Breast reconstruction with deep inferior epigastric perforator flaps

INTRODUCTION

Approximately 45,000 women are diagnosed with breast cancer in the UK each year. The success of screening and the introduction of adjuvant therapies have meant that prognosis is improving and an increasing number of patients are seeking reconstruction following mastectomy. The purpose of this study was to evaluate the deep inferior epigastric perforator (DIEP) flap reconstructions performed in Stoke Mandeville Hospital and, through analysis of complications, detail the evolution of the current care pathway.

METHODS

A retrospective analysis was performed of all the DIEP flap reconstructions performed by the senior author (MT) between July 2003 and December 2010.

RESULTS

Overall, 159 flaps were performed on 141 patients (including 36 bilateral flaps). The average patient age was 49 years (range: 28-70 years) and 13% of flaps were risk reducing for BRCA1/2. Twenty-six per cent of patients suffered one or more complication post-operatively, including systemic complications (pulmonary embolism 2%) and flap specific complications (partial flap necrosis 9%, reanastomosis 3%, fat necrosis 9%). Seventy-four per cent had further elective operations including nipple reconstruction (72%), contralateral breast reduction (36%) and scar revision (21%).

CONCLUSIONS

DIEP flaps are a safe and reliable option for breast reconstructions. This series illustrates the significant leaning curve, with complications, operative time and ischaemic time reducing through the series and post-operative haemoglobin increasing. The complications experienced in this series of 159 flaps with no total flap loss provide the framework for the evolution of the current care pathway including pre-operative imaging, peri-operative deep vein thrombosis prophylaxis and analgesia.

Oncolytic Vaccinia virus and radiotherapy in head and neck cancer

OBJECTIVE

Oncolytic forms of attenuated Vaccinia virus are now in clinical development, assessing the compatibility of this novel treatment with radiotherapy may reveal exploitable synergistic relationships.

MATERIALS AND METHODS

In vitro analyses of cell killing, cell cycle effects and caspase activation were carried out on HN3, HN5, CAL27, Detroit, SIHN5B, and PJ41 cells. In vivo studies of the virus and X-radiation were performed on H&N xenografts in CD1 nude mice.

RESULTS

Cell killing in vitro was demonstrated to be dose- and time-dependent. Infection causes an increase in S-phase and sub-G1 cells. A dose dependent increase in active caspase-3 indicated induction of apoptosis. Xenografts injected with Vaccinia stabilised and frequently completely regressed. Combination with radiation generated additional cell death, induction of caspase activity and in vivo further improved long term regression rates.

CONCLUSIONS

These data support continued exploration of this therapy combination and indicates potential for clinical trials in head and neck cancer.

Identification of a third osmoprotectant transport system, the osmU system, in Salmonella enterica

The growth of Salmonella enterica serovar Typhimurium mutants lacking the ProP and ProU osmoprotectant transport systems is stimulated by glycine betaine in high-osmolarity media, suggesting that this organism has an additional osmoprotectant transport system. Bioinformatic analysis revealed that the genome of this organism contains a hitherto-unidentified operon, designated osmU, consisting of four genes whose products show high similarity to ABC-type transport systems for osmoprotectants in other bacteria. The osmU operon was inactivated by a site-directed deletion, which abolished the ability of glycine betaine to alleviate the inhibitory effect of high osmolarity and eliminated the accumulation of [(14)C]glycine betaine and [(14)C]choline-O-sulfate in high-osmolarity media in a strain lacking the ProP and ProU systems. Although the OsmU system can take up glycine betaine and choline-O-sulfate, these two osmoprotectants are recognized at low affinity by this transporter, suggesting that there might be more efficient substrates that are yet to be discovered. The transcription of osmU is induced 23-fold by osmotic stress (0.3 M NaCl). The osmU operon is present in the genomes of a number of Enterobacteriaceae, and orthologs of the OsmU system can be recognized in a wide variety of Bacteria and Archaea. The structure of the periplasmic binding protein component of this transporter, OsmX, was modeled on the crystallographic structure of the glycine betaine-binding protein ProX of Archaeoglobus fulgidus; the resultant model indicated that the amino acids that constitute substrate-binding site, including an "aromatic cage" made up of four tyrosines, are conserved between these two proteins.

