Peripheral venous pressure as an alternative to central venous pressure in patients undergoing laparoscopic colorectal surgery

BACKGROUND

Peripheral venous pressure (PVP) is strongly correlated with central venous pressure (CVP) during various surgeries. Laparoscopic surgery in the Trendelenburg position with pneumoperitoneum typically increases CVP. To determine whether PVP convincingly reflects changes in CVP, we evaluated the correlation between PVP and CVP in patients undergoing laparoscopic colorectal surgery.

METHODS

Both CVP and PVP were measured simultaneously at predetermined time intervals during elective laparoscopic colorectal surgery in 42 patients without cardiac disease. The pairs of venous pressure measurements were analysed for correlation, and the Bland-Altman plots of repeated measures were used to evaluate the agreement between CVP and PVP.

RESULTS

A total of 420 data pairs were obtained. The overall mean CVP was 11.3 (sd 4.5) mm Hg, which was significantly lower than the measured PVP of mean 12.1 (4.5) mm Hg (P=0.005). There was a strong positive correlation between overall CVP and PVP (correlation coefficient=0.96, P<0.0001). The mean bias (PVP-CVP) corrected for repeated measurements using random-effects modelling was 0.9 mm Hg [95% confidence interval (CI) 0.54-1.19 mm Hg] with 95% limits of agreement of -1.2 mm Hg (95% CI -1.75 to -0.62 mm Hg) to 2.9 mm Hg (95% CI 2.35-3.48 mm Hg).

CONCLUSIONS

PVP displays a strong correlation and agreement with CVP under the increased intrathoracic pressure of pneumoperitoneum in the Trendelenburg position and may be used as an alternative to CVP in patients without cardiac disease undergoing laparoscopic colorectal surgery.

Phase I study of fenretinide (4-HPR) oral powder in patients with recurrent or resistant neuroblastoma: New Approaches to Neuroblastoma Therapy (NANT) Consortium trial

10009

Background: Fenretinide (4-HPR), a cytotoxic retinoid, achieved limited and variable plasma levels when tested in a corn oil-based capsule. 4HPR/Lym-X-Sorb (LXS) oral powder is a new formulation intended to increase bioavailability, especially in children. Methods: This trial sought to define the toxicities, dose limiting toxicities (DLTs), maximum tolerated dose (MTD), and pharmacokinetics of 4-HPR/LXS oral powder when given mixed in Slim-Fast nutritional shakes, twice a day for 7 days, every 21 days. Eligible patients had high-risk neuroblastoma with recurrent/progressive disease, or disease refractory or persistent after frontline therapy. Dose escalation was in 30% increments using the traditional 3 + 3 design. Plasma levels were measured by HPLC. Results: Thirty-two patients accrued to 8 Dose Levels (DL) (352 –2210 mg/m2/day); 30 patients were evaluable. No MTD was identified. There was a DLT elevation of alkaline phosphatase on DL1. No other DLT's were observed. Other toxicities included dry skin, elevated triglycerides, reversible nyctalopia, and transient transaminase elevation. Course 1 day 7 peak 4HPR plasma levels (Dose (mg/m2/day) - mean, (range)) were: 352 –6 μM (3.8–9.6); 458–11.5 μM (9.7–14.9); 595–17.6 μM (6–24.3); 774–15 μM (9.1–25.3); 1006–6.7 μM (5.2–9.2); 1308–13.9 μM (2.9–23.8); 1700–19.7 μM (17.3–24.3); and 2210–10.8 μM (4–16.5). Course 2 day 7 peak plasma levels trended higher than course 1 at DL5–8. Three patients with isolated bone marrow disease and one with MIBG avid bone lesions, had complete responses (DL4, DL4, DL7, DL8) receiving 10, 17, 18 and 10 courses of therapy, respectively. Six patients had stable disease for 4–27 courses (median 5.5) (DL3, DL4, DL4, DL5, DL6, DL8). Twenty patients had progressive disease. Central review of responses is pending. Conclusions: 4-HPR/LXS oral powder was well tolerated, obtained 2 - 5 fold higher 4HPR plasma levels than fenretinide capsules on the same dose and schedule (P < 0.01), and showed anti-tumor activity (complete responses in 4/15 patients at DL4–8). Based on pharmacokinetic data, a recommended Phase II dose and schedule is 1700 mg/m2/day × 7days every 3 weeks.

No significant financial relationships to disclose.

