How surgeon age affects post-treatment surveillance strategies for melanoma patients.

The intensity of post-treatment melanoma patient follow-up varies widely among physicians. We investigated whether physician age accounts for the observed variation in surveillance intensity among plastic surgeons. A custom-designed questionnaire was mailed to USA and non-USA surgeons, all of whom were members of the American Society of Plastic and Reconstructive Surgeons. Subjects were asked how they use 14 specific follow-up modalities during years 1-5 and 10 following primary treatment for patients with cutaneous melanoma. Repeated-measures analysis of variance was used to compare practice patterns by TNM stage, year post-surgery, and age. Of the 3,032 questionnaires mailed, 1,142 (38%) were returned. Of those returned, 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Follow-up strategies for most of the 14 modalities were highly correlated across TNM stages and years post-surgery, as expected. The pattern of testing varied significantly by surgeon age for 3 modalities (complete blood count, liver function tests, and chest X-ray), but the variation was quite small. We concluded that the post-treatment surveillance practice patterns of ASPRS members caring for patients with cutaneous melanoma vary only marginally with physician age. Continuing medical education could account for this observation.

Effect of initial tumor stage on patient follow-up after potentially curative surgery for cutaneous melanoma.

The optimal follow-up strategy after completion of therapy for melanoma is not known. We evaluated the effect of TNM stage on the self-reported surveillance strategies employed by practicing plastic surgeons caring for otherwise healthy patients subjected to potentially curative treatment for cutaneous melanoma. Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to a random sample (N=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons. The effect of TNM stage on the surveillance strategies chosen was analyzed by repeated-measures ANOVA. There were 1,142 responses to the 3,032 surveys; 395 were evaluable. Plastic surgeons often do not provide postoperative follow-up themselves; this was the most frequent reason for non-evaluability. Surveillance of patients after resection of melanoma relies most heavily on office visits, chest X-ray, CBC, and liver function tests. All other surveillance modalities are used infrequently. Most respondents modify their surveillance practices slightly according to the patient's initial TNM stage. Most commonly used modalities are employed significantly more frequently with increasing TNM stage. This effect persists through ten years of follow-up, but the differences across stages are tiny. We conclude that most plastic surgeons performing surveillance after potentially curative surgery in otherwise healthy patients with melanoma use similar follow-up strategies for patients of all TNM stages. These data permit the rational design of a controlled clinical trial of high-intensity vs. low-intensity follow-up.

Current practice of patient follow-up after potentially curative resection of cutaneous melanoma.

Follow-up care for patients who have undergone potentially curative resection of cutaneous melanoma varies widely among physicians, and the underlying rationale has not been assessed. To quantify current practice patterns and to discern motivation, a custom-designed questionnaire was mailed to U.S. and non-U.S. surgeons, all of whom were members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Surveys were mailed to 3,032 ASPRS members, chosen randomly from a total of 4,320 members. Of the 1,142 questionnaires that were returned, 395 were evaluable. Nonevaluability was usually due to lack of melanoma patients receiving follow-up in the surgeons' practices. Surveillance of patients after resection of melanoma relies most heavily on office visit, chest x-ray, complete blood count, and liver function tests. There was surprisingly little influence of elective node dissection on follow-up practices. Imaging tests such as computed tomography, magnetic resonance imaging, and position emission tomography scan were rarely employed. Surveillance is motivated by many factors, particularly early detection of recurrence of the index melanoma and second primary melanomas. This survey provides information regarding current follow-up strategies recommended by ASPRS surgeons after potentially curative resection of cutaneous melanoma. There is considerable variation in surveillance intensity and in motivation among practitioners, thus representing a lack of consensus.

The relationship of oxidized lipids to coronary artery stenosis.