Botanicals to control soft rot bacteria of potato

Extracts from eleven different plant species such as jute (Corchorus capsularis L.), cheerota (Swertia chiraita Ham.), chatim (Alstonia scholaris L.), mander (Erythrina variegata), bael (Aegle marmelos L.), marigold (Tagetes erecta), onion (Allium cepa), garlic (Allium sativum L.), neem (Azadiracta indica), lime (Citrus aurantifolia), and turmeric (Curcuma longa L.) were tested for antibacterial activity against potato soft rot bacteria, E. carotovora subsp. carotovora (Ecc) P-138, under in vitro and storage conditions. Previously, Ecc P-138 was identified as the most aggressive soft rot bacterium in Bangladeshi potatoes. Of the 11 different plant extracts, only extracts from dried jute leaves and cheerota significantly inhibited growth of Ecc P-138 in vitro. Finally, both plant extracts were tested to control the soft rot disease of potato tuber under storage conditions. In a 22-week storage condition, the treated potatoes were significantly more protected against the soft rot infection than those of untreated samples in terms of infection rate and weight loss. The jute leaf extracts showed more pronounced inhibitory effects on Ecc-138 growth both in in vitro and storage experiments.

Inheritance of plumage colour variations in a large flock of Japanese quail

1. The inheritance of various plumage colour variants and their underlying interactions were investigated in a large flock of Japanese quail maintained at CARI (India) by conducting reciprocal crosses between four breeding stocks inheriting Pharaoh, White Breasted, White and Brown plumages, followed by test crosses. 2. Based on the proportion of plumage-colour types in the progeny, putative genotypes were determined for parents and offspring for each of the crosses. 3. The White and Brown phenotypes were attributed to the Panda (S) and Roux (Br) loci respectively in agreement with contemporary quail stocks. 4. The White Breasted plumage type present in our stock was caused by a novel mutation with dominant gene action at an autosomal locus that was not allelic to either Panda or the White feather locus. 5. A recessive epistatic action of the Panda locus (S) on White Breasted (Wb) resulted in a White colour phenotype. 6. A novel phenotype, White Breasted-Brown was co-expressed with the Br and Wb loci. 7. It was concluded that breeding for customized feather colour phenotypes in Japanese quail using colour mutations was feasible and would be advantageous in order to overcome the limitations of legislation to protect wildlife in India.

Isolation, characterization, and identification of biological control agent for potato soft rot in Bangladesh

A total of 91 isolates of probable antagonistic bacteria of potato soft rot bacterium Erwinia carotovora subsp. carotovora (Ecc) were extracted from rhizospheres and endophytes of various crop plants, different soil varieties, and atmospheres in the potato farming areas of Bangladesh. Antibacterial activity of the isolated probable antagonistic bacteria was tested in vitro against the previously identified most common and most virulent soft rot causing bacterial strain Ecc P-138. Only two isolates E-45 and E-65 significantly inhibited the in vitro growth of Ecc P-138. Physiological, biochemical, and carbon source utilization tests identified isolate E-65 as a member of the genus Bacillus and the isolate E-45 as Lactobacillus sp. The stronger antagonistic activity against Ecc P-138 was found in E-65 in vitro screening and storage potatoes. E-65 reduced the soft rot infection to 22-week storage potatoes of different varieties by 32.5–62.5% in model experiment, demonstrating its strong potential to be used as an effective biological control agent for the major pectolytic bacteria Ecc. The highest (62.5%) antagonistic effect of E-65 was observed in the Granola and the lowest (32.7%) of that was found in the Cardinal varieties of the Bangladeshi potatoes. The findings suggest that isolate E-65 could be exploited as a biocontrol agent for potato tubers.

