Percutaneous Tracheostomy under Bronchoscopic Visualization Does Not Affect Short-Term or Long-Term Complications.

Percutaneous tracheostomy is a safe and effective bedside procedure. Some advocate the use of bronchoscopy during the procedure to reduce the rate of complications. We evaluated our complication rate in trauma patients undergoing percutaneous tracheostomy with and without bronchoscopic guidance to ascertain if there was a difference in the rate of complications. A retrospective review of all tracheostomies performed in critically ill trauma patients was performed using the trauma registry from an urban, Level I Trauma Center. Bronchoscopy assistance was used based on surgeon preference. Standard statistical methodology was used to determine if there was a difference in complication rates for procedures performed with and without the bronchoscope. From January 2007, to April 2016, 649 patients underwent modified percuteaneous tracheostomy; 289 with the aid of a bronchoscope and 360 without. There were no statistically significant differences in any type of complication regardless of utilization of a bronchoscope. The addition of bronchoscopy provides several theoretical benefits when performing percutaneous tracheostomy. Our findings, however, do not demonstrate a statistically significant difference in complications between procedures performed with and without a bronchoscope. Use of the bronchoscope should, therefore, be left to the discretion of the performing physician.

Accumulation of murine subretinal macrophages: effects of age, pigmentation and CX3CR1.

Macrophages or activated microglia in the subretinal space are considered a hallmark of some retinal pathologies. We investigated the effects of age, pigmentation and CX(3)CR1 deficiency on the accumulation of macrophages/activated microglia in the outer retina of young and old Cx(3)cr1(gfp/gfp) (CX(3)CR1-deficient) or Cx(3)cr1(gfp/+) mice on either a pigmented (C57BL/6) or albino (BALB/c) background. Quantitative analysis of immunostained retinal-choroidal whole mounts revealed an increase in subretinal macrophage (SRMΦ) numbers in young Cx(3)cr1(gfp/gfp) mice compared with Cx(3)cr1(gfp/+) mice, however the increase was more marked in albino Cx(3)cr1(gfp/gfp) mice. In aged mice, large numbers of SRMΦ/activated microglia replete with autofluorescent debris were noted in both old pigmented Cx(3)cr1(gfp/gfp) and Cx(3)cr1(gfp/+) mice proving this accumulation was not CX(3)CR1-dependent. While CX(3)CR1 deficiency leads to an early onset of SRMΦ accumulation, our data reveal that this change occurs in both aged Cx(3)cr1(gfp/+) and Cx(3)cr1(gfp/gfp) pigmented mice in the absence of marked retinal degeneration and is likely a normal response to aging.

Neoadjuvant chemotherapy's role in triple negative breast cancer.

Neoadjuvant chemotherapy (NC) facilitates breast conservation in women with large tumors, which are common in our inner city breast clinic. We performed this review of our NC breast cancer experience, which includes a disproportionate number of triple negative patients. Patients treated with NC were divided into two groups based on their tumor's receptor status. Patients with tumors negative for estrogen, progesterone, and HER2-neu were considered triple negative (TN) and patients with positive staining for any of these receptors were considered nontriple negative (NTN). Response to NC was considered a complete response (CR) if no residual tumor was detected at surgery, partial response (PR) if the height and width was reduced by at least 50 per cent, and no response (NR) for anything less than a PR. Differences were assessed by χ(2) analysis and Student's t test. We identified 30 patients treated with NC (11 TN and 19 NTN). Twenty-one patients (70%) were African American (11/11 TN and 10/19 NTN; P = 0.01). Age (46.8 ± 6.0 years TN vs 49.5 ± 11.7 years NTN), response rates (18% NR, 55% PR, and 27% CR TN; 37% NR, 42% PR, and 21% CR NTN), and node positivity (64% TN vs 74% NTN) were statistically similar. Two TN (20%) and seven (41%) NTN patients underwent breast conservation therapy. Our results demonstrate the association of African American race and TN breast cancer. TN cancers respond similarly to NC when compared with NTN, allowing for tumor downstaging and possible breast conservation surgery.

History of the Georgia Baptist/Atlanta Medical Center surgical residency.

The Georgia Baptist Hospital established itself as a premier healthcare facility during the first 50 years of the 20th century. The surgical residency started in the 1940s, became accredited in 1958, and has grown into one of the most respected independent programs in the country. The development and growth of the program was a result of the commitment and dedication of the Program Directors in Surgery over the past 50 years. These key leaders included A. Hamblin Letton, John P. Wilson, Paul Stanton, and George Lucas. The hospital's name has changed to Atlanta Medical Center with the sale of the hospital to Tenet in 1997. The same old school approach to surgical training that characterized the residency when it was known as Georgia Baptist persists and provides outstanding training for future surgeons interested in a broadly based surgical education and experience.