A total of 1200 patients with angina were cardiac catheterized establishing that 63% had 70-100% stenosis, 12% had 10-69% stenosis of one or more of their coronary arteries and 25% had microvascular angina listed as 0% stenosis. Prior to catheterization 10 ml of blood was drawn and the plasma subjected to analysis for the concentration of cholesterol, lipid peroxides (LPX), total antioxidant capacity (TAOC), fibrinogen (FB), ceruloplasmin (CP) and activation of polymorphonuclear leukocytes (PMNLs). Comparisons were made to non-smoking controls without angina. Significant differences in LPX were found between the patients with 0 and 10-69% stenosis (P<0.001), with 10-69 and 70-100% stenosis (P<0.001), and with 0 and 70-100% stenosis (P<0.001). Under 70 years of age there was a significant difference in LPX between patients with all levels of stenosis and age and sex matched controls (P<0.001). Differences in the mean plasma cholesterol concentration for different levels in the degree of stenosis were not significant, indicating that LPX provided consistent data on the severity of stenosis while the plasma cholesterol concentration did not. Compared with controls an increase in activation of PMNLs (P<0.01), an increase in concentration of both FB and CP (P<0.01) and a decrease in total antioxidant capacity were noted in the plasma of catheterized patients. In summary the concentration of oxidation products rather than the concentration of cholesterol in the plasma identified stenosis in cardiac catheterized patients.

An excess concentration of oxysterols in the plasma is cytotoxic to cultured endothelial cells.

To test if there is an excess concentration of oxysterols in the plasma of the patients with cardiovascular disease, we analyzed the oxysterol content in the plasma from 105 cardiac catheterized patients with angina and 80+/-8% stenosis in their coronary arteries. The result showed that the plasma contained a significantly higher concentration of oxysterols than did plasma from 105 age- and sex-matched, non-catheterized and angina-free controls (P<0.05). We used endothelial cells (ECs) cultured in medium containing either [3H]thymidine, [3H]mevalonolactone or 45Ca(2+) to determine how the plasma from the patients influences cell growth and function. We found that less [3H]thymidine (P<0.05), less [3H]mevalonolactone (P<0.05) and more 45Ca(2+) (P<0.001) was incorporated into ECs cultured in the plasma from 36 patients with 83+/-4% stenosis than from the 36 controls. When synthetic 7beta-hydroxycholesterol, cholesterol 5beta,6beta-epoxide, cholesterol 5alpha,6alpha-epoxide and 7-ketocholesterol were added to the plasma from the controls, the influx of 45Ca(2+) into ECs then equaled that in the plasma of patients. The enhanced incorporation of 45Ca(2+) into the ECs cultured in the plasma both from the patients and from controls with added synthetic oxysterols substantiates in vitro the hypothesis that oxysterols increase the influx of calcium into cells. These data indicated that an excess of oxysterols in the plasma of the patients was cytotoxic to the cultured cells.

The hemolytic activity of homocysteine is increased by the activated polymorphonuclear leukocytes.

Homocysteine is an accepted risk factor when its plasma level exceeds the physiological upper limit of 12 mumol/L. We found in vitro that homocysteine is able to lyse the erythrocytes (RBCs) at higher concentrations than 15 mumol/L only when activated polymorphonuclear leukocytes (PMNL) are present. The hemolytic effect of homocysteine was higher in RBCs obtained from cardiac catheterized patients with 100% stenosis of the coronary arteries. Homocysteine was also able to increase the activation in vitro of PMNLs triggered by opsonized zymosan. The hemolytic action of homocysteine was found to be dependent on the ratio of PMNLs to RBCs. This relationship may help to explain the great individual variations in the hemolytic activity noticed in blood obtained from cardiac catheterized patients, and also may explain the mild anemia in some patients suffering from cardiovascular disease.

Studies on the role of TRH and corticosterone in the regulation of prolactin and thyrotrophin secretion during lactation.

