Improving Long-Term Projection in Nipple Reconstruction Using Human Acellular Dermal Matrix

Reconstructed nipples rapidly lose projection. We describe the use of human acellular dermal matrix (ADM) to improve long-term projection of nipple flaps. Athymic rats were randomized to 3 groups; each received 2 nipples: bell flap (control, n = 16 nipples), bell flap with a cylinder of implanted ADM (n = 24), or bell flap with intraflap injection of micronized ADM (MADM) (n = 10). Seven of 24 ADM nipples extruded (30%). By 12 weeks, the control nipples maintained 44% of initial projection compared with 70% for ADM nipples (P = 0.000025). The MADM nipples maintained 49% of initial projection after 12 weeks (P = 0.55 compared with control). No MADM nipples extruded. ADM grafts maintain long-term projection better than local tissue flaps alone. We hypothesize that MADM may limit extrusion and allow for serial injection of nipples. Based on the promising results of this study, clinical trials are warranted using human ADM and/or human MADM for nipple reconstruction.

Is osteitis pubis associated with the use of bone anchors in urinary continence operations?

We studied 130 patients who underwent either a vaginal needle suspension procedure or a pubofascial sling procedure with Mitek titanium bone anchors to determine the association of osteitis pubis with bone anchoring in these procedures. Fifteen patients complained of postoperative suprapubic pain; five cases were due to wound infections and another five were associated with tying the suspension sutures too tightly. We suggest the use of the term 'periostitis pubis' to describe the remaining five patients who suffered suprapubic pain. We found no radiological evidence of osteitis pubis in any patients.

The Randomized Nitric Oxide Tocolysis Trial (RNOTT) for the treatment of preterm labor

OBJECTIVE

This study was undertaken to assess the effectiveness of glyceryl trinitrate (GTN) patches in comparison with beta2 sympathomimetics (beta2) for the treatment of preterm labor.

STUDY DESIGN

A multicenter, multinational, randomized controlled trial was conducted in tertiary referral teaching hospitals. Women in threatened preterm labor with positive fetal fibronectin or ruptured membranes between 24 and 35 weeks' gestation were recruited and randomly assigned to either beta2 or GTN with rescue beta2 tocolysis if moderate-to-strong contractions persisted at 2 hours. Obstetric and neonatal outcomes were assessed.

RESULTS

Two hundred thirty-eight women were recruited and randomly assigned, 117 to beta2 and 121 to GTN. On a strict intention-to-treat basis, there was no significant difference in the time to delivery using Kaplan-Meier curves (P = .451). At 2 hours, 27% of women receiving beta2 had moderate or stronger contractions compared with 53% in the GTN group (P < .001). This led to 35% of women in the GTN group receiving rescue treatment. If delivery or requirement for beta2 rescue are regarded as treatment failure, then a significant difference was observed between the 2 arms (P = .0032). There were no significant differences in neonatal outcomes.

CONCLUSION

GTN is a less efficacious tocolytic compared with ss2 sympathomimetics.

The relationship between COLI A1 polymorphisms (Sp 1) and COLI A2 polymorphisms (Eco R1 and Puv II) with bone mineral density in Chinese men and women

Polymerase chain reaction was used to amplify across variable restriction sites of the COLI A1 and COLI A2 genes that encode the alpha 1 and 2 subunits of type I collagen. The relationship between these polymorphisms and bone mineral density (BMD) was studied in 683 Chinese men and women. In 100 men and women, COLI A1 Sp1 polymorphism was not found, which was consistent with other previous studies in Asian populations. However a statistically significant relationship was observed between COLI A2 Eco R1 and Puv II genotypes among the Chinese men studied. The mean BMD was consistently lower in men of the EE and PP genotype (P < 0.05 by analysis of variance [ANOVA]) than in men of the ee and pp genotypes. However, no association between BMD and the Eco R1 or Puv II genotypes was observed in Chinese women (P > 0.05 by ANOVA). We conclude that the COLI Al Sp1 binding site is absent in Hong Kong Chinese, whereas the COLI A2 Eco R1 and Puv II genetic polymorphisms may be associated with the BMD of elderly Chinese men.

Classification and course of alcohol problems among adolescents in addictions treatment programs

BACKGROUND

This study tested whether adolescents in addictions treatment programs could be reliably classified into milder and more severe alcohol problem categories using latent class analysis, and examined the relation of latent class structure to DSM-IV alcohol diagnoses. Transition probabilities among the latent classes at 1-year follow-up and their predictors were used to characterize the short-term course of alcohol problems.

METHODS

Adolescents recruited from addictions treatment were administered a modified section of the Structured Clinical Interview for the DSM (SCID) alcohol use disorders (AUD) during or shortly after addictions treatment and at 1-year follow-up. DSM-IV lifetime conduct disorder diagnosis was assessed at baseline using a modified version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS).

RESULTS

A 3-class solution that represented increasing severity of alcohol problems (i.e., asymptomatic, mild, and severe) provided the best fit to the alcohol symptom data, and was consistent across gender, ethnicity, and presence of conduct disorder. Cross-classification of latent class membership with DSM-IV alcohol diagnosis indicated only a fair level of agreement. There was an overall decrease in alcohol problem severity from baseline to follow-up. Conditional transition probabilities indicated that males and those with conduct disorder, particularly for those in the severe class at baseline, had a lower likelihood of transitioning to the asymptomatic class at 1-year follow-up.

CONCLUSIONS

The latent class structure of alcohol problems in an adolescent clinical sample was best represented by a 3-class severity-based model. Cross-classification of latent class membership with DSM-IV alcohol diagnosis suggests the potential utility of re-organizing diagnostic criteria to better distinguish the relative severity of abuse and dependence diagnoses. Transitions between latent classes were fairly common at 1-year follow-up, and characterized by a general reduction in alcohol symptoms.