A potential serum panel for breast cancer diagnosis: ongoing clinical validation for its clinical implication

Abstract #5006

Although every effort has been made to discover single potent biomarkers in oncology, the promising single biomarker often loses its clinical potency in the course of clinical validations. We aimed to construct and verify a biomarker panel with multiple proteins for breast cancer diagnosis. Using Surface-Enhanced Laser Desorption/ Ionization Time-of-Flight mass spectrometry (SELDI-TOF-MS) and microbead array system, epidermal growth factor (EGF), vascular cell adhesion molecule-1 (VCAM-1), CD40L, vitronectin, plasminogen activation inhibitor-1 (PAI-1), vitamin-D binding protein (VDBP), C-reactive protein (CRP), kininogen, apolipoprotein A1 and proapolipoprotein A1 were identified and validated as useful biomarkers for detection of breast cancer. The multiplexing panel (MP) which was constructed by combining algorithm (random forest, support vector machine) with above biomarkers showed that the diagnostic accuracy approached 91% in 216 test samples. A following double blind test verified that the diagnostic accuracy of the MP was 68% with an additional validation set including sera from 49 patients with breast cancer and 51 healthy women (sensitivity=74%; 95% confidence interval (CI)=58.9–85.0%, specificity=62.7%; 95% CI=48.1–75.9%, positive predictive value=65.5%; 95% CI=55.7-75.3%, negative predictive value=71.7%; 95% CI=61.7-80.35%). We suggest that these results support the potential use of the MP as an early detector of breast cancer. In order to validate the role and potency of the MP in routine clinical practice, a large scale clinical validation in a cohort consisting of 500 patients with breast cancer and the same number of healthy women are underway and the results will be released in the near future.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5006.

Ki-67 gives additional prognostic information on St Gallen 2007 and Adjuvant! Online risk categories in early breast cancer

Abstract #1086

Purpose: We sought to determine the significance of Ki-67, one of the tumor cell proliferation indexes, as a useful prognostic factor in early breast cancer.&#x2028; Patients and Methods: 1,080 consecutive patients with stage I or II breast cancer operated between 1998 and 2003 were enrolled. Patients were categorized based on the 2007 St. Gallen consensus and Adjuvant! Online. The expression of Ki-67 in the tumor was assayed using immunohistochemistry (cut-off value: 10%).&#x2028; Results: Univariate analysis revealed that tumor size, lymph node involvement, histologic grade, estrogen receptor, progesterone receptor, bcl-2, and Ki-67 (≥10%) were significant for both overall survival (OS) and distant metastasis-free survival (DFS). Of them, lymph node involvement and high Ki-67 expression were identified as independent prognostic factors for OS at multivariate analysis. The survivals of intermediate- and high-risk groups according to 2007 St Gallen consensus were further separated by Ki-67 expression level (5-yr DFS rate=93.3% vs 86.6% for Ki-67&lt;10% and ≥10%, respectively in intermediate-risk group (p=.001); 5-yr DFS rate=83.1% vs 61.5% for Ki-67&lt;10% and ≥10%, respectively in high-risk group (p=.006)). The survivals of low- and high-risk groups according to Adjuvant! Online were further separated by Ki-67 expression level [5-yr DFS rate=97.8% vs 89.5% for Ki-67&lt;10% and ≥10%, respectively in low-risk group (p=.010); 5-yr DFS rate=90.4% vs 82.6% for Ki-67&lt;10% and ≥10% in high-risk group (p=.005)).&#x2028; Conclusion: Ki-67 was an independent prognostic factor for DFS and OS in early breast cancer, and could give additional prognostic information on the risk grouping by 2007 St Gallen consensus and Adjuvant! Online.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1086.

Effect of glass phase on the dissolution of hydroxyapatite

Nano size defect formation at grain boundary during the dissolution of hydroxyapatite in water was evaluated by adding several sintering additives for sinterability enhancement. In the case of sintered pure hydroxyapatite, significant dissolution occurred after immersion in distilled water or in simulated body fluid. The dissolution initiated at the grain boundaries creating nano-size defects like small pores that afterwards grew up to micro scale by increasing immersion time. This dissolution resulted in grain separation at the surfaces and finally in fracture. The dissolution concentrated on the grains adjacent to pores rather than those in the dense region. So hydroxyapatite ceramics containing glass powders were prepared to prevent the dissolution by strengthening grain boundary. Calcium silicate and phosphate glasses were added at 0 to 10 mass% and sintered at 1200 degrees C for 2 h in air with moisture protection. Glass phase was incorporated into hydroxyapatite to act as the sintering aid followed by crystallization in order to improve the mechanical properties without reducing biocompatibility. Dissolution tests, as well as X-ray diffraction and SEM showed little decomposition of hydroxyapatite to secondary phases and the fracture toughness increased compared to pure hydroxyapatite.

