Carotid body denervation in dogs: eupnea and the ventilatory response to hyperoxic hypercapnia

We assessed the time course of changes in eupneic arterial PCO(2) (Pa(CO(2))) and the ventilatory response to hyperoxic rebreathing after removal of the carotid bodies (CBX) in awake female dogs. Elimination of the ventilatory response to bolus intravenous injections of NaCN was used to confirm CBX status on each day of data collection. Relative to eupneic control (Pa(CO(2)) = 40 +/- 3 Torr), all seven dogs hypoventilated after CBX, reaching a maximum Pa(CO(2)) of 53 +/- 6 Torr by day 3 post-CBX. There was no significant recovery of eupneic Pa(CO(2)) over the ensuing 18 days. Relative to control, the hyperoxic CO(2) ventilatory (change in inspired minute ventilation/change in end-tidal PCO(2)) and tidal volume (change in tidal volume/ change in end-tidal PCO(2)) response slopes were decreased 40 +/- 15 and 35 +/- 20% by day 2 post-CBX. There was no recovery in the ventilatory or tidal volume response slopes to hyperoxic hypercapnia over the ensuing 19 days. We conclude that 1) the carotid bodies contribute approximately 40% of the eupneic drive to breathe and the ventilatory response to hyperoxic hypercapnia and 2) there is no recovery in the eupneic drive to breathe or the ventilatory response to hyperoxic hypercapnia after removal of the carotid chemoreceptors, indicating a lack of central or aortic chemoreceptor plasticity in the adult dog after CBX.

Distinctive patterns of Her-2/neu, c-myc, and cyclin D1 gene amplification by fluorescence in situ hybridization in primary human breast cancers

BACKGROUND

Human solid tumors undergo clonal evolution as they progress, but evidence for specific sequences of genetic changes that occur in individual tumors and are recapitulated in other tumors is difficult to obtain.

METHODS

Patterns of amplification of Her-2/neu, c-myc, and cyclin D1 were determined by fluorescence in situ hybridization (FISH) in relation to the presence of p53 dysfunction and ploidy in 60 primary human breast cancers.

RESULTS

We show that there are clusters of genophenotypic abnormalities that distinguish lobular breast cancers from nonlobular tumors; that cyclin D1 amplification occurs prior to the divergence of lobular breast cancers from nonlobular cancers; that p53 dysfunction, Her-2/neu amplification, and c-myc amplification are characteristic features of nonlobular breast cancers, but not of lobular breast cancers; and that the frequencies of amplification of all three oncogenes examined increase progressively with increasing aneuploidy, but that each gene exhibits a different profile of increasing amplification in relation to tumor progression. Early amplification of c-myc appears to be an especially prominent feature of hypertetraploid/hypertetrasomic tumors.

CONCLUSIONS

The data suggest that in tumors containing multiple abnormalities, these abnormalities often accumulate in the same cells within each tumor. Furthermore, the same patterns of accumulation of multiple genophenotypic abnormalities are recapitulated in different tumors.

The relation of daily stressors to somatic and emotional symptoms in children with and without recurrent abdominal pain

Prior investigations of the relation between stressors and symptoms in children with recurrent abdominal pain (RAP) have focused on major negative life events. This study used consecutive daily telephone interviews to assess daily stressors and symptoms in 154 pediatric patients with RAP and 109 well children. Results showed that patients with RAP reported more frequent daily stressors than well children reported both at home and at school. Idiographic (within-subject) analyses indicated that the association between daily stressors and somatic symptoms was significantly stronger for patients with RAP than for well children. In contrast, the relation between daily stressors and negative affect did not differ between the groups. The relation between daily stressors and somatic symptoms was stronger for patients with RAP who had higher levels of trait negative affectivity.

