Carotid endarterectomy in patients 55 years of age and younger.

Prior studies have suggested that young patients may be more prone to recurrent disease after carotid endarterectomy (CEA). The goal of this study was to review a series of CEAs performed on younger patients (< or = 55 years) and to determine if these patients are more likely to develop recurrent stenosis. A review was conducted of CEAs performed from 1985 through 1994. Analysis was performed on a study group of 94 young patients who underwent 109 CEAs during this time. A control group of 222 patients older than 55 years who underwent 256 CEAs during the years 1991 through 1993 was selected for comparison. During a mean of nearly 4 years of follow-up, younger patients were significantly more likely to experience a late failure of CEA, including total occlusion of the operated artery, or recurrent stenosis requiring redo surgery. Careful patient evaluation is important in choosing younger patients who require CEA. Implications of these data include mandating careful noninvasive follow-up examinations for younger patients undergoing CEA.

Outcome of mammary prostheses explantation: a patient perspective.

A retrospective study to characterize determinants of subjective outcome following removal of silicone gel-filled mammary implants was undertaken. One hundred consecutive female patients (aged 24 to 69 years, mean 46 years) who underwent removal of implants were surveyed. Eighty-two patients had mammary implants for cosmetic indications, 17 for postmastectomy reconstruction, and 1 for correction of congenital breast absence. The survey was conducted 6 to 12 months after explantation. Sixty-three patients (63%) returned questionnaires. Fifty-one patients were satisfied with the overall outcome of explantation (81% of respondees). Quality of life, as measured by self-assessed physical and cognitive functions, and improvement of symptoms attributed by the patients to the presence of implants, improved in 49 patients (78%), worsened in 2 patients (3%), and has not changed in 12 patients (19%). Twenty-one patients (33%) judged postexplantation and/or breast recontouring surgery aesthetic outcome as expected, 26 (41%) as an improvement better than expected, 9 (14%) judged their appearance as worse than expected, and 7 have not responded. Twenty-three patients (37%) perceived their postoperative course as "complicated" (scarring, inflammation, infection, seroma, asymmetry, distortion of breast contour, among those items listed). Five patients (8%) complained of mastalgia (not present prior to explantation). However, only 1 patient stated that the "complications" changed her opinion about "benefits" of this procedure. Sixty respondents (95%) indicated that comprehensive informed consent prior to explantation was instrumental in their acceptance of the outcome. If convinced that implants are safe, fifteen patients (24%) would and 41 patients (65%) would not like implants "back," and 7 patients (11%) gave no answer. Analysis of the patients' perspective should help to care for patients who contemplate or have undergone surgery with mammary implants.

Characterization of microbial presence at the surface of silicone mammary implants.

The purpose of this project was to examine the incidence of microbial presence on the surface of mammary implants and its correlation with clinical presentation. The significance of microbial presence without signs of overt infection is questioned. Several issues are raised, including whether the presence of micro-organisms may immunize the host, trigger autoimmune reactions, or locally change the course of healing (resulting in capsular contracture). A total of 150 explanted silicone mammary implants from 87 patients were cultured. Cultures of 81 devices were positive (54%); the predominant isolate was Staphylococcus epidermidis (found on 68 implants, or 84%). Bacteria were detected on 76% (62 of 82) of implants surrounded by contracted capsules and on 28% (19 of 68) of those without capsular contracture (p < 0.05). Among 40 patients (46%) who had no general health problems, 11 (28%) had positive cultures of explanted devices (15 of 62 explants, or 24%). In the remaining 47 patients (54%) who complained of myalgia (77%), arthralgia (68%), chronic fatigue (38%), skin rashes (21%), cognitive problems (19%), dry mucosal membranes (19%), episodes of low-grade fever (17%), and hair loss (13%), 38 (81%) had positive cultures (66 of 88 explants, or 75%) (p < 0.05). The hypothesis that capsular contracture or problems that might be related to chronic infection and immunization are associated with subclinical infection is supported by this study.