Protecting Pakistan's health during the global economic crisis

The world is facing an unprecedented global economic crisis, with many countries needing to reconsider their level of health care spending. This paper explores the many consequences of the global economic turndown on Pakistan's health, including reduced government and donor spending and increased poverty with the consequent diversion of funds away from health. Nevertheless, these challenges may provide opportunities not only to mitigate the adverse effects of the economic crisis but also to institute some much-needed reforms that may not receive political support during more affluent times. Our suggestions focus on setting priorities based on the national disease burden, prioritizing prevention interventions, demanding results, curbing corruption, experimenting with innovative funding mechanisms, advocating for increased funding by presenting health spending as an investment rather than an expense and by selected recourse to civil society interventions and philanthropy to bridge the gap between available and needed resources.

Isolation and characterization of multidrug-resistant Klebsiella spp. isolated from shrimp imported from Thailand

A study was undertaken to isolate and characterize tetracycline and nalidixic acid-resistant Klebsiella spp. in farm-raised, imported shrimp sold in the United States. Sixty-seven multiple antibiotic-resistant Klebsiella spp. strains were isolated from imported shrimp samples. Using morphological and biochemical methods, fifty-three strains were tentatively identified as Klebsiella pneumoniae and fourteen as K. oxytoca. Although all isolates were resistant to tetracycline, only 8 were resistant to nalidixic acid. These 8 isolates were further screened by PCR for quinolone resistance genes (qnrA, B, S, gyrA, B and parC). PCR protocols failed to amplify any qnr genes. The purified PCR amplicons of gyrA, gyrB and parC were sequenced and analyzed for point mutations that confer resistance to fluoroquinolone antibiotics. Analysis of the sequences of the gyrA amplicons from nalidixic acid-resistant Klebsiella spp. indicated two point mutations in gyrA at positions 83 (Ser→Phe) and 87 (Asp→Ala). Sequence analysis of the parC amplicons indicated an amino acid change at position 80 (Ser→Ile). No mutations were detected in gyrB. Template DNA from all isolates was screened for tetracycline resistance genes (tetA-E). Oligonucleotide primers specifically targeting a 305-bp region of tetB and a 477-bp region of tetD successfully amplified sequences from 91.0 and 44.0% of the isolates, respectively. None of the isolates contained tetA, tetC or tetE genes. Plasmids (2.0-16.0kb) were found in 23 of the 67 isolates. XbaI-PFGE identified 32 distinct macro restriction patterns (mrps) among the 61 multiple drug-resistant Klebsiella spp. that were typable. Our results indicate that imported shrimp is a reservoir for multidrug resistant Klebsiella spp. and potential health risks posed by such strains should not be underestimated.

Requirements for emergent neurosurgical procedures among patients undergoing neuroendovascular procedures in contemporary practice

BACKGROUND AND PURPOSE

Provisions for an emergent neurosurgical procedure have been a mandatory component of centers that perform neuroendovascular procedures. We sought to determine the need for emergent neurosurgical procedures following neuroendovascular interventions in 2 comprehensive stroke centers in settings with such provisions.

MATERIALS AND METHODS

Analysis of retrospectively collected data from procedure logs and patient charts was performed to identify patients who required immediate (before the termination of the intervention) or adjunctive (within 24 hours of the intervention) neurosurgical procedures related to a neuroendovascular intervention complication. The types of neurosurgical procedures and in-hospital outcomes of identified patients are reported as an aggregate and per endovascular procedure-type analyses.

RESULTS

We reviewed a total of 933 neuroendovascular procedures performed during 3.5 years (2006-2010). A total of 759 intracranial procedures were performed. There was a need for emergent neurosurgical procedures in 8 patients (0.85% cumulative incidence and 1.05% for major intracranial procedures) (mean age, 46 years; 7 were women); the procedures were categorized as 3 immediate and 5 adjunctive procedures. There were 5 in-hospital deaths (62.5%) among these 8 patients. Neurosurgical procedures performed were external ventricular drainage placement in 6 (6 of 8, 75%) patients, decompressive craniectomy in 1 (12.5%) patient, and both surgical procedures in 1 (12.5%) patient.

CONCLUSIONS

The need for emergent neurosurgical procedures is very low among patients undergoing intracranial neuroendovascular procedures. Survival in such patients despite emergent neurosurgical procedures is quite low.