Location of nerve entry points of flexor digitorum profundus

The aim of this study was to elucidate the anatomical location of nerve entry points of Flexor digitorum profundus (FDP) and its implications for non-surgical neurolysis. A total of 21 amputated forearms of 11 Korean fresh cadavers were dissected. Two transverse x-axes joined the medial and lateral epicondyles and the radial and ulnar styloid processes. The longitudinal y-axis joined the midpoints of the proximal and distal transverse x-axes. The locations of the points were marked relative to the forearm length (x) and forearm width (y). The number of nerve entry points from median nerve and ulnar nerve were average 3.91 +/- 0.62 (range 3-5, median 4) and 2.14 +/- 0.65 (range 1-3, median 2) respectively. Most (82.9%) nerve entry points of FDP from the median nerve were within two circles, with 15 mm diameter. The two circles were on medial 1/10 of forearm width from the y-axis, and on proximal 1/3 (1:2) and 2/5 (2:3) of forearm length on x-axis. Most (80.0%) nerve entry points of the ulnar nerve innervating FDP were within a 15 x 30 mm rectangle. Its center was located at +26.5% on x-axis and -36.0% on y-axis. The nerve entry points used to be selected in performing non-surgical neurolysis with either ethyl alcohol (50%) or phenol (5-12%).

Influence of excitation light rejection on forward model mismatch in optical tomography

Fluorescence enhanced tomography for molecular imaging requires low background for detection and accurate image reconstruction. In this contribution, we show that excitation light leakage is responsible for elevated background and can be minimized with the use of gradient index (GRIN) lenses when using fibre optics to collect propagated fluorescence light from tissue or other biological media. We show that the model mismatch between frequency-domain photon migration (FDPM) measurements and the diffusion approximation prediction is decreased when GRIN lenses are placed prior to the interference filters to provide efficient excitation light rejection. Furthermore, model mismatch is correlated to the degree of excitation light leakage. This work demonstrates the importance of proper light filtering when designing fluorescence optical imaging and tomography.

Anatomic variations of the infraorbital fat compartment

Resection of the infraorbital fat is performed in blepharoplasty of the lower eyelid, however, the previous anatomical reports on its compartmentalization have been in disagreement. The aim of this study was to classify the infraorbital fat based on the extent of compartmentalization, and to clarify its topographic relationship with the surrounding structures. Sixty orbits from 30 cadavers were dissected. The infraorbital fat was classified into four types based on its compartmentalization. In type I, which was the most common type (60.0%), the infraorbital fat was compartmentalised into three encapsulated medial, central, and lateral parts, which were side by side. In type II (11.7%), the medial or lateral compartment, or both compartments were under the central fat compartment. In type III (26.7%), there were two compartments, the medial and remaining part or the lateral and remaining part. In type IV (1.7%), the fat was not compartmentalised, but presented as a single pad. The average heights from the inferior orbital rim, the average widths, and the average distances from the fornix were 7.3, 17.2, and 7.1 mm in the medial compartment, 8.9, 24.2, and 8.0mm in the central compartment, and 8.1, 17.2, and 6.9 mm in the lateral compartment, respectively. The average distance from the end of the margin of the stretched lower eyelid to the most cephalic point in the compartments was 8.6 mm. These results are relevant to blepharoplasty with removal of the infraorbital fat.

Skin thickness of Korean adults

Skin thickness varies considerably between different races and age-groups, between men and women, and between different regions of the body surface. A few authors reported the skin thickness of different regions of the body, but no detailed study have been performed on Asian. We performed 452 biopsies on 28 different regions of the normal skin of Korean men and women. The specimens were stained with hematoxylin-eosin and measured microscopically. The thickness of the skin (epidermis plus dermis) ranged from 521 to 1977 microm; the eyelid, prepuce, and inguinal skin was thinnest (521-626 microm), and the back was thickest (1977 microm). The thickness of the epidermis varied from 31 to 637 microm; skin thickness in the prepuce, eyelid, supraclavicular region, postauricular region, and axilla ranged from 31 to 71 microm; the buttock, dorsum of the hand, and dorsum of the foot were relatively thick (138-189 microm); the palm and sole were thickest (601-637 microm). The thickness dermis varied from 469 to 1942 microm; skin thickness in the eyelid, prepuce, inguinal region, and postauricular region ranged from 469 to 645 microm; the buttock, chest, and anterior neck were relatively thick (1318-1586 microm); the back was thickest (1942 microm). The epidermis accounted for 3.7-16.8% of the entire skin in most regions, except in the palm and sole (40.6-44.6%). Thickness data may be useful in harvesting full- or split-thickness skin grafts.

Determination of recombinant human epidermal growth factor (rhEGF) in a pharmaceutical preparation by capillary electrophoresis

A simple assay method of recombinant human epidermal growth factor (rhEGF) in a pharmaceutical preparation was studied and validated by capillary electrophoresis (CE) using micellar electrokinetic chromatography (MEKC) techniques. Factors affecting the migration behavior and separation performances of the peptide; type of buffer, pH, buffer concentration, and concentration of sodium dodecyl sulfates (SDS) were investigated to optimize the analytical performance. CE was performed using running buffer, 50.0 mM borate (pH 8.5) containing 12.5 mM SDS at 20 kV of the applied voltage. Calibration curves for the rhEGF showed good linearity (r>0.999) over the wide dynamic range from 1.25 to 100 microg/ml. Sample analysis was performed by using standard addition method to eliminate the matrix effects of dosage vehicle. This method is assumed to be useful for quality control (QC) of various forms of pharmaceutical products of the peptide.

