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South Burlington, VT, United States

Cook D.L.,Fletcher Allen Health Care | Pugliano-Mauro M.A.,University of Pittsburgh | Schultz Z.L.,University of Vermont
Journal of Cutaneous Pathology | Year: 2013

Cutaneous leiomyomas are relatively common benign smooth muscle tumors that may arise as solitary or multiple lesions. Rare forms with cytologic atypia, and features similar to symplastic leiomyomas of the uterus, have been described. We report a case of multiple cutaneous atypical leiomyomas occurring in a 43-year-old man with long history of lesions of the right lower leg and a family history of leiomyomatosis. Twenty of the lesions were excised due to pain and were examined histopathologically. All the lesions exhibited features described in atypical leiomyomas of the skin including increased cellularity, nuclear atypia and pleomorphism, and low mitotic activity. The biologic potential of cutaneous atypical leiomyomas is uncertain. Only a few case reports exist in the literature with the majority occurring as solitary lesions. Most of the reported atypical leiomyomas have behaved in a benign fashion. However, a rare account of transformation to leiomyosarcoma emphasizes the need for long-term follow up of these patients. Herein, we describe a case of multiple atypical cutaneous leiomyomas arising in the setting of familial leiomyomatosis. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Persing S.,University of Vermont | James T.A.,University of Vermont | Mace J.,University of Vermont | Goodwin A.,Fletcher Allen Health Care | Geller B.,University of Vermont
Annals of Surgical Oncology | Year: 2011

Background: Accurately determining margin status is important for breast cancer treatment. The College of American Pathologists (CAP) developed guidelines to standardize reporting of margin status. The aim of this study is to determine statewide concordance with CAP breast cancer reporting guidelines for margin status. Methods: The Vermont Breast Cancer Surveillance System (VBCSS) tracks mammography-related services provided to all women treated for breast cancer at hospitals in Vermont. These data include accompanying pathology reports, which were analyzed for descriptions of margin status. The CAP protocols have both requirements and recommendations for margin status reporting. Reports were "minimally compliant" if they adhered to the requirements stated in the CAP protocols or "maximally compliant" if they included the recommended protocols in addition to those required. Results: There were 2,016 reports that met the inclusion criteria. A total of 71.1% were minimally compliant and 37.3% were maximally compliant with the CAP guideline standards. There was a statistically significant rise in compliant reports, with minimally compliant reports increasing from 55.7% in 1998 to 79.3% in 2006, and maximally compliant reports rising from 4.7% in 1998 to 53.7% in 2006 (χ 2 trend test, P <0.001) for both cohorts. Conclusions: Reporting of margin status in breast-conserving surgery varies widely. There is a significant rise in guideline compliance with margin status reporting from 1998 to 2006; however, overall compliance remains suboptimal. This study provides evidence to support the need for quality improvement measures in the implementation of CAP guidelines for reporting margin status following breast-conserving surgery. © Society of Surgical Oncology 2011.

Ricci M.A.,University of Vermont | Brumsted J.R.,Fletcher Allen Health Care
Aviation Space and Environmental Medicine | Year: 2012

Introduction: Since the publication of the Institute of Medicine report estimating nearly 100,000 deaths per year from medical errors, hospitals and physicians have a renewed focus upon error reduction. We implemented a surgical crew resource management (CRM) program for all operating room (OR) personnel. Methods: In our academic medical center, 19,000 procedures per year are performed in 27 operating rooms. Mandatory CRM training was implemented for all peri-operative personnel. Aviation techniques introduced included a pre-operative checklist and brief, post-operative debrief, read and initial files, and various other aviationbased techniques. Compliance with conduct of the brief/debrief was monitored as well as wrong-site surgeries and retained foreign body events. The malpractice insurance database for claims was also queried for the period prior to and after training. Results: Initial training was accomplished for 517 people, including all anesthesiologists, surgeons, nurses, technicians, and OR assistants. Pre-operative briefing increased from 6.7 to 99% within 4 mo. Wrong site surgeries and retained foreign bodies decreased from a high of seven in 2007 to none in 2008, but, after 14 mo without additional training, these rose to five in 2009. Malpractice expenses (payouts and legal fees) totaled $793,000 (2003-2007), but have been zero since 2008. Discussion: CRM training and implementation had an impact on reducing the incidence of wrong site surgery and retained foreign bodies in our operating rooms. However, constant reinforcement and refresher training is necessary for sustained results. Though no one technique can prevent all errors, CRM can effect culture change, producing a safer environment. © by the Aerospace Medical Association, Alexandria, VA.