This study describes the effects of litter size and acute suckling on the synthesis and release of hypothalamic TRH, as indirectly estimated by determination of hypothalamic prothyrotrophin-releasing hormone (proTRH) mRNA and median eminence TRH content. The effects of litter size (five or ten pups) were studied throughout lactation, while suckling-induced acute changes were analyzed on day 13 of lactation in dams with ten pups. In view of the enhanced adrenal activity during lactation and recent evidence that corticosteroids have negative effects on hypothalamic TRH, we also studied adrenalectomized (ADX) dams treated with corticosterone to maintain basal plasma corticosterone levels. In addition to an increased plasma level of prolactin (PRL), adrenal weight and plasma corticosterone increased, while plasma TSH, tri-iodothyronine (T3), thyroxine (T4) and free T4 (FT4) levels decreased during lactation. Litter size correlated positively with plasma PRL, adrenal weight and plasma corticosterone. No effect of litter size was observed on plasma T3, but rats with ten pups had lower plasma TSH, T4 and FT4 than rats with a five-pup litter. Compared with dioestrous rats, lactating rats showed an increased hypothalamic proTRH mRNA content on day 2, but not on days 8 and 15 of lactation. Median eminence TRH in lactating rats gradually increased until day 15 and decreased thereafter. Acute suckling, after a 6-h separation of mother and pups, rapidly increased plasma PRL and corticosterone in the mothers, but had no effects on plasma TSH and thyroid hormone levels. Hypothalamic proTRH mRNA increased twofold after 0.5 h of suckling, and then gradually returned to presuckling values after 6 h. Compared with sham-operated rats, corticosterone-substituted ADX rats with ten pups had increased plasma PRL and TSH, hypothalamic proTRH mRNA and pituitary TSH beta mRNA on day 15 of lactation. Moreover, while acute suckling did not enhance TSH release in sham-operated rats, it provoked not only PRL but also TSH release in corticosterone-substituted ADX dams. It is concluded that suckling exerts a rapid, positive effect on hypothalamic proTRH mRNA content. However, the concurrent enhanced adrenal activity has negative effects on hypothalamic proTRH gene expression resulting in a suppressed hypophysial-thyroid axis during lactation. While TRH appears to play a role in PRL release during the first days of lactation and during acute suckling, TRH seems not important in maintaining PRL secretion during continued suckling.

Imaging of percutaneous tube gastrostomies: spectrum of normal and abnormal findings.

Enteral alimentation is a crucial component of care for the malnourished patient who cannot eat. Until recently, long-term alimentation was delivered through nasogastric tubes or gastrostomy tubes placed at surgery. In the past few years, percutaneous endoscopic gastrostomy (PEG) has almost completely supplanted these traditional methods. PEG is a safer and better-tolerated procedure. The advantages of PEG over nasogastric tubes include greater social acceptance and improved cosmetic appearance, increased ease of feedings, and decreased nasal alar deformities and gastroesophageal reflux. Complications are less common with PEG than with open gastrostomy but still occur in as many as 15% of cases [1-3]. Percutaneous gastrostomies performed using fluoroscopic guidance have complications in approximately 10% of cases [4]. Despite a rapid increase in the use of percutaneous gastrostomies and their placement by radiologists [4], few published reports have described imaging findings after the placement of such tubes. This pictorial essay illustrates a spectrum of normal and abnormal imaging findings observed with the use of PEG tubes, including tube migration and misplacement, infection, tumor seeding along the PEG tube track, and a variety of gastric wall defects and pseudomasses.

Gastrointestinal disease in patients receiving salvage chemotherapy or bone marrow transplantation.

Thirty-three patients receiving either salvage chemotherapy or bone marrow transplantation with potential surgical illness related to gastrointestinal symptoms were identified. Sixty-nine percent of patients received salvage chemotherapy for either hematological (61%) or visceral malignancies (39%). Twenty-one percent of patients had a previous bone marrow transplant. Twenty-two (66%) had an absolute neutrophil count less than 10(3)/mm3. Ulcerative foregut disease (51%) and perianal disease (21%) were the most common disease entities identified. Esophagogastroduodenoscopy (79%) and anorectal examination under anesthesia (21%) provided the greatest diagnostic yield. The mean hospitalization was 21 days. Surgery was performed in 21% of patients, but was seldom required for abdominal pain or intestinal bleeding. Perianal disease was often chronic and required multiple operative procedures. Overall, a 27% mortality was found. Gastrointestinal disease in patients receiving salvage chemotherapy or bone marrow transplantation is usually manifested by bleeding and localized to the proximal gut, or related to perianal disease.

The conduction system of the swine heart.

