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Selected AbstractsErgonomics in Office-Based Surgery: A Survey-Guided Observational StudyDERMATOLOGIC SURGERY, Issue 11 2007ADAM C. ESSER MD BACKGROUND The practice of office-based surgery is increasing in many specialties. OBJECTIVE Using Mohs surgery as a model, we investigated the role of ergonomics in office-based surgery to limit work-related musculoskeletal disorders. METHODS All Mayo Clinic surgeons currently performing Mohs surgery and Mohs surgeons trained at Mayo Clinic between 1990 and 2004 received a questionnaire survey between May 2003 and September 2004. A sample of respondents were videotaped during surgery. The main outcome measures were survey responses and an ergonomist's identification of potential causes of musculoskeletal disorders. RESULTS All 17 surgeons surveyed responded. Those surveyed spend a mean of 24 hours per week in surgery. Sixteen said they had symptoms caused by or made worse by performing surgery. Symptom onset occurred on average at age 35.4 years. The most common complaints were pain and stiffness in the neck, shoulders, and lower back and headaches. Videotapes of 6 surgeons revealed problems with operating room setup, awkward posture, forceful exertion, poor positioning, lighting, and duration of procedures. CONCLUSION Symptoms of musculoskeletal injuries are common and may begin early in a physician's career. Modifying footwear, flooring, table height, operating position, lighting, and surgical instruments may improve the ergonomics of office-based surgery. [source] Prognostic relevance of cytogenetic abnormalities in primary myelofibrosis: comparison of recent reports from Japan, the Mayo Clinic and MD Anderson Cancer CenterEUROPEAN JOURNAL OF HAEMATOLOGY, Issue 4 2009Ayalew Tefferi No abstract is available for this article. [source] Serum aminotransferase activity and mortality risk in a United States community,HEPATOLOGY, Issue 3 2008Tae Hoon Lee Serum aminotransferase [such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT)] is commonly used as an indicator of liver disease. The aim of the study was to determine the degree to which aminotransferase results are associated with increased mortality at the population level. All adult residents of Olmsted County, Minnesota, who had a health care encounter at Mayo Clinic, Rochester, in 1995 were identified and their AST or ALT results extracted from a laboratory database. These subjects were followed forward from January 1995 to April 2006 and their survival determined. To exclude patients with abnormal results because of a terminal illness, deaths within the first 2 years were excluded. The main outcome measure was survival. Standardized mortality ratios (SMRs) were calculated, based on Minnesota White death rates. During 1995, AST was measured at least once in 18,401 community residents, of whom 2,350 (13%) had results greater than the upper limit of normal (ULN). Of 6,823 subjects who had their ALT measured, 911 (13%) had results higher than ULN. Abnormal AST was associated with a significantly increased SMR (1.32 for 1,2× ULN and 1.78 for >2× ULN). SMR was also higher for abnormal ALT (SMR = 1.21 for 1,2× ULN and 1.51 for >2× ULN). In contrast, normal AST or ALT was associated with a risk of death lower than expected (SMR 0.95 for AST, 0.61 for ALT). Conclusion: Serum levels of AST and ALT obtained in a routine medical care setting are associated with future mortality in community residents. (HEPATOLOGY 2008;47:880,887.) [source] Cryptococcal infection in sarcoidosisINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 11 2002Khosrow Mehrany MD A 48-year-old man with a history of sarcoidosis was transferred to the Mayo Clinic for evaluation and management of progressive neurologic decline. Two years before admission, he was admitted to a local hospital with mental status changes accompanied by ataxia and severe headache. A diagnosis of pulmonary and central nervous system sarcoidosis was made based on computed tomography of the head, lumbar puncture, and chest radiography. A mediastinoscopy with lymph node biopsy exhibited noncaseating granulomas and negative stains for microorganisms. Prednisone therapy was initiated at 80 mg/day. Clinical improvement was apparent for 13 months during steroid therapy until the slow taper reached a dosage of 20 mg/day. At that time, the patient was readmitted to the local hospital with severe confusion and skin lesions. When intravenous methylprednisolone therapy for presumed central nervous system sarcoidosis did not improve the patient's mental status, he was transferred to the Mayo Clinic. Physical examination of the thighs revealed large, well-marginated, indurated, irregularly bordered, violaceous plaques and rare, umbilicated, satellite papules with central hemorrhagic crusts (Fig. 1A). Superficially ulcerated plaques with a similar appearance to the thigh lesions were coalescing around the lower legs (Fig. 1B). A skin biopsy specimen of the thigh demonstrated abundant numbers of encapsulated organisms and minimal inflammatory response (Fig. 2). Skin, blood, and cerebrospinal fluid cultures confirmed the presence of Cryptococcus neoformans. Amphotericin and flucytosine combination therapy was initiated, and steroid dosages were gradually tapered. A test for human immunodeficiency virus was negative. The patient was dismissed from hospital after a complicated 2-month course resulting in improved mental status but progression of the lower extremity ulcerations as a result of polymicrobial infection. Figure 1. (A) Violaceous plaque with satellite papules on thigh. (B) Ulcerating plaques coalescing around leg Figure 2. (A) Sparse inflammatory infiltrate and abundant encapsulated organisms (hematoxylin and eosin; × 20). (B) Cryptococcal organisms (Gomori's methenamine silver; × 40) [source] Treatment of late-stage Sézary syndrome with 2-ChlorodeoxyadenosineINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 6 2002Saskia A. Bouwhuis MD Background, 2-Chlorodeoxyadenosine (2-CdA), a purine adenosine analog, is safe and effective chemotherapy for patients with hairy cell leukemia and low-grade lymphomas. Adverse effects include neutropenia, lymphocytopenia, and infectious complications. Our objective was to evaluate the efficacy of 2-CdA (2,6 seven-day cycles) in the treatment of late-stage, recalcitrant Sézary syndrome. Methods, Retrospective review of medical records of six patients with Sézary syndrome who had received 2-CdA cycles at Mayo Clinic, Rochester between March 1995 and