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Selected AbstractsSelective Application of the Pediatric Ross Procedure Minimizes Autograft FailureCONGENITAL HEART DISEASE, Issue 6 2008David L.S. Morales MD ABSTRACT Objective., Pulmonary autograft aortic root replacement (Ross' operation) is now associated with low operative risk. Recent series suggest that patients with primary aortic insufficiency have diminished autograft durability and that patients with large discrepancies between pulmonary and aortic valve sizes have a low but consistent rate of mortality. Therefore, Ross' operation in these patients has been avoided when possible at Texas Children's Hospital. Our objective was to report outcomes of Ross' operation when selectively employed in pediatric patients with aortic valve disease. Methods., Between July 1996 and February 2006, 55 patients (mean age 6.8 ± 5.5 years) underwent Ross' procedure. Forty-seven patients (85%) had a primary diagnosis of aortic stenosis, three (5%) patients had congenital aortic insufficiency, and five (9%) patients had endocarditis. Forty-two (76%) patients had undergone prior aortic valve intervention (23 [55%] percutaneous balloon aortic valvotomies, 12 [29%] surgical aortic valvotomies, 12 [29%] aortic valve replacements, 2 [5%] aortic valve repairs). Fourteen (25%) patients had ,2 prior aortic valve interventions. Thirty-two patients (58%) had bicuspid aortic valves. Follow-up was 100% at a mean of 3 ± 2.5 years. Results., Hospital and 5-year survival were 100% and 98%, respectively. Morbidity included one reoperation (2%) for bleeding. Median length of hospital stay was 6 days (3 days,3 months). Six (11%) patients needed a right ventricular to pulmonary artery conduit exchange at a median time of 2.3 years. Freedom from moderate or severe neoaortic insufficiency at 6 years is 97%. Autograft reoperation rate secondary to aortic insufficiency or root dilation was 0%. Conclusions., By selectively employing Ross' procedure, outcomes of the Ross procedure in the pediatric population are associated with minimal autograft failure and mortality at mid-term follow-up. [source] Electrophysiologist-Implanted Transvenous Cardioverter Defibrillators Using Local Versus General AnesthesiaPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 1 2000ANTONIS S. MANOLIS With the advent of smaller biphasic transvenous implantable Cardioverter defibrillators (ICDs) and the experience gained over the years, it is now feasible for electrophysioiogists to implant them safely in the abdominal or pectoral area without surgical assistance. Throughout the years, general anesthesia has been used as the standard technique of anesthesia for these procedures. However, use of local anesthesia combined with deep sedation only for defibrillation threshold (DFT) testing might further facilitate and simplify these procedures. The purpose of this study was to test the feasibility of using local anesthesia and compare it with the standard technique of general anesthesia, during implantation of transvenous ICDs performed by an electrophysiologist in the electrophysiology laboratory. For over 4 years in the electrophysiology laboratory, we have implanted transvenous ICDs in 90 consecutive patients (84 men and 6 women, aged 58 ± 15 years). Early on, general anesthesia was used (n = 40, group I), but in recent series (n = 50, group II) local anesthesia was combined with deep sedation for DFT testing. Patients had coronary (n = 58) or valvular (n = 4) disease, cardiomyopathy (n = 25) or no organic disease (n = 3), a mean left ventricular ejection fraction of 35%, and presented with ventricular tachycardia (n = 72) or fibrillation (n = 16), or syncope (n = 2). One-lead ICD systems were used in 74 patients, two-lead systems in 10 patients, andan AVICD in 6 patients. ICDs were implanted in abdominal (n = 17, all in group I) or more recently in pectoral (n = 73) pockets. The DFT averaged 9.7 ± 3.6 J and 10.2 ± 3.6 J in the two groups, respectively (P = NS) and there were no differences in pace-sense thresholds. The total procedural duration was shorter (2.1 ± 0.5 hours) in group II (all pectoral implants) compared with 23 pectoral implants of group I (2.9 ± 0.5 hours) (P < 0.0001). Biphasic devices were used in all patients and active shell devices in 67 patients; no patient needed a subcutaneous patch. There were six complications (7%), four in group I and two in group II: one pulmonary edema and one respiratory insufficiency that delayed extubation for 3 hours in a patient with prior lung resection, both probably related to general anesthesia, one lead insulation break that required reoperation on day 3, two pocket hematomas, and one pneumothorax. There was one postoperative arrhythmic death at 48 hours in group I. No infections occurred. Patients were discharged at a mean time of 3 days. All devices functioned well at predischarge testing. Thus, it is feasible to use local anesthesia for current ICD implants to expedite the procedure and avoid general anesthesia related cost and possible complications. [source] The Possibility of Deontic LogicRATIO JURIS, Issue 3 2002Sean Coyle A recent series of papers, sparked off by a note by Robert Walter (1996), has rekindled the debate over the possibility of creating a logic of normative concepts. The debate correctly centres on ways in which Jørgensen's dilemma might be resolved (Jørgensen 1937,8), since a means of resolving that dilemma is the only apparently available way in which to establish that a logic of norms is possible. Two separate questions require answers: (i) what is the correct way in which to regard Jørgensen's dilemma; and (ii) how should one face that dilemma? I shall argue that traditional responses to the first question are inadequate, and I shall then try to expose as flawed two recent attempts to resolve the dilemma. Finally, I shall relate my conclusions in the earlier part of the paper to the wider question of whether a logic of normative concepts is, after all, a possibility. [source] Oncological and Aesthetic Considerations of Conservational Surgery for Multifocal/Multicentric Breast CancerTHE BREAST JOURNAL, Issue 3 2010Neill Patani BSc Abstract:, Conventional indications for mastectomy (MX) reflect circumstances where breast conserving therapy (BCT) could