Efficient retrovirus-mediated PIG-A gene transfer and stable restoration of GPI-anchored protein expression in cells with the PNH phenotype

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal hematopoietic stem cell disorder characterized by complement-mediated hemolysis due to deficiencies of glycosylphosphatidylinositol-anchored proteins (GPI-APs) in subpopulations of blood cells. Acquired mutations in the X-linked phosphatidylinositol glycan-class A (PIG-A) gene appear to be the characteristic and pathogenetic cause of PNH. To develop a gene therapy approach for PNH, a retroviral vector construct, termed MPIN, was made containing the PIG-A complementary DNA along with an internal ribosome entry site and the nerve growth factor receptor (NGFR) as a selectable marker. MPIN transduction led to efficient and stable PIG-A and NGFR gene expression in a PIG-A-deficient B-cell line (JY5), a PIG-A-deficient K562 cell line, an Epstein-Barr virus-transformed B-cell line (TK-14(-)) established from a patient with PNH, as well as peripheral blood (PB) mononuclear cells from a patient with PNH. PIG-A expression in these cell lines stably restored GPI-AP expression. MPIN was transduced into bone marrow mononuclear cells from a patient with PNH, and myeloid/erythroid colonies and erythroid cells were derived. These transduced erythroid cells restored surface expression of GPI-APs and resistance to hemolysis. These results indicate that MPIN is capable of efficient and stable functional restoration of GPI-APs in a variety of PIG-A-deficient hematopoietic cell types. Furthermore, MPIN also transduced into PB CD34(+) cells from a normal donor, indicating that MPIN can transduce primitive human progenitors. These findings set the stage for determining whether MPIN can restore PIG-A function in multipotential stem cells, thereby providing a potential new therapeutic option in PNH.

Current status of retroviral vector mediated gene transfer into human hematopoietic stem cells

Genetic modification of hematopoietic stem cells (HSCs) has been proposed as a treatment strategy for a variety of hematologic diseases, tracking marked cells or conferring resistance to chemotherapeutic agents. Despite early enthusiasm, the results of clinical studies involving gene transfer into HSCs has not resulted in therapeutic benefits for the vast majority of treated patients. This review describes the limitations and advances that have been made in the areas of gene transfer vectors, identification of the appropriate HSCs to target for genetic modifications and the methods used to perform gene transfer.

Nonchemical Elimination of Inspiratory Motor Output via Mechanical Ventilation in Sleep

In six dogs studied in nonrapid eye movement (NREM) sleep, we found that the frequency, volume, and timing of application of mechanical ventilator breaths had marked and sustained inhibitory effects on diaphragm electromyogram (EMG(di)). Single ventilator breaths of tidal volume (VT) 75-200% of control caused apnea (up to three times eupneic expiratory time [TE]) when applied during the initial 25-65% of expiratory time. When continuous controlled mechanical ventilation (CMV) was applied with ventilator frequency increased as little as 1 cycle/min > eupnea and Pa(CO(2)) and VT maintained at near eupneic control levels, EMG(di) was silenced and triangularis sterni EMG (EMG(ts)) became tonic within 2 to 5 ventilator cycles. On cessation of normocapnic CMV, apnea ensued with TE ranging from 1.2 to five times eupneic TE. The spontaneous VT and EMG(di) determined immediately after these prolonged apneas were also markedly reduced in amplitude. The larger the VT applied during the isocapnic CMV (120-200% of eupnea) and the longer the duration of the CMV (3-90 s), the longer the duration of the postventilator apnea. Significant postventilator apneas and postapneic hypoventilation also occurred even when end-tidal CO(2) pressure (PET(CO(2))) was raised 3-5 mm Hg > eupnea (and 7-10 mm Hg > normal apneic threshold) throughout CMV trials at raised frequency and VT. Our findings demonstrate that the increased frequency of CMV was critical to the elimination of inspiratory motor output and the onset of tonic expiratory muscle activity; furthermore, once EMG(di) was silenced, the tidal volume and duration of the passive mechanical ventilation determined the magnitude of the short-term inhibition of inspiratory motor output after cessation of CMV.