March 2000. Variables assessed from the records included improvement in global appearance, extent of erythroderma, size of lymph nodes, pruritus, and leukocyte, lymphocyte, and absolute Sézary cell counts. Results, Two patients, both with stage III Sézary syndrome, whose previous treatment consisted of only two modalities, responded well to the treatment, with moderate to total clearing of erythroderma and pruritus associated with a significant decrease in Sézary cell counts. The other four patients had only a partial response (one patient) or no response (three patients) to 2-CdA. The mortality rate was 50%. All three patients died of Staphylococcus aureus sepsis. However, only one patient was receiving 2-CdA treatment when he died. The other two patients died 8 and 9 weeks after the last 2-CdA cycle. This high mortality rate is attributed to infectious complications after 2-CdA treatment in patients with recalcitrant disease. Conclusion, 2-Chlorodeoxyadenosine shows efficacy in stage III Sézary syndrome, but it also carries a substantial risk of septic complications and mortality. It can be used if no other suitable alternatives are available. Caution should be exercised in all these patients regarding skin care and avoidance of infections or sepsis. [source] Mucous membrane pemphigoid, thymoma, and myasthenia gravisINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 9 2000Haideh Yazdani Sabet In November 1997, approximately 1 year before being evaluated at the Mayo Clinic, Rochester, a 63-year-old woman presented with erosive tongue lesions that were diagnosed by her physician as oral lichen planus. The lesions responded well to 3 months of treatment with systemic and topical corticosteroids and topical antiyeast medication. She stopped taking the medications and had a relapse. A few months after the oral lesions developed, her left eyelid became ptotic. Results of magnetic resonance imaging of her brain were normal, and the ptosis resolved spontaneously after 2 weeks. One year later, her right eyelid began to droop, and the results of edrophonium testing were positive. She was prescribed prednisone, 30 mg daily, and pyridostigmine, as needed. The ptosis improved, but never fully resolved. Radiography revealed a left ,,thyroid nodule,'' but computed tomography did not show a mediastinal mass. She was advised to have the ,,nodule'' removed surgically and came to the Mayo Clinic, Rochester, for a second opinion. Her medical history was significant for the following: tinnitus, glaucoma, early bilateral cataracts, and long-standing hypertension, for which she took losartan, 50 mg twice daily. Other medications included: prednisone, 30 mg daily; pyridostigmine as needed; famotidine, 40 mg daily; and eyedrops for glaucoma. She denied any history of hyperthyroidism or hypothyroidism, head and neck irradiation, family history of thyroid disease, or diplopia. Hepatitis serologic studies revealed hepatitis B exposure and recovery, hepatitis C immunity, and a previous hepatitis A viral infection. On examination at the Mayo Clinic, Rochester, an erosive hypertrophic plaque was noted on the posterior dorsal half of the tongue, and vesicles and erythematous erosions on the hard and soft palates ( Fig. 1a). A lace-like white pattern was seen on the buccal mucosa bilaterally, and a small erosive patch on the left buccal mucosa ( Fig. 1b). Ocular and nasal mucous membranes were normal in appearance, and there were no pertinent skin findings. Dermatopathologic examination of an excisional biopsy specimen from the left dorsum of the tongue demonstrated an ulcer with epitheliomatous hyperplasia and a granulomatous reaction, presumably due to yeast infection. Silver staining showed hyphae and yeast at the base of the tongue ulcer. The results of the direct immunofluorescence study were negative and revealed no lichenoid changes on hematoxylin and eosin staining. Indirect immunofluorescence testing of the serum revealed a 1 : 80 titer of basement membrane zone antibodies, reflecting pemphigoid. This test was positive on repeat study. Salt-split skin on monkey esophagus revealed an epidermal pattern of basement membrane zone antibodies. Treatment included fluocinonide gel applied to the involved areas four times daily and oral antiyeast therapy (fluconazole, 200 mg once daily by mouth) while the rest of the evaluation was being completed. Figure 1(a). Erosive hypertrophic tongue plaque. Figure (b) ,. Erosive patch on the buccal mucosa. As part of the evaluation of the ptosis, a myasthenia gravis antibody panel was performed. It revealed the following abnormalities: striated muscle antibody at 1 : 480 (reference range, <1 : 60), acetylcholine receptor binding antibody at 6.33 nmol/L (reference range, ,,0.02 nmol/L), acetylcholine receptor blocking antibody at 31% (reference range, 0,25%), and acetylcholine receptor modulating antibody at 100% (reference range, 0,20%), suggesting thymoma. Treatment included pyridostigmine, 30,45 mg 3,4 times daily, to control the myasthenia symptoms, while the ill-defined neck mass was being evaluated. A mildly enlarged thyroid was noted on physical examination. Hematology panel revealed thyroid-stimulating hormone (TSH) levels in the low normal range; the thyroid microsomal antibody was normal. Chest radiography showed minor tracheal deviation, and a previous computed tomogram showed what appeared to be a 3-cm enlarged mass in the thyroid. Ultrasonographically guided thyroid biopsy did not show malignancy, but a benign mesenchymal-type tumor was found and surgical excision was planned. Intraoperatively, a thymoma of the left cervical thymic tongue was found. At 6 months' follow-up, the ptosis and oral mucosal lesions had improved significantly, although she continued topical corticosteroid therapy intermittently for minor erosive oral disease. [source] Effect of Radiofrequency Ablation of Atrial Flutter on the Natural History of Subsequent Atrial ArrhythmiasJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 11 2008DAVID M. LURIA M.D. Introduction: Patients with atrial flutter (AFL) treated medically are at high risk for subsequent development of atrial fibrillation (AF). Whether curative radiofrequency ablation of AFL can modify the natural history of arrhythmia progression is not clear. We aimed to determine whether ablation of AFL decreases the subsequent development of AF in patients without previous AF. Methods and Results: Patients with AFL as the sole atrial arrhythmia were selected from patients who underwent successful AFL ablation at