Unusual presence of Wormian (sutural) bones in human skulls

Wormian bones are a subset of the small intrasutural bones that lie between the cranial sutures formed by the bones of the skull vault. They are formed due to additional ossification centres in or near sutures. They are usually considered as normal variants and seem to be determined genetically in certain populations. They have been linked with rapid cranial expansion as they appear in great number in hydrocephalic skulls. They are commonly found in the lambdoid suture and fontanelles but are occasionally seen in other sutures especially the coronal, squamosal, and sagittal sutures. We examined 25 dried human skulls with the aim to find out the occurrence and variations of Wormian bones, and surprisingly we found Wormian bones in the coronal, squamosal, and sagittal sutures in 6 skulls. These are uncommon sites of occurrence of sutural bones as reported in the literature. These findings prompted us to report these cases as their presence can lead to confusion in diagnosis in cases of skull fractures.

Ex vivo sentinel lymph node mapping in laparoscopic resection of colon cancer

AIM

The study examined the feasibility and potential benefit of ex vivo sentinel lymph node (SLN) mapping, including multilevel sectioning (MLS) and immunohistochemistry (IHC) in colon cancer patients undergoing laparoscopic colectomy. The secondary goals were (i) to identify patient and tumour characteristics that might influence the success of the SLN technique, (ii) to investigate the extent of lymphadenectomy required to encompass tumour-positive nonsentinel lymph nodes (NSLN) and (iii) to ascertain the association of SLN status with oncological outcomes.

METHOD

SLN mapping was performed after specimen extraction using 1% Isosulfan blue. The SLNs were analysed with H&E staining after MLS, and if negative, IHC was performed. NSLNs were grouped by distance either greater than or less than 4 cm from the tumour.

RESULTS

Seventy-one patients completed the study between 2003 and 2007. Using H&E with MLS, the accuracy of SLN mapping was 76%, sensitivity was 52% and the false-negative rate was 48%. Excluding patients with clinically positive lymph nodes resulted in a significant improvement in accuracy to 81% and decreased the false-negative rate to 30%. Furthermore, as the only positive NSLN > 4 cm from the tumour was grossly positive, SLN mapping with a 4-cm mesenteric cuff would have given 100% sensitivity in patients without macroscopically involved nodes.

CONCLUSIONS

SLN mapping may be of value in selected patients. It may be possible to accurately stage patients with a 4-cm cuff of mesentery, although further validation of this proposal is required.

Genetic analysis of NaCl tolerance in tomato

We attempted to find the suitable parents for the development of tomato hybrids for high salt soils by exploiting combining ability, gene action and heterosis. Six salt-tolerant and three salt-intolerant genotypes, along with their 18 F1 crosses, were evaluated at seedling stage under 10 and 15 dS/m (NaCl) salinity stress, compared to the control level of salinity. The experiment was laid out based on a two-way complete randomized design factorial arrangement with two replications; data on root and shoot length, fresh and dry weights, leaf area, plant length, Na(+), K(+) and K(+)/Na(+) concentrations were recorded. There was significant variation within genotypes, lines, testers, crosses, and line × tester interaction for all plant characters studied under normal and two salinity levels. Estimates of combining ability indicated that under low (10 dS/m) and high (15 dS/m) salinities, line BL1176 and tester LO2875 showed significant GCA effects for most of the traits studied. The cross-combinations 6233 × LO2875, CLN2498A x LO2875 and BL1176 × 17902 showed highest SCA values for most of the characters under 10 and 15 dS/m, respectively. Potence ratio showed that under low and high salinities, all the traits showed over dominant type of gene action except leaf area and K(+) concentration (in 10 dS/m) and shoot length, and leaf area (in 15 dS/m). The highest heterosis for most of the parameters was observed in cross-combinations BL1176 × LO2875 and CLN2498A x LO2875.