Patterns of telephone use among nursing home residents

There is convincing evidence that nursing home residents who have more visitors fare better than those who have fewer visitors. However, as many as one third of all individuals living in nursing homes have virtually no visitors. The purpose of this study was to address this concern by examining telephone use in older adults living in nursing homes, and evaluating the potential of telephone communications as a means of social support for this at-risk group. Using a recording device activated each time the receiver was picked up, the research team "listened in" on the telephone conversations of three nursing home residents (aged 76, 79, and 92) for a period of 1 week. The transcripts revealed 56 minutes of actual conversation during the week (10, 21, and 25 minutes, respectively), most often with family or longtime friends living out of town. Each resident laughed aloud more than once per minute. The telephone conversations provided the residents with vivid glimpses of life outside the walls of their facility and appeared to help them stay connected with their family and friends. The findings support further study of the telephone as a way to sustain authentic social support in long-term care populations.

Current status of retroviral vector mediated gene transfer into human hematopoietic stem cells

Genetic modification of hematopoietic stem cells (HSCs) has been proposed as a treatment strategy for a variety of hematologic diseases, tracking marked cells or conferring resistance to chemotherapeutic agents. Despite early enthusiasm, the results of clinical studies involving gene transfer into HSCs have not resulted in therapeutic benefits for the vast majority of treated patients. This review describes the limitations and advances that have been made in the areas of gene transfer vectors, identification of the appropriate HSCs to target for genetic modifications and the methods used to perform gene transfer.

Crystal structure of the NADP(H)-dependent ketose reductase from Bemisia argentifolii at 2.3 A resolution

Polyhydric alcohols are widely found in nature and can be accumulated to high concentrations as a protection against a variety of environmental stresses. It is only recently, however, that these molecules have been shown to be active in protection against heat stress, specifically in the use of sorbitol by the silverleaf whitefly, Bemisia argentifolii. We have determined the structure of the enzyme responsible for production of sorbitol in Bemisia argentifolii, NADP(H)-dependent ketose reductase (BaKR), to 2.3 A resolution. The structure was solved by multiwavelength anomalous diffraction (MAD) using the anomalous scattering from two zinc atoms bound in the structure, and was refined to an R factor of 21.9 % (R(free)=25.1 %). BaKR belongs to the medium-chain dehydrogenase family and its structure is the first for the sorbitol dehydrogenase branch of this family. The enzyme is tetrameric, with the monomer having a very similar fold to the alcohol dehydrogenases (ADHs). Although the structure determined is for the apo form, a phosphate ion in the active site marks the likely position for the adenyl phosphate of NADP(H). The catalytic zinc ion is tetrahedrally coordinated to Cys41, His66, Glu67 and a water molecule, in a modification of the zinc site usually found in ADHs. This modified zinc site seems likely to be a conserved feature of the sorbitol dehydrogenase sub-family. Comparisons with other members of the ADH family have also enabled us to model a ternary complex of the enzyme, and suggest how structural differences may influence coenzyme binding and substrate specificity in the reduction of fructose to sorbitol.

An Epstein-Barr virus deletion mutant associated with fatal lymphoproliferative disease unresponsive to therapy with virus-specific CTLs

There is a growing interest in using antigen-specific T cells for the treatment of human malignancy. For example, adoptive transfer of Epstein-Barr virus (EBV)-specific cytotoxic T lymphocytes (CTLs) has been effective prophylaxis and treatment of EBV-associated lymphoproliferative disease in immunocompromised patients. For all immunotherapies, however, there has been a hypothetical concern that mutations in tumor-specific antigens may lead to tumor escape. We now demonstrate that such events may indeed occur, with lethal outcome. A patient who developed lymphoma after marrow transplantation received donor-derived, EBV-specific CTLs but died with progressive disease. The tumor cells proved substantially less sensitive to cytolysis than the EBV-transformed B-cell line used for CTL generation. The major cytolytic activity of the donor CTL was directed against 2 HLA-A11-restricted epitopes in the viral EBNA-3B antigen. Sequence analysis of this gene in the tumor virus revealed a 245-base pair deletion, which removed these 2 CTL epitopes. Hence, the viral antigen in the tumor had mutated in a way that allowed escape from CTLs. Analysis of EBV polymorphisms demonstrated that before CTL infusion, more than one virus was present, including a virus with wild-type EBNA-3B. After CTL infusion, only the virus with the EBNA-3B deletion could be detected, suggesting that the infused CTLs had selected a resistant strain in vivo. Such an occurrence, even when polyclonal CTL lines are used against genetically stable virus antigens, suggests that escape mutants may be a serious problem when CTL therapy is directed against more unstable tumor cell-derived targets.