Reconstruction of palatal defect using mucoperiosteal hinge flap and pushback palatoplasty

This article describes a simple, new surgical technique to provide a complete two-layer closure of palatal defect resulting from a surgical complication of trans palatal resection of skull base chordoma. The nasal layer was reconstructed with triangular shape oral mucoperiosteal turn over hinge flap based on anterior margin of palatal defect and rectangular shaped lateral nasal mucosal hinge flaps. The oral layer was reconstructed with conventional pushback V-Y advancement 2-flaps palatoplasty. Each layer of the flaps were secured with two key mattress suture for flap coaptation. This technique has some advantages: simple, short operation time, one-stage procedure, no need of osteotomy. It can close small- to medium-sized palatal defect of palate or wide cleft palate and can prevent common complication of oronasal fistula, which could be caused by tension.

Patterns of oculomotor nerve distribution to the levator palpebrae superioris muscle, and correlation to temporary ptosis after blepharoplasty

Transient diplopia, blepharoptosis, or both conditions are rare postoperative complications of blepharoplasty performed with the patient under local anesthesia. It has been hypothesized that some cases of postoperative diplopia and blepharoptosis could be attributed to the myotoxic effects of local anesthetics to the extraocular muscles and the levator muscle or to the neurotoxic effects of lidocaine. In 30 cadavers, the superior division of the oculomotor nerve was severed en bloc 1.5 cm anterior to the annulus of Zinn with the levator palpebrae superioris (LPS) and the superior rectus muscles. These muscles were detached from their origins, and their attachments to the scleral and tarsal plates were divided respectively. The specimens were treated in guanidine-hydrochloride and Alizarin Red solution, and were dissected under an operating microscope. The nerve branches of the superior division of the oculomotor nerve innervated the proximal third (type I) in 2 of 30 LPS muscles (6.7%), in 8 of 30 muscles (26.7%) extended to the middle third (type II), and reached the distal third (type III) in 20 of 30 muscles (66.7%). The terminal branches ran through the medial third (type IIIa) in 6 of 20 type III LPS muscles (30%), the central third (type IIIb) in 8 muscles(40%), and the lateral third (type IIIc) in 6 muscles (30%). The oculomotor nerve ends that extend forward to the distal third of the LPS muscle (type III) are exposed and vulnerable to local anesthetics and may be numbed during blepharoplasty. If this is so, postoperative blepharoptosis may be caused by transient paralysis of the LPS muscle, and great care should be taken during the injection of local anesthetics near the LPS.

Determination of recombinant human epidermal growth factor (rhEGF) in a pharmaceutical formulation by high performance liquid chromatography with electrochemical detection

A novel HPLC method with electrochemical detection has been developed for the determination of recombinant human epidermal growth factor (rhEGF) in pharmaceutical products. rhEGF was separated from other components in formulation on a reversed-phase C18 column with 24% acetonitrile in 0.1 M phosphate buffer (pH 4.75). The optimum electrochemical oxidation of EGF was obtained at 0.85 V vs. Ag/AgCl in a glassy carbon working electrode due to electroactive tyrosine, tryptophan, methionine, and arginine residues. The quantitation range was from 1.0 to 200 ng of rhEGF with the linear correlation coefficient greater than 0.999. The method was successfully applied for the quantitation of rhEGF in a pharmaceutical preparation.

A false-positive I-131 whole-body scan in chronic parotitis: a case report

Although I-131 whole-body scanning is a useful method to evaluate and manage well-differentiated thyroid cancer, several causes of false-positive findings require careful evaluation. The authors describe a case of benign parotitis mimicking metastasis on an I-131 whole-body scan.

Decussation patterns of the platysma in Koreans

The importance of the platysma muscle in plastic surgery is well known. During surgery, we have observed that the platysmal fibres do not merely decussate and interlace from each side but that sometimes one side of the muscle overlaps and covers the other side. The aim of this study was to clarify the precise anatomical variations in the decussation and overlapping patterns of the platysma muscle in 70 Korean cadavers. We defined three groups (types I--III) and four patterns (types A--D) according to the length of decussation and the pattern of overlapping, respectively. In 60 specimens (85.7%) we observed decussation and in 10 (14.3%) we did not. In type I there was 0--20 mm of decussating fibres below the mandibular border (43% of specimens). In type II, the decussation of fibres extended over more than 20 mm (43% of specimens). Type III had no decussation (14% of specimens). The proportions of type A (interlacing pattern), type B (right dominant), type C (left dominant) and type D (no decussation) were 41%, 29%, 16% and 14%, respectively. In 45% of the specimens, one side of the platysma covered and overlapped the other side. This is relevant to the removal of the subplatysmal fat in corset platysmaplasty, submental Z-plasty and vertical myectomy of the platysma muscle.