Analysis of demographic and tumor characteristics of an inner city breast cancer patient population compared with patients treated in National Surgical Adjuvant Breast and Bowel Project trials.

In June of 2008 we initiated a breast clinic designed to serve patients regardless of funding status. We analyzed age, race,tumor size, nodal status, estrogen, progesterone, and her-2-neu status. We compared our results to NSABP B-06 (nodal status), B-15 (estrogen, progesterone, and Her-2-neu receptor status), B-18, and B-27 (age, race, and tumor size) to determine whether our patient population was similar to patients included in these trials. Forty-nine patients with newly diagnosed breast cancer were treated during our first year (53 total cancers). Eight patients had noninvasive cancer; 45 had invasive disease. The mean age was 52.2 +/- 12.2 years compared to a mean age of 48.4 +/- 9.8 years in the B-06 trial (P = 0.005). Thirty six patients were African American (74%) compared to 10% and 12% in the NSABP B-18 and B-27 trials (P < 0.00001). A total of 23 of our patients with invasive cancer had involved axillary lymph nodes which was statistically more common than the 35.3% of node positive patients in the B-06 trial (P = 0.03). Tumor size (3.6 +/- 3.3 cm), estrogen (54.4%), and progesterone (52.8%) receptor status were similar to NSABP trials. Only 6 (13.3%) of our patients were considered Her-2-neu positive compared to 29.4% in the B-15 trial which was significantly less prevalent (P = 0.02). Significantly different demographic and tumor characteristics were identified in our inner city breast cancer patient population compared to NSABP patients. These results question the validity of using recommendations from large cooperative group trials in the development of treatment plans for our inner city patient population.

Can private, non-university-affiliated cardiothoracic training programs provide sufficient surgical experience in cardiac tumors?

Surgical case volumes in non-university-affiliated cardiothoracic surgery training programs in the US have been extensively studied by the Residency Review Committee (RRC) for thoracic surgery. The RRC has established that these programs offer a broad experience in common cardiothoracic procedures such as myocardial revascularization, valvular surgery, and cardiopulmonary transplantation. However, resident exposure to other important but less common cardiac surgical conditions in these programs remains unanswered. To address this question, an institutional review board-approved retrospective review of the experience of thoracic surgery residents with one of the rarest of surgical conditions, cardiac tumors, was conducted at the Ochsner Clinic Foundation in New Orleans, Louisiana. A survey of existing private, non-university-affiliated US cardiothoracic surgery training programs was conducted to determine the extent of the cardiac tumor experience in these programs. The results were then compared with selected university programs.

Turnover of bone marrow-derived cells in the irradiated mouse cornea.

In light of an increasing awareness of the presence of bone marrow (BM)-derived macrophages in the normal cornea and their uncertain role in corneal diseases, it is important that the turnover rate of these resident immune cells be established. The baseline density and distribution of macrophages in the corneal stroma was investigated in Cx3cr1(gfp) transgenic mice in which all monocyte-derived cells express enhanced green fluorescent protein (eGFP). To quantify turnover, BM-derived cells from transgenic eGFP mice were transplanted into whole-body irradiated wild-type recipients. Additionally, wild-type BM-derived cells were injected into irradiated Cx3cr1(+/gfp) recipients, creating reverse chimeras. At 2, 4 and 8 weeks post-reconstitution, the number of eGFP(+) cells in each corneal whole mount was calculated using epifluorescence microscopy, immunofluorescence staining and confocal microscopy. The total density of myeloid-derived cells in the normal Cx3cr1(+/gfp) cornea was 366 cells/mm(2). In BM chimeras 2 weeks post-reconstitution, 24% of the myeloid-derived cells had been replenished and were predominantly located in the anterior stroma. By 8 weeks post-reconstitution 75% of the myeloid-derived cells had been replaced and these cells were distributed uniformly throughout the stroma. All donor eGFP(+) cells expressed low to moderate levels of CD45 and CD11b, with approximately 25% coexpressing major histocompatibility complex class II, a phenotype characteristic of previous descriptions of corneal stromal macrophages. In conclusion, 75% of the myeloid-derived cells in the mouse corneal stroma are replenished after 8 weeks. These data provide a strong basis for functional investigations of the role of resident stromal macrophages versus non-haematopoietic cells using BM chimeric mice in models of corneal inflammation.