The use of mirrors during an assembly task: a study of ergonomics and productivity

Industrial assembly tasks often require awkward, sustained neck and/or shoulder postures that can lead to increased musculoskeletal discomfort and reduced productivity. The aim of this study was to investigate the effects of mirror and periscope visual aids as ergonomic interventions designed to eliminate awkward postures of the cervicobrachial region during assembly tasks. Participants simulated a simple assembly task by using a cordless screwdriver to drive screws into a pre-tapped aluminium block. Trials of 15 min were run for each of four distinct assembly workstation configurations: industry standard (in-line screwdriver, work at elbow height, no visual aid); pistol grip (pistol grip screwdriver, work at shoulder height, no visual aid); mirror (in-line screwdriver, work at elbow height, single mirror visual aid); and periscope (in-line screwdriver, work at elbow height, two-mirror visual aid system). Muscular activity, discomfort, body posture, productivity and operator subjective assessment were recorded to determine the effects of the visual aid interventions. The results show that when comparing the interventions to the industry standard condition, there was a 45% reduction in average cervical erector spinae activity, a 90% reduction in average neck flexion angle and a 72% reduction in neck discomfort with the interventions. When comparing these interventions to the pistol grip condition there was an 80% reduction in activity of the dominant side deltoid, a 92% reduction in shoulder flexion angle and an 81% decrease in shoulder discomfort with the interventions. Productivity was greatest in the industry standard configuration followed by the pistol grip (9% lower), the periscope (13% lower) and the mirror (23% lower) configurations. A follow-up study that compared the productivity of the periscope configuration with that of the industry standard configuration showed that within a 4-h work period this productivity differential decreased by over 33%.

The relation of daily stressors to somatic and emotional symptoms in children with and without recurrent abdominal pain

Prior investigations of the relation between stressors and symptoms in children with recurrent abdominal pain (RAP) have focused on major negative life events. This study used consecutive daily telephone interviews to assess daily stressors and symptoms in 154 pediatric patients with RAP and 109 well children. Results showed that patients with RAP reported more frequent daily stressors than well children reported both at home and at school. Idiographic (within-subject) analyses indicated that the association between daily stressors and somatic symptoms was significantly stronger for patients with RAP than for well children. In contrast, the relation between daily stressors and negative affect did not differ between the groups. The relation between daily stressors and somatic symptoms was stronger for patients with RAP who had higher levels of trait negative affectivity.

Homoeopathy for induction of labour

BACKGROUND

This is one of series of reviews of cervical ripening and labour induction using standardised methodology. Homoeopathy involves the use, in dilution, of substances which cause symptoms in their undiluted form. A type of herb, 'caulophyllum' is one type of homoeopathic therapy that has been used to induce labour.

OBJECTIVES

To determine the effects of homoeopathy for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: March 2001.

SELECTION CRITERIA

Randomised controlled trials comparing homeopathy used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

A generic strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally.

MAIN RESULTS

One trial involving 40 women was included in the review. This trial was placebo controlled and double blind, but the quality was not high. Insufficient information was available on the method of randomisation and the study lacked clinically meaningful outcomes. This trial demonstrated no differences in any outcome between the treatment and control group.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to recommend the use of caulophyllum as a method of induction. It is likely that the demand for complementary medicine will continue and women will continue to consult a homoeopath during their pregnancy. Although caulophyllum is a commonly used homoeopathic therapy to induce labour, the treatment strategy used in this trial may not reflect routine practice of homoeopathy. It may be more appropriate to undertake further evaluation of individualised homeopathic therapies for induction of labour in future clinical trials.