Deep middle masseteric artery (dMMA) attributed to hemorrhage in resection of masseter muscle and mandibular angle

This study aimed to investigate pertinent arterial supplies of masseter muscle to prevent fatal hemorrhage in resection of masseter muscle and/or mandibular angle ostectomy. Fifty-three postmortem cadavers of Koreans were used for the work. Color latex was injected into the arteries to outline 17 of 53 specimens. We found that an artery branches off the external carotid artery and enters the masseter muscle at the midpoint of its posterior margin 31 mm above the gonion. We termed this the middle masseteric artery. The middle masseteric artery is divided into superficial and deep branches. The deep branch of the middle masseteric artery travels deep in the muscle close the periosteum of the mandible in 94% of cases. The average diameter is 1.23 +/- 0.26 mm. A small artery with 1.23-mm diameter is enough to cause massive bleeding if severed. The deep branch of the middle masseteric artery is vulnerable in such procedures as resection of the masseter muscle and/or ramus and angle of the mandible.

Innervation of the lower eyelid in relation to blepharoplasty and midface lift: clinical observation and cadaveric study

Ectropion or scleral show resulting from weakness of the lower eyelids is not uncommon after lower blepharoplasty or midface lift via blepharoplasty incision. Denervation of the pretarsal orbicularis oculi muscle (OOM) attributes to such complications. The authors analyzed 102 patients who underwent midface lift via lower blepharoplasty incision for the past 3 years and investigated the motor nerve innervation of the lower OOM in 20 cadavers. They encountered two cases of ectropion attributed to the denervation of the pretarsal OOM: one with dry-eye syndrome and scleral show, and the other with a "polar bear-like appearance" (i.e., outer eversion of the lower eyelid). All pretarsal and preseptal OOMs were innervated by five to seven terminal twigs of the zygomatic branches of the facial nerve that approached the muscle at a right angle. The medial portion of the lower OOM was innervated by one to two terminal twigs of the buccal branch, and the middle portion was innervated with two to three twigs of the zygomatic branch. The lateral portion was supplied by the uppermost zygomatic branch, which split into two to four twigs. The mean horizontal distance between the lateral canthus and the zygomatic branch was 2.31 +/- 0.29 cm (range, 1.7-2.7 cm) and the vertical distance was 1.20 +/- 0.20 cm (range, 0.8-1.5 cm). The critical zone was a circle with 0.5-cm radius, and its center was located 2.5 cm inferolaterally (30 deg) from the lateral canthus. It is very important to understand the motor nerve innervation of the lower eyelid and the "critical zone" to avoid postoperative ectropion or weakness of the lower eyelid resulting from paralysis of the pretarsal or preseptal OOM.

The emergence of erythromycin-resistant Streptococcus pyogenes in Seoul, Korea

High frequencies of erythromycin-resistant streptococci were reported in Japan in the mid-1970s, and in Finland in the late 1980s, related to an increase in the consumption of macrolide antibiotics in these countries. The frequency of erythromycin-resistant Streptococcus pyogenes was reported to be only 2% in 1994, but we know that the susceptibility of the strains to antibiotics had not been tested routinely. We studied the resistance rates of Streptococcus pyogenes to various antibiotics in Seoul, Korea, where antibiotics could be purchased without prescription. From January through December, 1998, 92 isolates of group A streptococci were collected from inpatients and outpatients with pharyngotonsillitis or invasive streptococcal infections, from institutions in five different geographic areas of Seoul; one pediatric clinic, three university hospitals, and one general hospital. All isolates were serotyped by T-agglutination, and minimum inhibitory concentrations (MICs) were determined by agar dilution methods, according to the guidelines of the National Committee for Clinical Laboratory Standards (NCCLS). The most common T-serotype was T12 (44.6%), followed by T4 (19.6%). All the isolates tested were susceptible to penicillin, vancomycin, and cefotaxime. However, 38 isolates (41.3%) were resistant to erythromycin, 32 (34.8%) were resistant to clindamycin, and 48 (52.1%) were resistant to tetracycline. Twenty-seven of 41 isolates serotyped T12 and 3 of 18 isolates serotyped T28 were multiresistant to erythromycin, clindamycin, and tetracycline. Almost half of the isolates obtained from the five different areas in Seoul showed erythromycin resistance in Streptococcus pyogenes. Routine monitoring of antibiotic susceptibility tests and further extensive nationwide surveys are needed to determine the frequency and the extent of the spread of resistant strains in various geographic regions in Korea.

