Negotiating pace, focus and identities: Patient/public involvement/engagement in a palliative care study.

Patient and public involvement and engagement (PPIE) is an increasingly important component of research conduct to enhance processes and potential for impact, yet is rarely critically interrogated. This paper draws on Foucauldian analysis to highlight the disciplinary powers and tensions arising in PPIE. The paper draws on a nested evaluation interview study with three PPIE members and eight academics, who had been involved in an implementation science study focused on palliative care. PPIE members were involved in the whole study and are co-authors of this article. Through shared values and commitments to the study, a team culture of equality was developed. Yet while power was dispersed and taken-up by all team members, in so doing a self-governance approach within the team was developed. The pace and focus of discussions was at times more subjugating than co-production. Identities and positions were porous; the simplistic division of 'academic' and 'PPIE' did not stand up to scrutiny, with an increasing blurring of boundaries as people's experiences and insights changed over time. Continual, subtle, negotiations of roles, inputs and identities were manifest throughout the project. PPIE in research involves subtle, complex and ongoing disciplinary practices enacted by all members of the team.

Liver transplant for neuroendocrine tumor metastatic to the liver: literature review and report of extirpation at 16-year recurrence.

New information has demonstrated that there are few long-term disease-free survivors after a liver transplant for neuroendocrine tumors. All studies have limited follow-up to 10 years after a transplant. We present the case of a recurrent metastatic carcinoid in a patient 16 years after an orthotopic liver transplant. The subject initially presented with worsening chronic diarrhea, hypoglycemia, and confusion with massive hepatomegaly. The postoperative pathology report showed 80% to 90% of the liver tissue replaced by biopsy-proven synaptophysin-positive intrahepatic tumor with neuroendocrine differentiation. At the time of his liver transplant, he also underwent a distal pancreatectomy and splenectomy. Nuclear medicine tumor location studies, ultrasound, and computed tomography studies were performed at regular yearly intervals for 8 years on follow-up. Sixteen years after his orthotopic liver transplant, a retroperitoneal mass was detected showing neuroendocrine differentiation. Older studies focusing on an orthotopic liver transplant for highlighted clinical features would positively predict long-term survival. Older studies found the following features to be predictive of long-term survival in liver transplant for neuroendocrine tumors: age < 55 years, < 50% replacement of liver with metastatic neoplastic tissue and carcinoid type. These features were identified on multiple studies as positive predictors of disease-free survival. These studies were limited to, at most, 10-year follow-up. Newer studies have examined molecular features such as expression of E-cadherin and Ki-67 as positive predictors of long-term survival. However, no study has determined the full natural history of these tumors and for how long these patients should be followed. This anecdotal report highlights that late recurrence can occur.

Endovascular stent grafting of a complicated type B aortic dissection with approach through the innominate artery using a side-branch graft.

Endovascular stent grafting has emerged as an effective method for the treatment of complicated acute type B aortic dissections. In cases where access to the aorta cannot be established through the ileofemoral trunks, the axillary arteries are used as an alternative route. Often, however, these arteries are too small to accommodate the device sheath. We report the case of an 82-year-old female with complicated type B aortic dissection treated with deployment of an endovascular stent-graft through an 8 mm Dacron graft sewn to the innominate artery.

Repair of an ascending aortic aneurysm using reduction aortoplasty in a Jehovah's Witness.

Reduction ascending aortoplasty has been advocated as a possible alternative to traditional graft replacement for treatment of aneurysms of the ascending aorta and root. We report a case of a 58-year-old Jehovah's Witness female, with a 5.5-cm ascending aortic aneurysm and critical aortic stenosis. She underwent aortic valve replacement and reduction aortoplasty buttressed with a Dacron graft. We reviewed the history and contemporary applications of this technique and concluded that aortic reduction with externally supported aortoplasty may represent a viable option to treat Jehovah's Witness patients with ascending aorta and root aneurysm.

Primary benign interatrial schwannoma encountered during aortic valve replacement.

Primary neurogenic tumors of the heart are extremely uncommon. We report the resection of a benign primary schwannoma of the right atrium found incidentally during an aortic valve replacement.

The role of preexisting pathology in the development of neointimal hyperplasia in coronary artery bypass grafts.

OBJECTIVE: Saphenous vein grafts (SVG) used for coronary artery bypass surgery (CABG) often develop a gradual luminal narrowing over the first year due to neointimal hyperplasia (NH). Although the basic science of NH is well studied, our clinical understanding of this issue is limited. The purpose of this cohort study was to investigate clinical risk factors for NH by monitoring luminal narrowing within SVG using multichannel CT angiography (CTA). METHODS: Thirty patients underwent CABG involving SVG (N = 44) and arterial grafts (N = 36). Patient variables were recorded and the baseline quality of each conduit determined intraoperatively by analyzing surplus segments for intima-media thickness ratio (IMT) by histology and matrix metalloproteinase-2 by enzyme-linked immunosorbent assay. Percent luminal narrowing (%LN) was calculated for each patent graft by comparing the CTA appearance on day 5 to a repeat study at 1 y. RESULTS: Compared with arterial grafts, SVG showed significantly higher IMT at baseline (0.9 +/- 0.65 versus 0.22 +/- 0.17, P < 0.0001) and more %LN over the first year (6.9 +/- 7.5 versus 25.3 +/- 13.3% LN, P< 0.0001). Of all of the measured variables, the only significant predictors of %LN included baseline IMT (r = 0.58, P = 0.002) and matrix metalloproteinase-2 levels (r = 0.60, P = 0.002) in SVG. CONCLUSIONS: The degree of NH at baseline, a phenomenon exclusive to SVG and not found in arterial grafts, was significantly related to the development of lumen loss in the conduit over the first year after CABG. The study of SVG using serial CTA may provide unique insights into the natural history of SVG remodeling and to identify factors that influence the long-term function of this conduit.