Acupuncture for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. The use of complementary therapies is rising and some women look to complementary therapies during pregnancy and childbirth to be used alongside conventional medical practice. Acupuncture involves the insertion of very fine needles into specific points of the body. The limited observational studies to date suggest acupuncture for induction of labour appears safe, has no known teratogenic effects, and may be effective. The evidence regarding the clinical effectiveness of this technique is limited.

OBJECTIVES

To determine the effects of acupuncture for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers.

SELECTION CRITERIA

The criteria for inclusion included the following: (1) clinical trials comparing acupuncture used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involves a two-stage method of data extraction. The initial data extraction is done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will then be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. To avoid duplication of data in the primary reviews, the labour induction methods have been listed in a specific order, from one to 25. Each primary review includes comparisons between one of the methods (from two to 25) with only those methods above it on the list.

MAIN RESULTS

No trials met the inclusion criteria for the systematic review.

REVIEWER'S CONCLUSIONS

There is a need for a well designed randomised controlled trial to evaluate the role of acupuncture to induce labour.

Multiparameter analysis of human epithelial tumor cell lines by laser scanning cytometry

Laser scanning cytometry (LSC) is a relatively new slide-based technology developed for commercial use by CompuCyte (Cambridge, MA) for performing multiple fluorescence measurements on individual cells. Because techniques developed for performing four or more measurements on individual lymphoid cells based on light scatter as a triggering parameter for cell identification are not suitable for the identification of fixed epithelial tumor cells, an alternative approach is required for the analysis of such cells by LSC. Methods for sample preparation, event triggering, and the performance of multiple LSC measurements on disaggregated fixed human cells were developed using normal lymphocytes and two human breast cancer cell lines, JC-1939 and MCF-7, as test populations. Optimal conditions for individual cell identification by LSC were found to depend on several factors, including deposited cell density (cells per unit area), the dynamic range of probe fluorescence intensities, and intracellular distribution of the fluorescent probe. Sparsely deposited cells exhibited the least cell overlap and the brightest immunofluorescent staining. Major advantages of using DNA probes over a cytoplasmic immunofluorescent protein marker such as tubulin for event triggering are that the former exhibit greater fluorescence intensity within a relatively sharply demarcated nuclear region. The DNA-binding dye LDS-751 was found to be suboptimal for quantitative DNA measurements but useful as a triggering measurement that permits the performance of simultaneous fluorescein isothiocyanate-, phycoerythrin-, and indodicarbocyanine-based measurements on each cell. A major potential advantage of LSC over flow cytometry is the high yields of analyzable cells by LSC, permitting the performance of multiple panels of multicolor measurements on each tumor. In conclusion, we have developed and optimized a technique for performing multiple fluorescence measurements on fixed epithelial cells by LSC based on event triggering using the DNA-binding dye LDS 751. Although not ideal for quantitative measurements of cell DNA content, the large Stokes shift of this dye permits the performance of three or more additional fluorescence measurements on each cell.

Recovery from 6 weeks of repeated strain injury to rat soleus muscles

Recovery from chronic strain injury (50 strains daily, five times weekly for 6 weeks to hyperactive soleus muscles) was followed for 3 months in female rats after cessation of chronic hyperactivity induced by pretreatment of the plantar flexor muscles with tetanus toxin. After 6 weeks of repeated strains, muscle mass decreased by 62%, myofiber areas were reduced by 87%, and noncontractile tissue expanded dramatically by 222%. Collagen content increased by almost ninefold (control 40 +/- 3 microg/mg, chronic injury 392 +/- 53 microg/mg), whereas the molar ratio of collagen (pyridinoline) crosslinks to collagen remained the same (control 0.20 +/- 0.01, chronic injury 0.16 +/- 0.01). After 3 months of ambulation, muscle mass returned to normal but myofiber areas remained smaller by 21%, noncontractile tissue was still markedly elevated by 18% with increased collagen content (107 +/- 15 microg/mg), and the molar ratio of crosslinks to collagen increased by 75% during recovery. Thus, rat soleus muscles recovered very slowly and incompletely from chronic strain injuries that produced muscle fibrosis, highlighting the necessity of devising preventative strategies for repeated strain injuries.

