estrogen receptor status, progesterone receptor status, and menopausal status. CONCLUSIONS: High eIF4E is an independent predictor of cancer recurrence in patients with stage 1 to 3 breast cancer. The relative risk for cancer recurrence increases with eIF4E protein elevation. High eIF4E elevation is also associated with an increased relative risk for cancer-related death.