Endoscopic ultrasound—guided fine needle aspiration in the diagnosis of mediastinal masses of unknown origin

The ability of endosonography to diagnose a variety of gastrointestinal pathology has been significantly advanced with the introduction of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy. EUS-FNA technology can also be applied to the evaluation of non-GI disorders. The role of EUS-FNA to establish the diagnosis of unexplained mediastinal masses has not been previously described. The aim of this study was to determine the diagnostic accuracy, impact on subsequent workup, and role of EUS-FNA in treating mediastinal masses of unknown cause. METHODS : A total of 26 patients (15 men and 11 women, mean age 61 yr, range 39–77 yr) underwent EUS-FNA in patients presenting with unexplained mediastinal masses at four tertiary referral centers. Presenting symptoms included: chest pain (10 patients), dysphagia (eight), cough (seven), fever (six), night sweats (three), and no symptoms/abnormal x-ray (five patients). Five of 26 patients had prior history of cancer (three lung, one tracheal, and one esophageal). RESULTS : Final diagnosis using EUS-FNA, surgery, autopsy, other diagnostic study, or long-term follow-up was available in all patients. EUS-FNA results were classified under three disease categories: 1) infectious, 2) benign/inflammatory, and 3) malignant. Final diagnosis included infectious in five patents, benign/inflammatory in nine, and malignant in 12. EUS-FNA was successful in 21 of 26 patients (81%) for all disease categories (infectious 60%, benign/inflammatory 78%, and malignant 92%). EUS-FNA was successful in directing subsequent workup in 77% (20 of 26) and therapy in 73% (19 of 26). Mean EUS-FNA passes for adequate tissue sampling was lower of nonmalignant disease categories (3.0 and 3.4) versus malignant disease (4.4). No complications were seen during the course of this study. CONCLUSIONS : EUS-FNA in patients presenting with idiopathic mediastinal masses establishes the diagnosis in the vast majority of cases, particularly for those with malignant disease. The emergence of transesophageal EUS-FNA of the mediastinum provides the ability to alter subsequent workup and therapy, obviating the need for more invasive diagnostic studies such as thoracotomy.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72588/1/j.1572-0241.2002.06023.x.pd

Clipless management of the renal vein during hand-assist laparoscopic donor nephrectomy

BACKGROUND: Laparoscopic live donor nephrectomy has become the preferred method of donor nephrectomy at many transplant centers. The laparoscopic stapling device is commonly used for division of the renal vessels. Malfunction of the stapling device can occur, and is often due to interference from previously placed clips. We report our experience with a clipless technique in which no vascular clips are placed on tributaries of the renal vein at or near the renal hilum in order to avoid laparoscopic stapling device misfires. METHODS: From December 20, 2002 to April 12, 2005, 50 patients underwent hand-assisted laparoscopic left donor nephrectomy (LDN) at our institution. Clipless management of the renal vein tributaries was used in all patients, and these vessels were divided using either a laparoscopic stapling device or the LigaSureTM device (Valleylab, Boulder, CO). The medical and operative records of the donors and recipients were reviewed to evaluate patient outcomes. RESULTS: The mean follow-up time was 14 months. Of the 50 LDN procedures, there were no laparoscopic stapling device malfunctions and no vascular complications. All renal allografts were functioning at the time of follow-up. CONCLUSION: Laparoscopic stapling device failure due to deployment across previously placed surgical clips during laparoscopic live donor nephrectomy can be prevented by not placing clips on the tributaries of the renal vein. In our series, there were no vascular complications and no device misfires. We believe this clipless technique improves the safety of laparoscopic donor nephrectomy

Factors affecting individual foraging specialization and temporal diet stability across the range of a large “generalist” apex predator