Appropriate length of epidural catheter in the epidural space for postoperative analgesia: evaluation by epidurography

In current practice, the length of epidural catheter that should be left in the epidural space is not standardised for effective postoperative analgesia. This prospective, randomised, double-blinded study aimed to determine the most appropriate length of epidural catheter that should be inserted into the epidural space for postoperative analgesia. We recruited 102 women and assigned them into three study groups (3, 5 and 7 cm insertion). An epidural catheter was inserted and epidurography was performed. Postoperatively, mean pain scores, motor and sensory levels, and any complications associated with the epidural catheter were recorded. No statistically significant difference for mean postoperative pain score was found at all study timings. Motor and sensory blockade was also statistically insignificant. Unilateral sensory analgesia developed in one patient in the 7 cm group and epidural catheter dislodgement was observed in four patients in the 3 cm group. In order to minimise catheter-related complications for postoperative analgesia, the most appropriate length that an epidural catheter should be left in the epidural space is 5 cm. You can respond to this article at http://www.anaesthesiacorrespondence.com.

Expressed sequence tag-simple sequence repeat-based molecular variance in two Salicornia (Amaranthaceae) populations

Salicornia spp is one of the most salt-tolerant vascular plants and is native to salt marshes and estuaries. We developed expressed sequence tag derived-simple sequence repeat (EST-SSR) markers for estimating genetic diversity and marker-assisted Salicornia breeding. Six polymorphic EST-SSRs of 40 detected 27 alleles, ranging from three to five alleles per locus. The average number of alleles per locus was 4.33 and 4.17, and the major allele frequency at locus DY529765 was high, being 0.859 and 0.857 in S. bigelovii and S. europea, respectively. Gene diversity, heterozygosity and polymorphism information content were highest at locus DY529950 and similar in these two species. Gene diversity increased with increase in the number of alleles that had a low major allele frequency at a locus. Six polymorphic loci effectively discriminated 46 taxa into three clusters via different analyses. Significant deviation of F(ST) from zero in three suggested populations for six loci indicated population differentiation and limited gene flow among them. A reduced median network established that taxon SB65 is primitive. SMART (simple modular architecture research tool) analysis of peptide sequences of six EST-SSRs showed that loci DY529765, DY529950 and EC906203 contained transmembrane, TLC, AgrB and NTR domains and might be involved in salinity stress tolerance. These EST-SSRs are a valuable resource for marker development and may be useful in marker-assisted Salicornia breeding.

Female spouses of injection drug users in Pakistan: a bridge population of the HIV epidemic?

An estimated 21% of injection drug users (IDUs) in Pakistan are HIV-positive and data suggest that the spouses of IDUs may be a critical component of the HIV transmission chain. This study interviewed 101 spouses of male IDUs about their sexual practices and drug use. We found that 43% had been sexually active with their partners in the past month but only 4% reported selling sex. Almost a quarter (23%) used drugs and 19% injected drugs, usually a combination of diazepam and pheniramine. Although sex work was infrequent among spouses of IDUs, their risk of contracting HIV and transmitting it to others was high because they received injection drugs, sometimes along with their IDU husbands, from the same health centres that provided therapeutic injections to the rest of the community. IDU spouses may thus serve as a bridge group via therapeutic injections, rather than via sex work.

Stereotactic radiosurgery for the treatment of symptomatic brainstem cavernous malformations

Object

The authors performed a retrospective review of prospectively collected data to evaluate the safety and efficacy of stereotactic radiosurgery (SRS) for the treatment of patients harboring symptomatic solitary cavernous malformations (CMs) of the brainstem that bleed repeatedly and are high risk for resection.

Methods

Between 1988 and 2005, 68 patients (34 males and 34 females) with solitary, symptomatic CMs of the brainstem underwent Gamma Knife surgery. The mean patient age was 41.2 years, and all patients had suffered at least 2 symptomatic hemorrhages (range 2–12 events) before radiosurgery. Prior to SRS, 15 patients (22.1%) had undergone attempted resection. The mean volume of the malformation treated was 1.19 ml, and the mean prescribed marginal radiation dose was 16 Gy.