Mayo Clinic between 1997 and 2003 (N = 137). The cohort was divided by presence (n = 50) or absence (n = 87) of structural heart disease. A control group comprised 59 patients with AFL and no history of paroxysmal AF, who received only medical therapy. Occurrence of AF after AFL ablation was compared among study groups and controls. Symptomatic AF occurred in 49 patients during 5 years of follow-up after AFL ablation, with similar frequency in both study groups. The cumulative probability of paroxysmal and chronic AF was similar in controls and each study group. By multivariate analysis, the AFL ablation procedure carries significant risk of AF occurrence during follow-up. Fifty patients discontinued antiarrhythmic drugs after AFL ablation, and the rate of cardioversions decreased. Conclusion: Successful ablation of AFL does not improve the natural history of atrial arrhythmia progression; postablation AF is frequent. This suggests that AFL may be initiated by bursts of AF and that in the absence of AFL substrate the AF continues to progress. [source] Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleedingJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 1 2006Gavin C Harewood Abstract Introduction:, Endoscopic obliteration of esophageal varices by endoscopic variceal ligation (EVL) is an effective form of secondary prophylaxis. However, there is no consensus regarding the technical aspects of EVL for secondary prophylaxis. The present study compares the technical aspects of EVL (frequency of sessions, number of sessions and number of bands used) in patients who rebled following secondary prophylaxis of esophageal varices by EVL compared to those who did not rebleed. Methods:, All patients who underwent EVL for treatment of acute variceal bleeding followed by EVL for secondary prophylaxis and who subsequently developed recurrent variceal bleeding at Mayo Clinic, Rochester between January 1995 and May 2003 were identified. A control group of patients undergoing EVL for secondary prophylaxis who did not rebleed was identified. Results:, During the study period, 216 patients with acute esophageal variceal hemorrhage underwent emergent EVL treatment with follow-up EVL for secondary prophylaxis, of whom 20 (9.3%) subsequently rebled. Both rebleeding and non-rebleeding patient groups were well-matched with respect to liver function (Child,Pugh class), number and size of variceal trunks, endoscopic stigmata of hemorrhage and beta-blocker usage. The median interval between EVL sessions in the rebleeding group (2 weeks, interquartile range 0,2 weeks) was significantly shorter compared to the non-rebleeding group (5 weeks, interquartile range 3,7 weeks; P = 0.004). Adjusting for age, gender, and Child,Pugh class, interbanding interval , 3 weeks was associated with increased likelihood of not rebleeding, hazard ratio 3.84 (95% confidence interval: 1.69,11.79; P = 0.0007). Conclusions:, These findings demonstrate the importance of technical aspects of EVL on patient outcome, suggesting the benefit of longer interbanding intervals. Future prospective studies are required to define the optimal intersession interval. Standardizing procedural aspects of EVL will aid in objectively evaluating the benefit of this procedure when compared to other modalities such as medical treatment. [source] Enduring leadership: Lessons from the Mayo ClinicLEADER TO LEADER, Issue 52 2009Kent D. Seltman [source] Recurrence of primary sclerosing cholangitis after liver transplantationLIVER TRANSPLANTATION, Issue 7 2002Ivo W. Graziadei MD Orthotopic liver transplantation (OLT) has become the only effective therapeutic option for patients with end-stage liver disease caused by primary sclerosing cholangitis (PSC). Excellent long-term outcome has been reported, with 5-year patient survival rates of approximately 80%. In the last few years, increasing evidence has emerged that PSC recurs after OLT. The diagnosis of PSC is based on well-defined cholangiographic features combined with biochemical and histological findings. However, none of these features is specific for PSC, particularly after OLT, because biliary strictures in the liver allograft can occur from a variety of causes other than recurrence. Therefore, PSC recurrence remains a controversial issue, especially because of a lack of a gold standard for diagnosis and well-established diagnostic criteria. Some reports provided cholangiographic evidence that post-OLT biliary strictures occurred more frequently in patients with PSC than in those who underwent OLT for other liver diseases (including patients with a Roux-en-Y biliary reconstruction). Because no other possible cause of biliary strictures could be invoked to explain the greater prevalence of these strictures, recurrent disease has been implicated. There also is histological evidence suggesting that PSC recurs after OLT. Histological findings suggestive of PSC were found more often in PSC allografts compared with a control group. Furthermore, histological features typical for PSC (fibro-obliterative lesions) were seen exclusively in liver biopsy specimens from patients with PSC. Recurrence of PSC was defined in a recent study from the Mayo Clinic by means of strict cholangiographic and histological criteria in a large cohort of patients with PSC in whom other causes of biliary strictures were excluded. PSC recurrence was found in 20% of patients. No risk factor for PSC recurrence could be found, and recurrent disease did not influence patient or graft survival after a mean follow-up of 4.5 years. In conclusion, several studies provided convincing evidence that PSC recurs after OLT, with an incidence of 5% to 20% and an interval to diagnosis of at least 1 year after OLT. To date, patient and graft survival do not appear to be negatively affected by disease recurrence in the intermediate term of follow-up. (Liver Transpl 2002;8:575-581.) [source] Prolonged disease-free survival after orthotopic liver transplantation plus adjuvant chemoirradiation for cholangiocarcinomaLIVER TRANSPLANTATION, Issue 3 2000Ilja De Vreede Orthotopic liver transplantation (OLT) alone for unresectable cholangiocarcinoma is often associated with early disease relapse and limited survival. Because of these discouraging results, most programs have abandoned OLT for cholangiocarcinoma. However, a small percentage of patients have achieved prolonged survival after OLT, suggesting that adjuvant approaches could perhaps improve the survival outcome. Based on these concepts, a protocol was developed at the Mayo Clinic