Inhibition of calmodulin-dependent calcium-ATPase and phosphodiesterase by various cyclopeptides and peptide alkaloids from the Zizyphus species

The effects of various sedative cyclopeptides and peptide alkaloids from the Zizyphus species on calmodulin-dependent Ca2+-ATPase and phosphodiesterase were investigated. Calmodulin-induced activation of Ca2+-ATPase was strongly inhibited by sanjoinine-A dialdehyde (IC0O, 2.3 microM), -Ah1 (IC50, 4.0 microM), -A (IC50, 4.6 microM), and -G2 (IC50, 7.2 microM), while calmodulin-induced activation of phosphodiesterase was strongly inhibited by both deachuine-S10 (IC30, 4.9 microM) and sanjoinine-D (IC50, 9.0 microM). The inhibitory activity of the various cyclopeptides and peptide alkaloids on Ca2+-ATPase was found to correlate well with their sedative activity.

Pretarsal fat compartment in the lower eyelid

It is generally accepted that there are three infraorbital fat regions in the lower eyelid; medial, central, and lateral compartments. However, removing only the fat in the lateral compartment does not remove the bulge just below the eyelashes, which is caused by another fat pad. The aim of this study was to describe the anatomy of the pretarsal fat compartment and to demonstrate its clinical implications in lower lid blepharoplasty. Ten cadavers (total 20 lower eyelids) were studied. A skin-muscle flap was reflected to expose the soft pretarsal structures. A small stab incision was made on the lateral portion of the sac containing fat on the tarsus. Methylene blue dye was injected into the sac. Specimens were fixed and sagittal sections in four different planes were prepared for histological analysis. The injected dye remained within the sac and demarcated it as a pear or cone shaped structure. This encapsulated fat compartment sits on the lateral half of the tarsal plate above the lateral compartment fat. Auxillary or submuscular fat is well known. This study, however, designates the pretarsal fat as "encapsulated" in a compartment instead of being unbound. We have named it the "pretarsal fat compartment." Histologically, orbital septal fibers separate "pretarsal fat" from lateral infraorbital fat. It is recommended that fat in the pretarsal fat compartment be removed during lower lid blepharoplasty in order to alleviate the bulge or knoll of the skin just below the lower eyelashes.

Characterization, stability and in-vivo distribution of asialofetuin glycopeptide incorporating DSPC/CHOL liposomes prepared by mild cholate incubation

In this study, a small triantennary asialoglycopeptide of fetuin (A-F2) was used as a ligand to direct liposomes to hepatocytes. A-F2 was cleaved from asialofetuin, purified, conjugated with fatty acids and incorporated into pre-formed sonicated DSPC/Chol (2:1) liposomes. A mild cholate incubation method for incorporating the A-F2 ligand on pre-formed vesicles was used. In preliminary in vivo experiments 111In3+ encapsulated in A-F2/palmityl liposomes was seen to accumulate in the liver of mice significantly faster than when encapsulated in non-ligand bearing liposomes of the same lipid composition (studied before), justifying further investigation of this system. The presence of the A-F2/fatty acid conjugate in a functional form on the vesicle surface was confirmed by their reversible agglutination in the presence of Ricinus communis agglutinin (RCA120). Effects of ligand incorporation on the vesicle size distribution, z-potential, membrane integrity and stability were monitored. The results demonstrate that highest ligand incorporation was achieved when liposomes and ligand were co-incubated in the presence of 1 mM sodium cholate. Incorporation increased with the length of the fatty acid used for A-F2 conjugation. Ligand-bearing liposomes were demonstrated to be smaller in diameter (about 30%) with a more positive z-potential in comparison to control vesicles while ligand incorporation did not influence the liposome membrane integrity. The size of the ligand-incorporating vesicles was maintained after 24 hours of incubation in isotonic buffer, proving that the vesicles do not aggregate. Although the preliminary biodistribution results may suggest that ligand bearing liposomes are accumulating in the liver, further cell culture, in vivo distribution and especially liver fractionation studies are required in order to clarify the intrahepatic localization of these liposomes and the ability to target liver hepatocytes in vivo.

Congestion of right liver graft in living donor liver transplantation

BACKGROUND

Left liver graft from a small donor will not meet the metabolic demands of a larger adult recipient. One solution to this problem is to use a right liver graft without a middle hepatic vein (MHV). However, the need for drainage from the MHV tributaries has not yet been described.

METHODS

Five right liver grafts without a MHV were transplanted in patients including two hepatitis B virus-cirrhosis, two fulminant hepatic failure and one secondary biliary cirrhosis. The graft weight ranged from 650 to 1,000 g, corresponding to 48 to 83% of the standard liver volume of the recipients.

RESULTS

Two of five recipients were complicated with severe congestion of the right median sector immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction. One of the patients died of sepsis with progressive hepatic dysfunction 20 days after the operation.

CONCLUSIONS

Preservation and reconstruction of the MHV tributaries is recommended to prevent congestion of the right liver graft without MHV.