Although the pig has been used as an experimental model for ischemic heart disease and sudden death, relatively little is known about the anatomy of the conduction system (CS) of this animal. We attempted to correlate electrophysiologic and anatomic differences between the pig and human CS. Invasive electrophysiologic studies were performed in five healthy anesthetized pigs. In contrast to the adult human, the pig has sinus tachycardia, shortened PR and H-V intervals, and a relatively short sinoatrial conduction time. Compared with the human CS, serial sections of the CS of pig hearts showed the following differences: (1) the atrioventricular node is located more to the right of the summit of the ventricular septum; (2) the penetrating bundle is very short, and the bifurcation of the bundle into bundle branches occurs more proximally; (3) there is more connective tissue and less elastic tissue; and (4) there is a copious amount of nerve fibers (about 50 percent throughout the CS). The presence of the abundant neural tissue implies that there is an important neurogenic component to conduction in the pig. Because of the above differences from the human, the pig should be used with caution as an experimental model in ischemic heart disease and sudden death where arrhythmias are studied.

Equilibrium radionuclide gated angiography in patients with tricuspid regurgitation.

Equilibrium gated radionuclide angiography was performed in 2 control groups (15 patients with no organic heart disease and 24 patients with organic heart disease but without right- or left-sided valvular regurgitation) and in 9 patients with clinical tricuspid regurgitation. The regurgitant index, or ratio of left to right ventricular stroke counts, was significantly lower in patients with tricuspid regurgitation than in either control group (range and mean +/- standard error of the mean 0.4 to 1.0, 0.7 +/- 0.1 versus 1.0 to 1.5, 1.3 +/- 0.1 and 1.0 to 2.9, 1.5 +/- 0.1, respectively, p less than 0.001). Time-activity variation over the liver was used to compute a hepatic expansion fraction which was significantly higher in patients with tricuspid regurgitation than in either control group (1.4 to 11.4, 5.8 +/- 1.0% versus 0.6 to 3.4, 1.9 +/- 0.3% and 1.0 to 5.1, 2.3 +/- 0.2%, respectively, p less than 0.001). Fourier analysis of time-activity variation in each pixel was used to generate amplitude and phase images. Only pixels with values for amplitude at least 7% of the maximum in the image were retained in the final display. All patients with tricuspid regurgitation had greater than 100 pixels over the liver automatically retained by the computer. These pixels were of phase comparable to that of the right atrium and approximately 180 degrees out of phase with the right ventricle. In contrast, no patient with no organic heart disease and only 1 of 24 patients with organic heart disease had any pixels retained by the computer. In conclusion, patients with tricuspid regurgitation were characterized on equilibrium gated angiography by an abnormally low regurgitant index (7 of 9 patients) reflecting increased right ventricular stroke volume, increased hepatic expansion fraction (7 of 9 patients), and increased amplitude of count variation over the liver in phase with the right atrium (9 of 9 patients).

Bumetanide: a new diuretic. Results of clinical efficacy and safety in patients with congestive heart failure.

A clinical study of bumetanide, a new diuretic, was conducted in outpatients of a cardiology clinic to determine its long-term effectiveness and safety in the treatment of peripheral edema due to congestive heart failure. The drug was administered for at least 24 weeks on a selected group of 34 patients. The patients were monitored for clinical response, evidenced by changes in cardiac signs and symptoms, and by laboratory tests, as well as by slit-lamp ophthalmic examination, electrocardiogram, and chest x-ray. Based on the clinical evaluation of effects on body weight, chronic edema, functional physical capacity, and results of selected laboratory data, it was concluded that bumetanide is as effective as other diuretics and can be used as an initial diuretic for maintenance of body weight for long-term use in patients with peripheral edema due to congestive heart failure. Bumetanide mobilizes peripheral edema effectively in most patients and leads to improvement in functional physical capacity. Safety and adverse reactions during treatments are discussed.

Tricuspid insufficiency detected by equilibrium gated radionuclide study.

The results of a gated radionuclide cardiac study are reported in a patient with biventricular failure and tricuspid insufficiency demonstrated by clinical evaluation, M-mode and 2-D sector echocardiography, and cardia catheterization. The processed gated radionuclide cardiac study showed a left ventricular/right ventricular stroke volume ratio of 0.5; expansion of the hepatic blood pool demonstrated by hepatic time activity curve and calculation of an "'expansion fraction"; and synchronous changes of count rate of the atrial and hepatic regions detected by phase analysis (similar phase shifts).