Results

The mean follow-up period was 5.2 years (range 0.6–12.4 years). The pre-SRS annual hemorrhage rate was 32.38%, or 125 hemorrhages, excluding the first hemorrhage, over a total of 386 patient-years. Following SRS, 11 hemorrhages were observed within the first 2 years of follow-up (8.22% annual hemorrhage rate) and 3 hemorrhages were observed in the period after the first 2 years of follow-up (1.37% annual hemorrhage rate). A significant reduction (p < 0.0001) in the risk of brainstem CM hemorrhages was observed following radiosurgical treatment, as well as in latency period of 2 years after SRS (p < 0.0447). Eight patients (11.8%) experienced new neurological deficits as a result of adverse radiation effects following SRS.

Conclusions

The results of this study support a role for the use of SRS for symptomatic CMs of the brainstem, as it is relatively safe and appears to reduce rebleeding rates in this high-surgical-risk location.

Stereotactic radiosurgery for symptomatic solitary cerebral cavernous malformations considered high risk for resection

Object

A retrospective study was conducted to reassess the benefit and safety of stereotactic radiosurgery (SRS) in patients with solitary cerebral cavernous malformations (CCMs) that bleed repeatedly and are poor candidates for surgical removal.

Methods

Between 1988 and 2005 at the University of Pittsburgh, the authors performed SRS in 103 evaluable patients (57 males and 46 females) with solitary symptomatic CCMs. The mean patient age was 39.3 years. Ninety-eight percent of these patients had experienced 2 or more hemorrhages associated with new neurological deficits. Seventeen patients (16.5%) had undergone attempted resection before radiosurgery. Ninety-three CCMs were located in deep brain structures and 10 were in subcortical lobar areas of functional brain importance. The median malformation volume was 1.31 ml, and the median tumor margin dose was 16 Gy.

Results

The follow-up ranged from 2 to 20 years. The annual hemorrhage rate—that is, a new neurological deficit associated with imaging evidence of a new hemorrhage—before SRS was 32.5%. After SRS 22 hemorrhages were observed within 2 years (10.8% annual hemorrhage rate) and 4 hemorrhages were observed after 2 years (1.06% annual hemorrhage rate). The risk of hemorrhage from a CCM was significantly reduced after radiosurgery (p < 0.0001). Overall, new neurological deficits due to adverse radiation effects following SRS developed in 14 patients (13.5%), with most occurring early in our experience. Modifications in technique (treatment volume within the T2-weighted MR imaging–defined margin, use of MR imaging, and dose reduction for CCM in critical brainstem locations) further reduced risks after SRS.

Conclusions

Data in this study provide further evidence that SRS is a relatively safe procedure that reduces the rebleeding rate for CCMs located in high-surgical-risk areas of the brain.

Harnessing the purinergic receptor pathway to develop functional engineered cartilage constructs

OBJECTIVE

Mechanical stimulation is a widely used method to enhance the formation and properties of tissue-engineered cartilage. While this approach can be highly successful, it may be more efficient and effective to harness the known underlying mechanotransduction pathways responsible. With this aim, the purpose of this study was to assess the effect of directly stimulating the purinergic receptor pathway through exogenous adenosine 5'-triphosphate (ATP) in absence of externally applied forces.

METHODS

Isolated bovine articular chondrocytes were seeded in high density, 3D culture and supplemented with varying doses of ATP for up to 4 weeks. The effects on biosynthesis, extracellular matrix accumulation and mechanical properties were then evaluated. Experiments were also conducted to assess whether exogenous ATP elicited any undesirable effects, such as: inflammatory mediator release, matrix turn-over and mineralization.

RESULTS

Supplementation with ATP had a profound effect on the growth and maturation of the developed tissue. Exogenous ATP (62.5-250 microM) increased biosynthesis by 80-120%, and when stimulated for a period of 4 weeks resulted in increased matrix accumulation (80% increase in collagen and 60% increase in proteoglycans) and improved mechanical properties (6.5-fold increase in indentation modulus). While exogenous ATP did not stimulate the release of inflammatory mediators or induce mineralization, high doses of ATP (250 microM) elicited a 2-fold increase in matrix metalloproteinase-13 expression suggesting the emergence of a catabolic response.