Individual niche specialization (INS) is increasingly recognized as an important component of ecological and evolutionary dynamics. However, most studies that have investigated INS have focused on the effects of niche width and inter- and intraspecific competition on INS in small-bodied species for short time periods, with less attention paid to INS in large-bodied reptilian predators and the effects of available prey types on INS. We investigated the prevalence, causes, and consequences of INS in foraging behaviors across different populations of American alligators (Alligator mississippiensis), the dominant aquatic apex predator across the southeast US, using stomach contents and stable isotopes. Gut contents revealed that, over the short term, although alligator populations occupied wide ranges of the INS spectrum, general patterns were apparent. Alligator populations inhabiting lakes exhibited lower INS than coastal populations, likely driven by variation in habitat type and available prey types. Stable isotopes revealed that over longer time spans alligators exhibited remarkably consistent use of variable mixtures of carbon pools (e.g., marine and freshwater food webs). We conclude that INS in large-bodied reptilian predator populations is likely affected by variation in available prey types and habitat heterogeneity, and that INS should be incorporated into management strategies to efficiently meet intended goals. Also, ecological models, which typically do not consider behavioral variability, should include INS to increase model realism and applicability

Expanding global access to radiotherapy

Radiotherapy is a critical and inseparable component of comprehensive cancer treatment and care. For many of the most common cancers in low-income and middle-income countries, radiotherapy is essential for effective treatment. In high-income countries, radiotherapy is used in more than half of all cases of cancer to cure localised disease, palliate symptoms, and control disease in incurable cancers. Yet, in planning and building treatment capacity for cancer, radiotherapy is frequently the last resource to be considered. Consequently, worldwide access to radiotherapy is unacceptably low. We present a new body of evidence that quantifies the worldwide coverage of radiotherapy services by country. We show the shortfall in access to radiotherapy by country and globally for 2015-35 based on current and projected need, and show substantial health and economic benefits to investing in radiotherapy. The cost of scaling up radiotherapy in the nominal model in 2015-35 is US$26·6 billion in low-income countries,$62·6 billion in lower-middle-income countries, and $94·8 billion in upper-middle-income countries, which amounts to$184·0 billion across all low-income and middle-income countries. In the efficiency model the costs were lower: $14·1 billion in low-income,$33·3 billion in lower-middle-income, and $49·4 billion in upper-middle-income countries-a total of$96·8 billion. Scale-up of radiotherapy capacity in 2015-35 from current levels could lead to saving of 26·9 million life-years in low-income and middle-income countries over the lifetime of the patients who received treatment. The economic benefits of investment in radiotherapy are very substantial. Using the nominal cost model could produce a net benefit of $278·1 billion in 2015-35 ($265·2 million in low-income countries, $38·5 billion in lower-middle-income countries, and$239·3 billion in upper-middle-income countries). Investment in the efficiency model would produce in the same period an even greater total benefit of $365·4 billion ($12·8 billion in low-income countries, $67·7 billion in lower-middle-income countries, and$284·7 billion in upper-middle-income countries). The returns, by the human-capital approach, are projected to be less with the nominal cost model, amounting to $16·9 billion in 2015-35 (-$14·9 billion in low-income countries; -$18·7 billion in lower-middle-income countries, and$50·5 billion in upper-middle-income countries). The returns with the efficiency model were projected to be greater, however, amounting to $104·2 billion (-$2·4 billion in low-income countries, $10·7 billion in lower-middle-income countries, and$95·9 billion in upper-middle-income countries). Our results provide compelling evidence that investment in radiotherapy not only enables treatment of large numbers of cancer cases to save lives, but also brings positive economic benefits

Life After Succession in the Family Business: Is It Really the End of Problems?

The succession processes in family business are well chronicled in the business literature. Most of the research focuses on the process of transferring power within the business-family. What has not been as closely examined is the after-succession environment that exists when the management and leadership of the family business are passed on to the next generation. This article addresses that organizational climate and the potential for additional problems in the business-family if post-succession issues are not identified and addressed and suggests some steps that will be helpful in producing complete succession success.Yeshttps://us.sagepub.com/en-us/nam/manuscript-submission-guideline

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137753/1/acr23274.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137753/2/acr23274_am.pd

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137769/1/art40149.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137769/2/art40149_am.pd

The Impact of Timing and Mode of Entry on Successor Development and Successful Succession

Family businesses frequently are disrupted by the process of succession of leadership and ownership. This article focuses on causes of conflict and how to manage success after siblings have entered the business.Yeshttps://us.sagepub.com/en-us/nam/manuscript-submission-guideline