Metal substitution in transferrins: specific binding of cerium(IV) revealed by the crystal structure of cerium-substituted human lactoferrin

Proteins of the transferrin family play a key role in iron homeostasis through their extremely strong binding of iron, as Fe3+. They are nevertheless able to bind a surprisingly wide variety of other metal ions. To investigate how metal ions of different size, charge and coordination characteristics are accommodated, we have determined the crystal structure of human lactoferrin (Lf) complexed with Ce4+. The structure, refined at 2.2 A resolution (R=20.2%, Rfree=25.7%) shows that the two Ce4+ ions occupy essentially the same positions as do Fe3+, and that the overall protein structure is unchanged; the same closed structure is formed for Ce2Lf as for Fe2Lf. The larger metal ion is accommodated by small shifts in the protein ligands, made possible by the presence of water molecules adjacent to each binding site. The two Ce4+ sites are equally occupied, indicating that the known difference in the pH-dependent release of Ce4+ arises from a specific protonation event, possibly of the His ligand in one of the binding sites. Comparing the effects of binding Ce4+ with those for the binding of other metal ions, we conclude that the ability of transferrins to accommodate metal ions other than Fe3+ depends on an interplay of charge, size, coordination and geometrical preferences of the bound metal ion. However, it is the ability to accept the six-coordinate, approximately octahedral, site provided by the protein that is of greatest importance.

Performance of compensation seeking and non-compensation seeking samples on the Victoria symptom validity test: cross-validation and extension of a standardization study

Previous research suggests that the Victoria Symptom Validity Test (VSVT) is effective in confirming or disconfirming the validity of a patient's reported cognitive impairments. We sought to cross-validate the findings of the VSVT standardization study, and to determine cut-off scores that are most efficient in discriminating our samples of compensation-seeking patients, primarily with mild traumatic brain injury (CS; n = 53), and non-compensation seeking patients with intractable seizures (NCS; n = 30). All patients in the NCS sample scored in the "valid" range on the VSVT difficult memory items, compared to only 58.5% of the CS sample. We also identified VSVT measures and cut-off scores maximally efficient in discriminating these samples. This study confirms previous research that non-compensation seeking patients do well on the VSVT, but that many compensation seeking patients perform poorly on this measure.

An RNA-binding chameleon

The arginine-rich RNA binding motif is found in a wide variety of proteins, including several viral regulatory proteins. Although related at the primary sequence level, arginine-rich domains from different proteins adopt different conformations depending on the RNA site recognized, and in some cases fold only in the context of RNA. Here we show that the RNA binding domain of the Jembrana disease virus (JDV) Tat protein is able to recognize two different TAR RNA sites, from human and bovine immunodeficiency viruses (HIV and BIV, respectively), adopting different conformations in the two RNA contexts and using different amino acids for recognition. In addition to the conformational differences, the JDV domain requires the cyclin T1 protein for high-affinity binding to HIV TAR, but not to BIV TAR. The "chameleon-like" behavior of the JDV Tat RNA binding domain reinforces the concept that RNA molecules can provide structural scaffolds for protein folding, and suggests mechanisms for evolving distinct RNA binding specificities from a single multifunctional domain.

Monfort abdominoplasty with neoumbilical modification

PURPOSE

In patients who undergo the Monfort abdominoplasty the umbilicus is placed high on the abdominal wall. We describe a technique for abdominal wall reconstruction in patients with the prune-belly syndrome with the modification of neoumbilicus creation at an anatomically normal position.

MATERIALS AND METHODS

Five patients underwent modified Monfort abdominal wall reconstruction with the neoumbilicus created from an island flap of skin based on the fascial plate at the level of the iliac crest.

RESULTS

All patients and parents were satisfied with the outcome. In addition to abdominoplasty, orchiopexy and ureteral reconstruction were also safely and easily performed.

CONCLUSIONS

Neoumbilicus construction during Monfort abdominoplasty is an excellent approach to a more normal anatomical outcome.