An anatomic comparison of the skin of five donor sites for dermal fat graft

Kim performed more than 3,000 augmentation rhinoplasties using the dermal fat graft. He preferred the sacral area as the donor site over other areas because the dermis is thick and the fat is more compact. The authors conducted a comparative study of the thickness of the epidermis and dermis, and the numbers of fibroblasts and fibrocytes in the dermis of the abdominal wall, groin, lateral gluteal area, gluteal fold, and sacrum of 7 adult cadavers. The sacrum had the thickest epidermis (86.1 +/- 7.8 microm) and dermis (1,510.7 +/- 201.7 microm), and the groin had the thinnest epidermis (57.3 +/- 22.9 microm) and dermis (783.3 +/- 244.5 microm). The dermal thickness of the abdomen, lateral gluteal area, and gluteal fold was 913.3 +/- 271.7 microm, 1,018.7 +/- 305.6 microm, and 1,107.0 +/- 272.6 microm respectively. The sacral dermis was significantly thicker than the other four sites (p < 0.008), and the groin dermis was the thinnest (p < 0.039). The number of fibroblasts and fibrocytes in the sacral area and the gluteal skin folds was significantly higher than the other areas (p < 0.05). The sacral area, gluteal fold, and lateral gluteal region had relatively thicker panniculus adiposus than the abdomen and groin. The panniculus adiposus of the sacral skin was especially well developed and was comprised of several compact layers that were connected by parallel, thick collagen fibers. The authors conclude that the sacral skin is a suitable donor site for dermal grafting because its dermis has more fibroblasts and fibrocytes than the other areas studied, and its dermis is more viable and durable.

Could ionizing radiation forestall cauliflower ear?

Repeated trauma to the ear very often results in "cauliflower ear." Many methods have been suggested to prevent an injured ear from demonstrating a cauliflowerlike deformity. The principles of treatment are evacuation of the hematoma, control of the reaccumulation of fluid, and maintenance of the cartilage contour. The authors studied the effect of ionizing radiation on deformed rabbit ears induced by repeated trauma. Twenty ears (10 rabbits) were used in the experiment. The animals were divided into four groups (control, preradiation, low dose, and high dose). Hematoma was produced by pounding the lateral side of the auricle 10 times with a 50-g weight at a height of 15 cm. The thickness of the injured and uninjured sites was measured, and histological analysis was performed for each group. The thickness of the ears of the irradiated groups was significantly less than the control group. The authors think that radiation treatment of repeatedly injured ears could prevent ear deformity, and could possibly be an adjunctive form of management of cauliflower ear in addition to hematoma evacuation and compression therapy.

Le Fort I osteotomy with sparing fracture of lateral pterygoid plate

This study aimed to clarify the relation between the anatomical variations of the pterygomaxillary region and fracture of the pterygoid plate during Le Fort I osteotomy. We present a secure method to separate maxillary tuberosities from pterygoid plates without injuring the pterygoid plates. Thirty specimens of hemisection of Korean skulls were used for the study. The maxilla was sectioned transversely on the floor of the pyriform aperture and posteriorly to the lateral pterygoid plate with a mechanical saw. The section was 5 to 6 mm above the tooth roots. The pterygomaxillary junction was separated with a curved osteotome in two steps: initially with light tapping of the shallow groove 2 to 3 mm anterior to the pterygomaxillary fissure at a half right angle and then changing the course of forceful tapping to more than 60 degrees. The maxillary tuberosity separated from the medial and lateral pterygoid plates during the procedure was grouped into the "disjunction group" (24 of 30, 80%) and the pterygoid plates fractured were grouped into the "fracture group" (6 of 30, 20%). The thickness of the pterygomaxillary region (T) was significantly greater in the disjunction group than in the fracture group (P = 0.034). The concavity of the pterygomaxillary fissure (C) was significantly deeper in the disjunction group than in the fracture group (P = 0.020). There was no significant difference of width of the pterygomaxillary fissure between the disjunction group and the fracture group (P = 0.169). The thin pterygomaxillary region and less concave pterygomaxillary fissure on the preoperative computed tomography scan draw precautionary attention to vulnerable pterygoid plates fractured in the procedure of Le Fort I osteotomy.

Correction of sunken and/or multiply folded upper eyelid by fascia-fat graft

Sunken and/or multiply folded upper eyelid is one of the common, troublesome complications that can occur after Oriental blepharoplasty. In addition to orbital volume depletion, the traumatic surgical procedure of excessive fat removal might result in a varying degree of adhesion and injury to the orbital septum. Adhesiotomy followed by a restoration of volume is generally believed to be the logical way to correct such deformity. To restore volume and prevent re-adhesion, local tissues of the upper eyelid, free-fat graft, and dermis-fat graft have been used. However, local tissues are usually insufficient because of previous surgery, and the survival rate of grafted fat is often unpredictable. Moreover, the heaviness of the dermis-fat composite makes it a less than satisfactory choice. The authors value the use of free fascia-fat composite grafts for the treatment of such disfigurements. The fascia-fat composite is expected to have a better survival rate than free fat alone and to be lighter than a dermis-fat composite. In addition, the fascia-fat composite is abundant throughout the body and provides anatomical structure more similar to that of the repair site, namely, the damaged orbital septum and fat. The authors prefer the mons pubis, preauricular, and temporal areas for the donor site depending on the status of the damage. They treated 13 patients with sunken and/or multiply folded upper eyelids by fascia-fat composite grafts and obtained satisfactory results.