using preoperative irradiation and chemotherapy for patients with cholangiocarcinoma. We report our initial results with this pilot experience. Patients with unresectable cholangiocarcinoma above the cystic duct without intrahepatic or extrahepatic metastases were eligible. Patients initially received external-beam irradiation plus bolus fluorouracil (5-FU), followed by brachytherapy with iridium and concomitant protracted venous infusion of 5-FU. 5-FU was then administered continuously through an ambulatory infusion pump until OLT. After irradiation, patients underwent an exploratory laparotomy to exclude metastatic disease. To date, 19 patients have been enrolled onto the study and have been treated with irradiation. Eight patients did not go on to OLT because of the presence of metastasis at the time of exploratory laparotomy (n = 6), subsequent development of malignant ascites (n = 1), or death from intrahepatic biliary sepsis (n = 1). Eleven patients completed the protocol with successful OLT. Except for 1 patient, all had early-stage disease (stages I and II) in the explanted liver. All patients who underwent OLT are alive, 3 patients are at risk at 12 months or less, and the remaining 8 patients have a median follow-up of 44 months (range, 17 to 83 months; 7 of 9 patients > 36 months). Only 1 patient developed tumor relapse. OLT in combination with preoperative irradiation and chemotherapy is associated with prolonged disease-free and overall survival in highly selected patients with early-stage cholangiocarcinoma. [source] Effects of Scatter Radiation on ICD and CRT FunctionPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2008SURAJ KAPA M.D. Background: Effects of direct radiation on implantable cardiac devices have been well studied. However, the effects of scatter radiation are not as clear. Recommendations on management of patients with implantable cardiac devices undergoing radiotherapy are based on limited studies mostly involving pacemakers. We sought to elucidate the effects of scatter radiation on implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT)-ICDs. Methods: We exposed 12 ICDs and eight CRT-ICDs to 400 cGy of scatter radiation from a 6-MV photon beam. Devices were programmed with nominal parameters and interrogated prior to radiation, after each fraction, upon completion of the radiation course and again 1 week later. A retrospective review of patients undergoing radiotherapy at the Mayo Clinic,Rochester between 2002 and 2007 in whom the device was outside the radiation field was also performed. There were 13 patients with devices undergoing radiotherapy during this time period, 12 of whom were interrogated prior to and after radiation. Results: Interrogation reports were reviewed for device reset or parameter changes. There was no evidence of reset or malfunction during or after radiation. Also, no episodes of device reset, inappropriate sensing or therapy, or changes in programmed parameters were found in our review of patients undergoing radiotherapy. Conclusions: Device reset or malfunction associated with scatter radiation likely represents an unpredictable, rare occurrence. While we see no clear contraindication to radiotherapy in patients with ICDs or CRT-ICDs, precautions should be taken to avoid direct radiation exposure and to closely evaluate patient outcomes before and after the radiation course. [source] Clarithromycin (Biaxin)-lenalidomide-low-dose dexamethasone (BiRd) versus lenalidomide-low-dose dexamethasone (Rd) for newly diagnosed myelomaAMERICAN JOURNAL OF HEMATOLOGY, Issue 9 2010Francesca Gay The objective of this case-matched study was to compare the efficacy and toxicity of the addition of clarithromycin (Biaxin) to lenalidomide/low-dose dexamethasone (BiRd) vs. lenalidomide/low-dose dexamethasone (Rd) for newly diagnosed myeloma. Data from 72 patients treated at the New York Presbyterian Hospital-Cornell Medical Center were retrospectively compared with an equal number of matched pair mates selected among patients seen at the Mayo Clinic who received Rd. Case matching was blinded and was performed according to age, gender, and transplant status. On intention-to-treat analysis, complete response (45.8% vs. 13.9%, P < 0.001) and very-good-partial-response or better (73.6% vs. 33.3%, P < 0.001) were significantly higher with BiRd. Time-to-progression (median 48.3 vs. 27.5 months, P = 0.071), and progression-free survival (median 48.3 vs. 27.5 months, P = 0.044) were higher with BiRd. There was a trend toward better OS with BiRd (3-year OS: 89.7% vs. 73.0%, P = 0.170). Main grade 3,4 toxicities of BiRd were hematological, in particular thrombocytopenia (23.6% vs. 8.3%, P = 0.012). Infections (16.7% vs. 9.7%, P = 0.218) and dermatological toxicity (12.5% vs. 4.2%, P = 0.129) were higher with Rd. Results of this case-matchedanalysis suggest that there is significant additive value when clarithromycin is added to Rd. Randomized phase III trials are needed to confirm these results. Am. J. Hematol., 2010. © 2010 Wiley-Liss, Inc. [source] MULTIDISCIPLINARY PAIN ABSTRACTS: 26PAIN PRACTICE, Issue 1 2004Article first published online: 15 MAR 200 The objective of this study was to examine the incidence, prevalence, natural history, and response to treatment of complex regional pain syndrome (CRPS). All Mayo Clinic and Olmsted Medical Group medical records with codes for reflex sympathetic dystrophy (RSD), CRPS, and compatible diagnoses in the period 1989,1999 were reviewed as part of the Rochester Epidemiology Project. The authors used IASP criteria for CRPS. The study population was in the Olmsted County, Minnesota (1990 population, 106,470). The main outcome measures were CRPS-I incidence, prevalence, and outcome. Seventy-four cases of CRPS-I were identified, resulting in an incidence rate of 5.46 per 100,000 person years at risk, and a period prevalence of 20.57 per 100,000. Female: male ratio was 4 : 1, with a median age of 46 years at onset. Upper limb was affected twice as commonly as lower limb. All cases reported an antecedent event and fracture was the most common trigger (46%). Excellent concordance was found between symptoms and signs; vasomotor symptoms were the most commonly present. The authors concluded that CRPS-I is of low prevalence, more commonly affects women than men, the upper more than the lower extremity, and three out of four cases undergo resolution. These results suggest that invasive treatment of CRPS may not be warranted in the majority of cases. [source] Chromosome 8p11.2 translocations: Prevalence, FISH analysis for FGFR1 and MYST3, and clinicopathologic correlates in a consecutive cohort of 13 cases from a single institution,AMERICAN JOURNAL OF HEMATOLOGY, Issue 4 2010Mrinal M. Patnaik Chromosome 8p11.2 translocations result in diverse oncogenic fusion genes involving FGFR1 or MYST3. Among 24,262 unique patient cytogenetic studies performed at the Mayo Clinic, 8p11.2 translocations were identified in 14 cases (,0.06%). FISH analysis was performed in 13 patients (12 had myeloid neoplasms) and revealed abnormalities of MYST3 (n = 4) or FGFR1 (n = 4) in eight patients. MYST3 abnormalities were associated with acute myeloid leukemia (AML), M4 in three and M6 in one. Three of the four FGFR1 -rearranged cases were associated with myeloproliferative neoplasms but none, including the two with sole 8p11.2, displayed the typical phenotype for stem cell leukemia/lymphoma (SCLL) and only one had eosinophilia; the fourth case had AML-M4. FISH did not reveal FGFR1 involvement in the one patient with SCLL. We conclude that neither the SCLL phenotype nor blood eosinophilia is a consistent feature of FGFR1 -associated 8p11.2 translocations; conversely, FISH might not always reveal FGFR1 involvement in typical SCLL. Am. J. Hematol. 2010. © 2010 Wiley-Liss, Inc. [source] Host immunity affects survival in myelodysplastic syndromes: Independent prognostic value of the absolute lymphocyte count,AMERICAN JOURNAL OF HEMATOLOGY, Issue 3 2010Nisha L. Jacobs The prognostic significance of the peripheral blood absolute lymphocyte count (ALC) has been carefully examined in lymphoid malignancies, but the importance of the baseline ALC in chronic myeloid neoplasms is less clear. In a recent analysis of myelodysplastic syndromes (MDS) associated with deletion of chromosome 5q, we observed that an ALC < 1.2× 109 cells/L at diagnosis is independently associated with poorer survival. Clinicopathological data from 503 patients with non-del(5q) MDS evaluated at Mayo Clinic between 1996 and 2007 were reviewed to determine the prognostic impact of ALC at diagnosis in non-del(5q) MDS. Patients with MDS and an ALC at diagnosis ,1.2× 109 (N = 248) experienced a superior overall survival (OS) compared with patients with an ALC < 1.2× 109/L (N = 255, median OS of 26.6 months versus 18.5 months, P < 0.001, respectively). ALC at diagnosis was an independent predictor for OS when compared with the International Prognostic Scoring System and the WHO-based Prognostic Scoring System. This study suggests that ALC at diagnosis is a prognostic factor for OS in MDS, and argues in favor of further studies to assess the role of host immunity in MDS clinical outcomes. Am. J. Hematol. 2010. © 2009 Wiley-Liss, Inc. [source] Idiotype-pulsed antigen presenting cells following autologous transplantation for multiple myeloma may be associated with prolonged survival,AMERICAN JOURNAL OF HEMATOLOGY, Issue 12 2009Martha Q. Lacy Vaccines are attractive as consolidation therapy after autologous stem cell transplantation (ASCT) for multiple myeloma (MM). We report the results of a phase II trial of the immunotherapeutic, APC8020 (MylovengeÔ), given after ASCT for MM. We compared the results with that of other patients with MM who underwent ASCT at Mayo Clinic during the same time period. Twenty-seven patients were enrolled on the trial between July, 1998 and June, 2001, and the outcomes were compared to that of 124 consecutive patients transplanted during the same period, but not enrolled on the trial. The median (range) follow-up for patients still alive from the vaccine trial is 6.5 (2.9,8 years), and 7.1 (6,8 years) in the control group. The median age was 57.4 range (36.1,71.3) in the DB group and 56.4 (range, 30,69) in the trial group. Known prognostic factors including PCLI, B2M, and CRP were comparable between the groups. The median overall survival for the trial patients was 5.3 years (95% CI: 4.0 years,N/A) compared to 3.4 years (95% CI: 2.7,4.6 years) for the DB group (P = 0.02). The median time to progression and progression-free survival for the trial group was similar to the DB group. Although not a controlled trial, the vaccines given after ASCT appear to be associated with improved overall survival compared to historical controls. This approach warrants further investigation to confirm this and define the role of vaccine therapy in myeloma. Am. J. Hematol. 2009. © 2009 Wiley-Liss, Inc. [source] Acute weight gain and diastolic dysfunction as a potent risk complex for post stem cell transplant atrial fibrillation,AMERICAN JOURNAL OF HEMATOLOGY, Issue 8 2009Kaniz Fatema The management of atrial fibrillation (AF) following stem cell transplant (SCTX) is often challenging because of the universal presence of profound bone marrow suppression. The incidence of and risk factors for AF/flutter following SCTX are not well known. A total of 395 multiple myeloma (MM) patients consecutively underwent SCTX between 2002 and 2005 at the Mayo Clinic, and 383 of whom, mean age 57 ± 9 years, had no history of evidence of AF/flutter constituted the study population. During 1,002 person-years of follow up, 39 (10%) patients developed first AF/flutter (incidence of 39 per 1,000 person years), and 28 of these (72%) occurred within 21 days of SCTX. In multivariable-adjusted analyses, weight gain of ,7% in the 1st week post-SCTX (HR 3.68; P = 0.0120) and presence of diastolic dysfunction at MM diagnosis (HR 2.294; P = 0.0082) were independent predictors of AF/flutter. The risk of AF/flutter post-SCTX increased by about ninefold when both factors were present. Compared to age and sex-matched MM patients without SCTX, the risk of AF/flutter differed significantly only over the 1st year after MM diagnosis, during which SCTX was performed for the majority. Beyond the 1st year, there was no significant difference in risk of AF/flutter between the two groups. The data suggested that SCTX was associated with significantly increased risk of first AF/flutter, which typically occurred within the first 21 days of the transplant. Weight gain of ,7% was strongly predictive of first AF/flutter, and the risk was augmented by the presence of diastolic dysfunction at baseline. Am. J. Hematol. 