compromise oncological or cosmetic outcome. MX continues to be recommended for the majority of women with multiple lesions within the same breast. In this article, we review the oncological safety and aesthetic considerations of BCT in the context of multifocal (MF) or multicentric (MC) breast cancer. Literature review facilitated by Medline and PubMed databases. Published studies have reported divergent results regarding the oncological adequacy of BCT in the management of MF or MC disease. Earlier studies demonstrated high rates of local recurrence (LR) for BCT. More recent series have found BCT to be comparable to MX in terms of LR, distant failure, disease free and overall survival. Few studies have adequately evaluated cosmetic outcomes following BCT for MF or MC breast cancer. Contemporary oncoplastic techniques have extended the clinical utility of BCT and are of particular relevance to breast conservation in the context of MF or MC lesions. Appropriate case selection, preoperative oncological and aesthetic planning, satisfactory clearance of the surgical margins and adjuvant radiotherapy are of paramount importance. In the absence of level-1 guidance concerning the management of women with MF or MC disease, each case requires discussion with regard to tumor and patient related factors in the context of the multidisciplinary team. In selected patients with MF or MC disease, BCT is oncologically safe and cosmetically acceptable. Uniformity of practice and the establishment of a standard of care will require an evidence-base from prospective studies. [source] Evidence supports adjuvant radiotherapy in selected patients with rectal cancerANZ JOURNAL OF SURGERY, Issue 3 2004Peter Gibbs Background: Much recent data have been published on the risk of local recurrence (LR) following curative surgery for rectal cancer and the impact of adjuvant radiation therapy (RT). With improvements in surgical technique apparently reducing the risk of LR, the relevance of older data upon which the current recommendations for adjuvant RT are based has been questioned. Methods: A focused review was undertaken of the published literature on the risk of LR following surgery for rectal cancer and the impact of adjuvant radiation. In particular the authors attempt to define how accurately the risk for an individual patient can be predicted, trends in reported LR rates over the time period of randomized trials, and the relevance of changing surgical and RT techniques. Results: Many of the perceived differences in published results can be explained by variations in study entry criteria, length of follow up and data recording. Comparisons between studies are most accurate when defined subsets of patients, such as those with stage III disease, followed for the same period of time, are considered. In parallel with improvements in surgical technique, which may have reduced the risk of LR, modifications to RT delivery have resulted in recent series not reporting an increased mortality in those patients treated with modern RT techniques. Conclusion: All of the available evidence supports the use of adjuvant RT in selected patients with rectal cancer. Ongoing studies will better define individual patient risk and the risk,benefit ratio of adjuvant RT. [source] Organizational Slack and Corporate Greening: Broadening the DebateBRITISH JOURNAL OF MANAGEMENT, Issue 4 2002Frances E. Bowen Organizational slack seems to have an ambiguous relationship with corporate greening. On the one hand, excess resources can be used to experiment with new environmental innovations, or potential green market segments. On the other, excess resources can be used to build corporate buffers against pressures for environmental improvement, such as large corporate environmental departments or environmental lobbying activity, and resist changes to the core of the organization. This paper begins to resolve these conflicting arguments by broadening the debate on organizational slack and corporate greening. It builds on recent empirical studies of slack and corporate greening, and recognizes the many potential roles that different types of slack may play in a dynamic decision,making context. Using a theoretical framework suggested by Bourgeois (1981), the paper systematizes and draws lessons from examples of the roles of slack encountered in a recent series of 35 interviews within UK public limited companies. It concludes that future treatments of slack and environmental management should incorporate a more holistic view of slack, which recognizes its dynamic, complex and often contradictory effects on decision,making in organizations. [source] Wnt signaling inside the nucleusCANCER SCIENCE, Issue 4 2008Miki Shitashige Accumulation of the ,-catenin protein and transactivation of a certain set of T-cell factor (TCF)-4 target genes by accumulated ,-catenin have been considered crucial in colorectal carcinogenesis. In the present review, we summarize nuclear proteins that interact with, and regulate, the ,-catenin and TCF and lymphoid enhancer factor (LEF) transcriptional complexes. Our recent series of proteomic studies has also revealed that various classes of nuclear proteins participate in the ,-catenin,TCF-4 complex and modulate its transcriptional activity. Furthermore, the protein composition of the TCF-4-containing nuclear complex is not fixed, but is regulated dynamically by endogenous programs associated with intestinal epithelial cell differentiation and exogenous stimuli. Restoration of the loss-of-function mutation of the adenomatous polyposis coli (APC) gene in colorectal cancer cells does not seem to be a realistic approach with currently available medical technologies, and only signaling molecules downstream of the APC gene product can be considered as targets of pharmacological intervention. Nuclear proteins associated with the ,-catenin,TCF-4 complex may include feasible targets for molecular therapy against colorectal cancer. Recently, an inhibitor of the interaction between CREB-binding protein and ,-catenin was shown to efficiently shut down the transcriptional activity of TCF-4 and induce apoptosis of colorectal cancer cells. We also summarize current strategies in the development of drugs against Wnt signaling. (Cancer Sci 2008; 99: 631,637) [source] | ||||||||||