CONCLUSIONS

Harnessing the ATP-purinergic receptor pathway is a highly effective approach to improve tissue formation and impart functional mechanical properties. However, the dose of ATP needs to be controlled as not to elicit a catabolic response.

Creating synergies for health systems strengthening through partnerships in Pakistan--a case study of the national eye health programme

Blindness and visual impairment are major causes of noncomrnunicable diseases in Pakistan. Two national population-based blindness surveys conducted in 1988 and 2002-04 demonstrated a reduction in prevalence of blindness from 1.78% to 0.9% with a significant drop in cataract blindness as a result of accelerated nationwide interventions and eye care integration in primary health care. In addition, between 2006 and 2008, 88 facilities were upgraded as a result of the national eye health programme. These measures resulted in a 279% increase in eye outpatient attendances and a 375% increase in eye surgeries performed. Investment in human resources development and policy change contributed significantly to the sustainability of the programme. Key challenges facing the programme include aligning national eye health strategies with health system strengthening informed through health systems research. This paper attempts to document this extraordinary success.

STEREOTACTIC RADIOSURGERY FOR CAVERNOUS SINUS OR ORBITAL HEMANGIOMAS

OBJECTIVE

Hemangiomas are rare but highly vascular tumors that may develop in the cavernous sinus or orbit. These tumors pose diagnostic as well as therapeutic challenges to neurosurgeons during attempted removal. We analyzed our increasing experience using stereotactic radiosurgery (SRS).

METHODS

Eight symptomatic patients with hemangiomas underwent SRS between 1988 and 2007. The presenting symptoms included headache, orbital pain, diplopia, ptosis, proptosis and impaired visual acuity. The hemangiomas were located in either the cavernous sinus (7 patients) or the orbit (1 patient). Four patients underwent SRS as primary treatment modality based on clinical and imaging criteria. Four patients had previous microsurgical partial excision or biopsy. The median target volume was 6.8 mL (range, 2.5–18 mL). The median prescription dose delivered to the margin was 14.5 Gy (range, 12.5–19 Gy). The dose to the optic nerve in all patients was less than 9 Gy (range, 4.5–9 Gy).

RESULTS

The median follow-up period after SRS was 80 months (range, 40–127 months). Six patients had symptomatic improvement; 2 patients reported persistent diplopia. Follow-up imaging revealed tumor regression in 7 patients and no change in tumor volume in 1 patient. All the patients improved after SRS.

CONCLUSION

Our extended experience confirms that SRS is an effective management strategy for symptomatic intracavernous and intraorbital hemangiomas. Our study is the first long-term report on the safety and efficacy of SRS.

Simplified and versatile method for bisulfite-based DNA methylation analysis of small amounts of DNA

Epigenetic alterations of gene function play a central role in the pathogenesis of many tumors and in the process of aging. Abnormal methylation at transcriptional sites of genes results in epigenetic silencing of the genes that protect against tumor formation or that repair DNA. To date, several studies have analyzed methylation status by oligonucleotide arrays, restriction analysis (COBRA), methylation-specific amplification, and sequence analysis. This requires high concentration of bisulfite-treated DNA, which mandates use of commercially available expensive kits, and is an often laborious and time-consuming task. In this article, we report a simplified high-throughput method, which can serve as a surrogate for screening methylation profiles of various genes and has high sensitivity compared with the other methods described previously.

Growing burden of noncommunicable diseases: the contributory role of oral diseases, Eastern Mediterranean Region perspective

Associations of oral diseases with noncommunicable diseases such as diabetes, cardiovascular diseases, chronic respiratory diseases, osteoporosis and chronic renal failure are widely reported in the literature from developed countries. Commonality of risk factors, changes in systemic inflammatory mediators and body metabolism play a role in this association. This paper reviews current knowledge on the burden and association of oral and systemic diseases, and highlights the paucity of information and research from the Eastern Mediterranean Region and other developing countries. A call is made for further research to understand the status and significance of oral-systemic disease associations and develop guidelines for their control in this Region.