Chin augmentation with a bone graft from the mandibular region

The prominent, square angles of the mandible are not generally considered an alluring virtue in Asian women because a square chin is thought to be masculine, and sunken cheeks are thought to be ill-fated. An oval, slender face is customarily preferred. A 28-year-old single woman requested reduction of the mandibular angle and concomitant chin augmentation. Each scalene triangular piece of the bone from both mandibular angles was carved and shaped like an obtuse triangle. One side of its surface was serrated to effect a curve, and the revision was fixed with a miniplate. The pieces were placed on top of each other, set on the symphysis menti, and were immobilized with screws. The excised fragments of the mandible were used as bone grafts to augment the chin during the same operation.

Lipopolysaccharide enhances substance P-mediated neutrophil adherence to epithelial cells and cytokine release

Lipopolysaccharide (LPS) is implicated in many respiratory tract inflammatory diseases. Tachykinins, especially substance P (SP) through the NK-1 receptor, mediate leukocyte adhesion to the endothelial or airway epithelial cells. Here we assessed the enhancement by LPS of tachykinin-mediated neutrophil adherence to alveolar epithelial cells, and associated interleukin-1 beta (IL-1beta) and tumor necrosis factor (TNF-alpha) release. Neutrophil adherence to A549 epithelial cell was not increased by LPS (100 ng/ml), or SP (10(-)(12)-10(-)(8) M) alone, but was significantly enhanced by their combination (LPS + SP). Neutrophil adherence to epithelial cells induced IL-1beta and TNF-alpha release from A549 cells either spontaneously or stimulated by SP or LPS. LPS + SP significantly enhanced IL-1beta and TNF-alpha release. The NK-1 receptor antagonist L-732,138 inhibited this enhancement response. Prevention of neutrophil adherence by CD11b/CD18 blocking antibody or by placing a filter on the epithelial monolayer diminished spontaneous or LPS + SP-enhanced IL-1beta and TNF-alpha release. Pretreatment with the serine protease inhibitor cocktail also inhibited LPS + SP-enhanced neutrophil adherence-dependent IL-1beta and TNF-alpha release as well as their mRNA expression. In conclusion, we have demonstrated LPS enhanced SP-mediated neutrophil adherence and associated IL-1beta and TNF-alpha release from the A549 epithelial monolayer, partly through NK-1 receptors. Neutrophil adherence to epithelial cells may release serine protease to induce IL-1beta and TNF-alpha release and their synthesis.

Imaging of malignant lymphomas with F-18 FDG coincidence detection positron emission tomography

PURPOSE

The authors evaluated the utility of F-18 fluorodeoxyglucose (FDG) coincidence detection (CoDe) positron emission tomography (PET) for staging, post-treatment evaluation, and follow-up assessment of patients with malignant lymphomas.

MATERIALS AND METHODS

Fifty-eight patients with histologically proved malignant lymphomas (4 Hodgkin's disease, 54 non-Hodgkin's lymphoma) underwent CoDe PET using F-18 FDG. CoDe PET was performed using a dual-head gamma camera equipped with coincidence detection circuitry. Of the 87 CoDe PET studies, 26 were performed for staging, 38 for post-treatment evaluation, and 23 for follow-up evaluation of recurrence. The entire trunk, from the cervical to the inguinal regions, or selected regions were scanned with the patient in the supine position. No attenuation correction was made and reconstruction was performed using filtered back-projection rather than iterative reconstruction. CoDe PET findings were compared with corresponding results of computed tomographic (CT) and magnetic resonance imaging (MRI), tissue biopsy, or clinical follow-up.

RESULTS

For staging, 52 sites were positive on CoDe PET or CT-MRI. CoDe PET detected 49 sites (94%), and CT-MRI showed 47 sites (90%). CoDe PET detected five more lymphomatous lesions and missed three lesions. For post-treatment evaluation, CoDe PET showed a positive predictive value of 100% and a negative predictive value of 83%, but the validated cases numbered only 11. For follow-up for recurrence, CoDe PET had a negative predictive value of 90%, but frequent false-positive findings were noted in the head and neck region as a result of underlying inflammatory changes.

CONCLUSIONS

For staging, FDG CoDe PET alone without attenuation correction is not sensitive enough to be used as an independent imaging method, especially for small abdominal lesions. However, it appears to be an accurate method for assessing residual disease and for patient follow-up.