Wallaert J.B.,Dartmouth Hitchcock Medical Center | Cronenwett J.L.,Dartmouth Hitchcock Medical Center | Bertges D.J.,Fletcher Allen Health Care | Schanzer A.,UMass Memorial Health Care | And 4 more authors.
Journal of Vascular Surgery | Year: 2013

Objective: Although carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis. Methods: Prospectively collected data from 4114 isolated CEAs performed for asymptomatic stenosis across 24 centers in the Vascular Study Group of New England between 2003 and 2011 were used for this analysis. Late survival was determined with the Social Security Death Index. Cox proportional hazard models were used to identify risk factors for mortality within the first 5 years after CEA and to calculate a risk score for predicting 5-year survival. Results: Overall 3- and 5-year survival after CEA in asymptomatic patients were 90% (95% CI 89%-91%) and 82% (95% CI 81%-84%), respectively. By multivariate analysis, increasing age, diabetes, smoking history, congestive heart failure, chronic obstructive pulmonary disease, poor renal function (estimated glomerular filtration rate <60 or dialysis dependence), absence of statin use, and worse contralateral ICA stenosis were all associated with worse survival. Patients classified as low (27%), medium (68%), and high risk (5%) based on number of risk factors had 5-year survival rates of 96%, 80%, and 51%, respectively (P <.001). Conclusions: More than four out of five asymptomatic patients selected for CEA in the Vascular Study Group of New England achieved 5-year survival, demonstrating that, overall, surgeons in our region selected appropriate patients for carotid revascularization. However, there were patients selected for surgery with high risk profiles, and our models suggest that the highest risk patients (such as those with multiple major risk factors including age ≥80, insulin-dependent diabetes, dialysis dependence, and severe contralateral ICA stenosis) are unlikely to survive long enough to realize a benefit of prophylactic CEA for asymptomatic stenosis. Predicting survival is important for decision making in these patients. © 2013 by the Society for Vascular Surgery.

Aapro M.,Institute Multidisciplinaire dOncologie | Rugo H.,University of California at San Francisco | Rossi G.,Data Management | Rizzi G.,Data Management | And 9 more authors.
Annals of Oncology | Year: 2014

Background: Antiemetic guidelines recommend co-administration of agents that target multiple molecular pathways involved in emesis to maximize prevention and control of chemotherapy-induced nausea and vomiting (CINV). NEPA is a new oral fixed-dose combination of 300 mg netupitant, a highly selective NK1 receptor antagonist (RA) and 0.50 mg palonosetron (PALO), a pharmacologically and clinically distinct 5-HT3 RA, which targets dual antiemetic pathways. Patients and methods: This multinational, randomized, double-blind, parallel group phase III study (NCT01339260) in 1455 chemotherapy-naïve patients receiving moderately emetogenic (anthracycline-cyclophosphamide) chemotherapy evaluated the efficacy and safety of a single oral dose of NEPA versus a single oral dose (0.50 mg) of PALO. All patients also received oral dexamethasone (DEX) on day 1 only (12 mg in the NEPA arm and 20 mg in the PALO arm). The primary efficacy end point was complete response (CR: no emesis, no rescue medication) during the delayed (25-120 h) phase in cycle 1. Results: The percentage of patients with CR during the delayed phasewas significantly higher in the NEPA group compared with the PALO group (76.9% versus 69.5%; P = 0.001), as were the percentages in the overall (0-120 h) (74.3% versus 66.6%; P = 0.001) and acute (0-24 h) (88.4% versus 85.0%; P = 0.047) phases. NEPAwas also superior to PALO during the delayed and overall phases for all secondary efficacy end points of no emesis, no significant nausea and complete protection (CR plus no significant nausea). NEPAwas well tolerated with a similar safety profile as PALO. Conclusions: NEPA plus a single dose of DEX was superior to PALO plus DEX in preventing CINV following moderately emetogenic chemotherapy in acute, delayed and overall phases of observation. As a fixed-dose antiemetic drug combination, NEPA along with a single dose of DEX on day 1 offers guideline-based prophylaxis with a convenient, single-day treatment. © The Author 2014. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved.

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