2009. © 2009 Wiley-Liss, Inc. [source] Absolute lymphocyte count at the time of first relapse predicts survival in patients with diffuse large B-cell lymphomaAMERICAN JOURNAL OF HEMATOLOGY, Issue 2 2009Luis F. Porrata Peripheral blood absolute lymphocyte count (ALC) is a survival prognostic factor in hematological malignancies. No reports have addressed whether ALC at the time of first relapse (ALC-R) predicts survival. Thus, we assessed the prognostic significance of ALC-R in diffuse large B-cell lymphoma (DLBCL). Patients were required to have been diagnosed with first relapsed DLBCL, have ALC-R values, and to be followed at Mayo Clinic, Rochester. From Feb 1987 until March 2006, 97 first relapsed DLBCL patients qualified for the study. The overall survival (OS) and progression-free survival (PFS) were measured from the time of first relapse. The value of ALC- R , 1.0 × 109/L was used for the analysis. Both groups (ALC-R , 1 or < 1 × 109/L) were balanced for the international prognostic index at relapse (IPI-R) (P = 0.3), and for autologous stem cell transplantation (P = 0.4). Superior OS and PFS were observed with an ALC-R , 1.0 × 109/L (N = 60) versus ALC-R < 1.0 × 109/L (N = 37) [median OS: 28.7 months, 5 years OS rates of 39% versus median OS: 10.2 months, 5 years OS rates of 14%, P < 0.002; and median PFS: 14.8 months, 5 years PFS rates of 21% versus median PFS: 6.5 months, 5 years PFS rates of 8%, P < 0.004, respectively]. ALC-R was an independent prognostic factor for OS [RR = 0.4, P < 0.01] and PFS [RR = 0.5, P < 0.005]. ALC-R predicts survival suggesting that host immunity is an important variable predicting survival in first relapsed DLBCL. Am. J. Hematol. 2009. © 2008 Wiley-Liss, Inc. [source] Management Lessons From Mayo Clinic: Inside One of the World's Most Admired Service Organizations by Leonard L. Berry and Kent D. SeltmanPERSONNEL PSYCHOLOGY, Issue 2 2009Article first published online: 12 MAY 200 First page of article [source] In Newly Diagnosed Breast Cancer, Screening MRI of the Contralateral Breast Detects Mammographically Occult Cancer, Even in Elderly Women: The Mayo Clinic in Florida ExperienceTHE BREAST JOURNAL, Issue 2 2010Johnny Ray Bernard Jr MD Abstract:, The role of magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer is somewhat controversial. The purpose of this study was to evaluate the prevalence of synchronous, occult contralateral breast cancer detected by MRI but not by mammography or clinical breast examination in women with newly diagnosed breast cancer, including those aged 70 years or older at our institution. MRI results for women with newly diagnosed breast cancer who underwent bilateral breast MRI after negative mammography and clinical examination between February 2003 and November 2007 at Mayo Clinic in Florida were reviewed. The prevalence of pathologically confirmed contralateral carcinoma diagnosed solely by MRI was determined and analyzed in the context of age, family history, menopausal status, breast density, and primary-tumor characteristics. Logistic regression was used to explore the association between contralateral carcinoma and potential patient risk factors. A total of 425 women were evaluated, of whom 129 (30%) were aged 70 years or older. A contralateral biopsy was recommended and performed solely on the basis of MRI in 72 of the 425 women (17%). Sixteen of these 72 women (22%) had pathologically confirmed carcinoma, including seven in the older subgroup. The prevalence of clinically and mammographically occult contralateral carcinoma detected by MRI was 3.8% (16/425) overall and 5.4% (7/129) in the group of older women. When potential risk factors for contralateral breast cancer were evaluated, postmenopausal status was the only significant predictor of contralateral cancer detected by MRI (p = 0.016). We concluded that contralateral breast screening with MRI should be considered in postmenopausal women with newly diagnosed breast cancer, even those aged 70 years or older at diagnosis. [source] Cochlear Implants in Five Cases of Auditory Neuropathy: Postoperative Findings and Progress,THE LARYNGOSCOPE, Issue 4 2001Jon K. Shallop PhD Abstract Objectives To review our experiences with some of the preoperative and postoperative findings in five children who were diagnosed with auditory neuropathy and were provided with cochlear implants. We describe changes in auditory function, which enabled these children to have significant improvement in their hearing and communication skills. Study Design Pre- and postoperatively, these children received complete medical examinations at Mayo Clinic, including related consultations in audiology, pediatrics, neurology, medical genetics, otolaryngology, psychology, speech pathology, and radiology. Methods These children typically had additional medical and audiological examinations at more than one medical center. The hearing assessments of these children included appropriate behavioral audiometric techniques, objective measures of middle ear function, acoustic reflex studies, transient (TOAE) or distortion product (DPOAE) otoacoustic emissions, auditory brainstem responses (ABR), and, in some cases, transtympanic electrocochleography (ECoG). After placement of the internal cochlear implant devices (Nucleus CI24), intraoperatively we measured electrode impedances, visually detected electrical stapedius reflexes (VESR) and neural response telemetry (NRT). These intraoperative objective measures were used to help program the speech processor for each child. Postoperatively, each child has had regular follow-up to assure complete healing of the surgical incision, to assess their general medical conditions, and for speech processor programming. Their hearing and communication skills have been assessed on a regular basis. Postoperatively, we have also repeated electrode impedance measurements, NRT measurements, otoacoustic emissions, and electrical auditory brainstem responses (EABR). We now have 1 year or more follow-up information on the five children. Results The five children implanted at Mayo Clinic Rochester have not had any postoperative medical or cochlear implant device complications. All of the children have shown significant improvements in their sound detection, speech perception abilities and communication skills. All of the children have shown evidence of good NRT results. All but case D (who was not tested) showed evidence of good postoperative EABR results. Otoacoustic emissions typically remained in the non-operated ear but, as expected, they are now absent in the operated ear. Conclusion Our experiences with cochlear implantation for children diagnosed with auditory neuropathy have been very positive. The five children we have implanted have not had any complications postoperatively, and each child has shown improved listening and communication skills that have enabled each child to take advantage of different