Protoplasmic astrocytoma with multifocal involvement: case report and radiological findings.

Protoplasmic astrocytomas are a poorly characterized and extremely rare subtype of astrocytoma. We describe the CT, MR and 18F-fludeoxyglucose positron emission tomography (FDG-PET) findings of a multifocal protoplasmic astrocytoma in a 29-year-old male with neurological deficits. He was initially diagnosed with neurosarcoidosis based on imaging. MRI demonstrated intraparenchymal lesions involving the right temporal lobe and cerebellum. These appeared as extremely hyperintense signals on T 2 weighted imaging and as homogeneous enhancements with a small non-enhancing cystic component on contrast-enhanced MR. Diffuse post-contrast enhancement of the craniospinal meninges was also noted. Post-radiation therapy PET-CT demonstrated a highly FDG-avid tumour in the right temporal lobe and left cerebellum. To our knowledge, a multifocal form of protoplasmic astrocytoma in an adult patient has not been previously described.

Results of the Cox-Maze III/IV procedure in patients over 75 years old who present for cardiac surgery with a history of atrial fibrillation.

AIM: Elderly patients with atrial fibrillation (AF) present a special challenge. Despite the documented advantage in ablating AF, the addition of the procedure may add complexity and potentially impact patient outcome. This study explored the impact of the Cox-Maze III/IV procedure on elderly patients experiencing AF who present for cardiac surgery. METHODS: Forty-four patients aged ≥ 75 with concomitant surgery underwent the Cox-Maze III/IV procedure for AF. These patients were followed using our extensive longitudinally designed registry to include health related quality of life (HRQL). Late death was captured by the Social Security Index and the National Death Index. RESULTS: The mean age for this sample was 79.5 ± 3 years and mean additive euroSCORE was 9 ± 2.1 (high risk). The majority of patients with the Cox-Maze procedure underwent concomitant valve surgery (N. = 41, 93%). There was a low incidence of STS measured perioperative outcomes in this group. NSR rates at six months were 90% (26/29) and 85% (23/27) at 12 months for the ablation group. There were no embolic strokes and major bleeding events occurred in only two patients. By Kaplan-Meier analysis, two-year cumulative survival was 89.6% and there was only one operative mortality in this group (2.3%). CONCLUSION: Addition of the Cox-Maze III/IV procedure in patients ≥ 75 years may add to the complexity of the surgical procedure, but does not increase the operative risk. Age should not be the only discriminating factor when considering the Cox-Maze III/IV procedure for patients aged ≥ 75 years who present for cardiac surgery while experiencing atrial fibrillation.

The definition of chronic lung disease in patients undergoing cardiac surgery: a comparison between the Society of Thoracic Surgeons and the American Thoracic Society/European Respiratory Society Classifications.

AIM: Early and late outcomes following cardiac surgery may be adversely affected in patients with chronic lung disease (CLD) and the presence of CLD is definition dependent. The purpose of this study was to compare the Society of Thoracic Surgeons (STS) definitions for CLD to the modified American Thoracic Society (ATS)/European Respiratory Society (ERS) definitions in diagnosing and classifying CLD among a cohort of cardiac surgery patients. METHODS: A prospectively-designed study whereby high risk patients for CLD presenting for non-emergent cardiac surgery and had a history of asthma, a 10 or more pack year history of smoking or a persistent cough were included. All patients underwent spirometry testing within two weeks of surgery. The presence and severity of CLD was coded two times: 1) STS definitions with spirometry; 2) ATS/ERS guidelines. The rate of misclassification was determined using concordance and discordance rates. Sensitivity analysis of the STS spirometry definitions was calculated against the ATS/ERS definitions and respective classifications. RESULTS: The discordant rate for the STS spirometry driven definitions versus the ATS/ERS definitions was 21%. Forty patients (21%) classified as no CLD by the STS spirometry definition were found to have CLD by the ATS/ERS definition. The STS classification had 68% sensitivity (84/124) when identifying any CLD and only 26% sensitivity (14/54) when identifying moderate CLD. CONCLUSION: The current STS spirometry driven definitions for CLD did not perform as well as the ATS/ERS definitions in diagnosing and classifying the degree of CLD. Consideration should be given to using the ATS/ERS definitions.

Same-day transfer of patients to the cardiac telemetry unit after surgery: the Rapid after Bypass Back into Telemetry (RABBIT) program.

Early data from this project suggest that the RABBIT program fulfilled the process improvement goals of decreasing costs of cardiac surgery and maintaining high quality. Decreased cost was achieved by decreasing time to extubation and decreasing length of stay in the ICU and the total length of stay in the hospital. The cost savings were achieved without compromising the quality of care, which was assessed by measuring rates of readmission to the ICU and to the hospital and by surveying patients about their level of satisfaction. The success of the RABBIT program can be attributed to several factors. First, members of the cardiac surgery quality improvement team worked well together to solve problems and overcome obstacles, particularly after the pilot program. Second, naming the program helped to motivate staff, physicians, and patients. Outcome data was shared with the staff quarterly, and successes were celebrated. Finally, the use of a facilitator early in the process to establish the process with the surgeons and the staff was invaluable. Opportunities for continued improvement include resolving operational difficulties related to availability of beds and staffing, continuing work with physicians in changing practice patterns, increasing efficiency in scheduling operating rooms, and adjusting the preoperative education provided to patients and their families about the length of stay to expect. Quarterly outcome analysis continues, with reports to the cardiac surgery quality improvement team. The team continues to explore creative solutions to the aforementioned issues, as the goal of having 25% of patients who undergo cardiac surgery be transferred to the CTU on the day of surgery has remained elusive.