communication and educational options. [source] Incidence Rate and Outcome of Gram-Negative Bloodstream Infection in Solid Organ Transplant RecipientsAMERICAN JOURNAL OF TRANSPLANTATION, Issue 4 2009M. N. Al-Hasan Bacterial infections are common complications of solid organ transplantation (SOT). In this study, we defined the incidence, mortality and in vitro antimicrobial resistance rates of Gram-negative bloodstream infection (BSI) in SOT recipients. We identified 223 patients who developed Gram-negative BSI among a cohort of 3367 SOT recipients who were prospectively followed at the Mayo Clinic (Rochester, MN) from January 1, 1996 to December 31, 2007. The highest incidence rate (IR) of Gram-negative BSI was observed within the first month following SOT (210.3/1000 person-years [95% confidence interval (CI): 159.3,268.3]), with a sharp decline to 25.7 (95% CI: 20.1,32.1) and 8.2 (95% CI: 6.7,10.0) per 1000 person-years between 2 and 12 months and more than 12 months following SOT, respectively. Kidney recipients were more likely to develop Gram-negative BSI after 12 months following transplantation than were liver recipients (10.3 [95% CI: 7.9,13.1] vs. 5.2 [95% CI: 3.1,7.8] per 1000 person-years). The overall unadjusted 28-day all-cause mortality of Gram-negative BSI was 4.9% and was lower in kidney than in liver recipients (1.6% vs. 13.2%, p < 0.001). We observed a linear trend of increasing resistance among Escherichia coli isolates to fluoroquinolone antibiotics from 0% to 44% (p = 0.002) throughout the study period. This increase in antimicrobial resistance may influence the choice of empiric therapy. [source] The Impact of Obesity on Long-term Outcomes in Liver Transplant Recipients,Results of the NIDDK Liver Transplant DatabaseAMERICAN JOURNAL OF TRANSPLANTATION, Issue 3 2008J. Leonard The impact of obesity on outcomes following liver transplantation has been difficult to determine, in part due to the confounding effects of ascites on BMI. We evaluated the impact of pretransplant recipient obesity on outcomes following liver transplantation using the NIDDK Liver Transplantation Database. Pretransplant BMI, corrected for ascites, was categorized as underweight (BMI <18 kg/m2), normal weight (BMI 18,25 kg/m2), overweight (BMI 25.1,30 kg/m2), Class I obese (BMI 30.1,35 kg/m2), Class II obese (BMI 35.1,40 kg/m2) and Class III obese (BMI >40 kg/m2). Primary outcomes were patient and graft survival. Secondary outcomes included days in hospital and days in ICU. Data from 704 adult liver transplant recipients from the NIDDK LTD and a further 609 patients from the Mayo Clinic were analyzed. Early and late patient and graft survival was similar across all BMI categories. Correcting for ascites volume resulted in 11,20% of patients moving into a lower BMI classification. The relative risk for mortality increased by 7% for each liter of ascites removed. We conclude that corrected BMI is not independently predictive of patient or graft survival. Obesity, within the ranges observed in this study, should not be considered to be a contraindication to liver transplantation in the absence of other relative contraindications. [source] Prediction of survival using absolute lymphocyte count for newly diagnosed patients with multiple myeloma: a retrospective studyBRITISH JOURNAL OF HAEMATOLOGY, Issue 6 2008Hilmi Ege Summary Absolute lymphocyte count (ALC) recovery after autologous stem cell transplantation for multiple myeloma (MM) has been reported to be an independent prognostic factor for clinical outcome. The role of ALC on survival in newly diagnosed untreated MM patients is unknown. Between 1994 and 2002, we analysed retrospectively 537 MM patients of 1835 consecutive MM patients that were neither uniformly treated nor part of a clinical trail, but originally diagnosed and followed at the Mayo Clinic. The primary endpoint was to assess the role of ALC at the time of MM diagnosis on overall survival (OS). The median follow-up was 35·1 months (range: 1,152·5 months). ALC, as a continuous variable, was identified as prognostic factor for OS (Hazard ratio = 0·473, 95% confidence interval = 0·359,0·618, P < 0·0001). MM patients with an ALC ,1·4 × 109/l experienced superior OS compared with MM patients with an ALC <1·4 × 109/l (65 vs. 26 months, P < 0·0001). Multivariate analysis identified ALC as an independent prognostic factor for OS. This study showed that, in newly diagnosed MM, ALC is an independent prognostic factor for OS, suggesting a significant role of host immune status in the survival of MM. [source] Timing of autologous stem cell transplantation from last chemotherapy affects lymphocyte collection and survival in non-Hodgkin lymphomaBRITISH JOURNAL OF HAEMATOLOGY, Issue 6 2006Shernan G. Holtan Summary Autograft absolute lymphocyte count (A-ALC) is a prognostic factor for survival in non-Hodgkin lymphoma (NHL) after autologous stem cell transplantation (ASCT). An A-ALC is dependent upon the preaphaeresis absolute lymphocyte count (PA-ALC) at the time of aphaeresis. It was hypothesised that the time interval from last chemotherapy (TILC) to aphaeresis affects PA-ALC. One hundred and sixty consecutive NHL patients who underwent ASCT at the Mayo Clinic between 1996 and 2001 were evaluated. A strong correlation between TILC and PA-ALC (r = 0·67, P < 0·0001) was identified. Higher PA-ALC was observed in TILC ,55 d compared with TILC <55 d [median: 7·0 vs. 3·8 × 109/l], P < 0·0001). TILC as a continuous variable was identified as a prognostic factor for overall survival (OS) [hazard ratio (HR) = 0·989, P < 0·01] and progression-free survival (PFS) (HR = 0·992, P < 0·0492). Median OS and PFS were longer in the TILC ,55 d vs. TILC <55 d group (not reached vs. 21 months, P < 0·0008; 76 vs. 9 months, P < 0·0025, respectively). Multivariate analysis demonstrated TILC to be an independent prognostic indicator for OS and PFS. These findings suggest that the immune status of the host at the time of aphaeresis may predict survival after ASCT. [source] Malignant risk and surgical outcomes of presacral tailgut cysts,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 4 2010K. L. Mathis Background: Presacral tailgut cysts are uncommon and few data exist on the outcomes following surgery. Methods: Patients undergoing tailgut cyst resection at the Mayo Clinic between 1985 and 2008 were analysed retrospectively. Demographic data, clinicopathological features, operative details, postoperative complications and recurrence were reviewed. Results: Thirty-one patients were identified (28 women), with a median age of 52 years. Seventeen patients were symptomatic and 28 had a palpable mass on digital rectal examination. Median cyst diameter was 4·4 cm. Four patients had a fistula to the rectum. Complete cyst excision was achieved in all patients; eight underwent distal sacral resection or coccygectomy. Postoperative complications occurred in eight patients but without 30-day mortality. Malignant transformation was present in four patients: adenocarcinoma in three and carcinoid in one. The cyst recurred in one patient after surgery for a benign lesion. Conclusion: Presacral tailgut cysts should be removed due to the risk of malignant transformation. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Thromboembolic events with lenalidomide-based therapy for multiple myelomaCANCER, Issue 7 2008Smitha Patiyil Menon MBBS Abstract BACKGROUND. The purpose was to evaluate the incidence and risk factors of thromboembolism associated with lenalidomide therapy in newly diagnosed myeloma. METHODS. A pooled analysis was performed of patients with previously untreated multiple myeloma enrolled in clinical trials of lenalidomide-based therapy at the Mayo Clinic, Rochester, Minnesota, and the Italian Myeloma Network, Italy. The incidence of thrombosis, the effect of risk factors such as steroid dose and erythropoietin supplementation, and the effect of prophylaxis were examined. RESULTS. In all, 125 patients enrolled in 3 clinical trials were identified. Patients were stratified based on the concomitant corticosteroid dose. Fifty-two patients were in the high-dose group (dexamethasone 40 mg, 12 days a month); 73 patients were in the low-dose group (prednisone at any dose; or dexamethasone 40 mg, 4 days a month). A total of 110 patients were initiated on thromboprophylaxis; of these, 104 patients (95%) received aspirin. Ten patients (8%) developed deep vein thrombosis, including 4 who were not receiving any thromboprophylaxis at the time of the event. The rate of thromboembolic events was not different between patients who received concomitant erythropoietin therapy and those who did not, 4.8% and 8.6%, respectively (P = .54). A higher number of venous thrombotic episodes occurred in the high-dose corticosteroid group compared with the low-dose corticosteroid therapy group (12% vs 6%), but the difference was not statistically significant (P = .3). CONCLUSIONS. The incidence of deep vein thrombosis is lower than previously reported in the literature. There was a trend to a higher incidence of thrombosis in patients receiving high-dose corticosteroid therapy. Cancer 2008. © 2008 American Cancer Society. [source] Palliative goals, patient selection, and perioperative platelet management: Outcomes and lessons from 3 decades of splenectomy for myelofibrosiswith myeloid metaplasia at the Mayo ClinicCANCER, Issue 2 2006Ruben A. Mesa MD Abstract BACKGROUND. Although splenectomy may palliate massive splenomegaly in patients with myelofibrosis with myeloid metaplasia, this procedure carries significant risks. The authors retrospectively analyzed their experience with splenectomy over the course of 30 years to analyze the impact of improved techniques, antimicrobials, and aggressive postoperative control of platelet counts on outcome. METHODS. A total of 314 patients underwent splenectomy between 1976 and 2004 for mechanical symptoms (= 156 patients [49%]), anemia (= 78 patients [25%]), portal hypertension (= 47 patients [15%]), or thrombocytopenia (= 33 patients [11%]). Of a total of 91 patients studied during the last decade, 69 patients (76%) experienced a palliative benefit for their primary surgical indication for a median of 12 months (range, 1-91 months). RESULTS. Perioperative complications occurred in 87 patients (27.7%) including infection (= 31 patients [9.9%]), thrombosis (= 31 patients [9.9%]), or bleeding (= 44 patients [14%]), 21 of which (6.7% of all patients) were fatal. Perioperative thrombohemorrhagic complications decreased in the last decade through the use of platelet apheresis and the prompt use of cytoreductive agents to counteract postsplenectomy thrombocytosis. Survival after splenectomy was found to be decreased in patients with preoperative thrombocytopenia (<100 × 109/L [P = 0.006]) but not by indication, myelofibrosis with myeloid metaplasia (MMM) prognostic score, or the decade in which splenectomy was performed. CONCLUSIONS. The lack of improvement in overall postsplenectomy survival over time may be a reflection on the failure of medical therapy to improve survival in patients with MMM. Cancer 2006. © 2006 American Cancer Society. [source] Small cell carcinoma of the urinary bladderCANCER, Issue 6 2005The Mayo Clinic experience Abstract BACKGROUND Small cell carcinoma (SCC) of the urinary bladder accounts for 0.35,0.70% of all bladder tumors. There is no standard approach to the management of SCC of the urinary bladder. METHODS The authors performed a retrospective study at Mayo Clinic (Rochester, MN) to characterize the clinical and pathologic features of patients with SCC of the urinary bladder diagnosed between 1975 and 2003 with emphasis on management. RESULTS Forty-four patients were identified who had primary bladder SCC, 61.4% of whom had pure SCC. The male:female ratio was 3:1, the mean age was 66.9 years, and the mean follow-up was 3.2 years. Twelve patients (27.3%) had Stage II disease, 13 patients (29.6%) had Stage III disease, and 19 patients (43.2%) had Stage IV disease. The overall median survival was 1.7 years. The 5-year survival rates for patients with Stage II, III, and IV disease were 63.6%, 15.4%, and 10.5%, respectively. Six of eight patients with Stage II bladder SCC achieved a cure with radical cystectomy. Five patients with Stage IV disease had obvious metastases and received chemotherapy. Fourteen patients underwent radical cystectomy and were diagnosed later with locally advanced disease (T4b) or lymph node metastasis (N1,N3; Stage IV disease). Only 2 of 19 patients with Stage IV disease who received adjuvant chemotherapy were alive at 5 years. CONCLUSIONS Patients with bladder SCC should undergo radical cystectomy except when metastatic disease is present (M1), in which case, systemic chemotherapy is indicated. Adjuvant treatment is not indicated for patients with Stage II disease after radical cystectomy but should be considered for patients with Stage III and IV disease. Chemotherapy should be a platinum-based regimen. Cancer 2005. © 2005 American Cancer Society. 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