Fast three-point dixon MR imaging using low-resolution images for phase correction: a comparison with chemical shift selective fat suppression for pediatric musculoskeletal imaging

OBJECTIVE

The purpose of this study is to describe and to implement a new fast three-point Dixon MR imaging sequence with online image reconstruction, and to compare this sequence with conventional chemical shift selective (CHESS) suppression of fat in pediatric musculoskeletal imaging.

SUBJECTS AND METHODS

A three-point Dixon technique using a fast spin-echo sequence with a new phase-correction algorithm providing online image reconstruction was implemented on a 1.5-T scanner. Twelve pediatric patients and young adults were imaged with both the new three-point Dixon and conventional CHESS sequences. Three radiologists un-aware of imaging parameters and clinical information independently scored the homogeneity of fat suppression and conspicuity of abnormality using a four-point system. An additional comparison between the two techniques was made using a phantom.

RESULTS

The three-point Dixon method showed superior fat suppression and lesion conspicuity (p < 0.001), particularly in the hands and feet, where CHESS is prone to inconsistent fat suppression. The phantom study showed no significant difference in the ratio of suppressed fat signal to background noise and more homogeneous fat suppression using the three-point Dixon method.

CONCLUSION

Compared with CHESS, the new fast three-point Dixon sequence with online image reconstruction provides superior fat suppression and lesion conspicuity and can be routinely used in pediatric musculoskeletal imaging.

Fast three-point Dixon MR imaging of the retrobulbar space with low-resolution images for phase correction: comparison with fast spin-echo inversion recovery imaging

A new phase-correction algorithm for three-point Dixon (3PD) MR imaging allows on-line image reconstruction of three images per section: pure water, pure fat, and water plus fat. When combined with fast spin-echo acquisition, the sequence is suitable for routine MR imaging of the retrobulbar space. The 3PD pure water images have double the image signal-to-noise ratio of fast spin-echo inversion recovery images. The dramatic contrast-to-noise ratio of the 3PD pure fat images may offer improved lesion detection.

Assessment of alcohol tolerance in adolescents

OBJECTIVE

To improve assessment of the DSM-IV alcohol tolerance criterion in adolescents, this study tested the performance of a minimum percentage increase in drinking quantity, and a proxy measure of tolerance (i.e., average heavy-drinking quantity per occasion) in identifying adolescents with alcohol dependence.

METHOD

Two adolescent samples were examined. In one sample (N = 415, 58% male, 79% white, 57% clinical), a modified version of the SCID was used to determine DSM-IV alcohol diagnoses, and lifetime drinking history data were collected by interview. In the second sample (N = 470, 60% male, 76% white, 100% clinical), the Adolescent Diagnostic Interview was used to determine DSM-IV alcohol diagnoses and to collect data on initial- and current-drinking quantities needed to become intoxicated. The performance of a percentage increase and average heavy-drinking quantity in identifying those with dependence was evaluated using receiver operating characteristic analysis.

RESULTS

The utility of a percentage increase definition was limited by the high degree of variability in initial-drinking quantities. Percentage increase may underassign the tolerance symptom when initial-drinking quantities are high and overassign the symptom when initial-drinking quantities are low. Average heavy-drinking quantity per occasion, combined with a minimum frequency of drinking, demonstrated better performance than any percentage increase definition.

CONCLUSIONS

Alternatives to a change-based (e.g., percentage increase) definition of tolerance warrant study due to limits of change-based definitions when initial-drinking quantity shows a high degree of variability. The variability in initial-drinking quantity may reflect individual differences in initial sensitivity that need to be considered in tolerance assessment.

Changes in alcoholic patients' coping responses predict 12-month treatment outcomes

Patient subtypes (Types A and B alcoholism), determinants, and outcomes associated with changes in coping responses of 133 alcoholic patients in the year following admission to treatment were examined. In general, patients' use of avoidance coping declined and use of approach coping increased. Type B patients used more avoidance coping than did Type A patients, but the subtypes did not differ in rate of change in coping. As a determinant of coping, cognitive appraisal of threat showed a trend toward predicting avoidance coping at 6- and 12-month follow-ups. Decreased cognitive avoidance coping (e.g., daydreaming) predicted fewer alcohol, psychological, and interpersonal problems. Increased behavioral approach coping (e.g.. taking action) predicted lower severity of alcohol problems. Further study of changes in the cognitive aspects of coping (i.e., appraisals and cognitive avoidance coping) is needed to determine mechanisms underlying cognitive processes associated with treatment outcomes.

Heart size on chest x-ray as a predictor of cardiac enlargement by echocardiography in children

To determine the usefulness of heart size on chest radiograph (CXR) in predicting cardiac enlargement (CE) in children, we prospectively evaluated 95 consecutive outpatients, who had both a CXR and echocardiography performed. Their median age was 5.0 years (2 days to 19.9 years). All patients underwent CXR assessment by a pediatric radiologist, with classification of cardiac silhouette as normal, borderline, or enlarged. Echocardiographic assessment of CE was performed by a pediatric echocardiographer. Sensitivity, specificity, and predictive values of the pediatric radiologist's interpretation of heart size on CXR were estimated. The presence of CE by echocardiography was used as the gold standard. Seventy-nine patients (83.2%) had no CE on CXR, and 16 patients (16.8%) had CE. Sensitivity of the CXR to identify CE was 58.8%, 95% confidence interval (CI) [32.9, 81.6], with a positive predictive value of 62.5% [35.4, 84.8]. Specificity was 92.3% [84.0, 97.1], with a negative predictive value of 91.1% [82.6, 96.4]. These data suggest that the assessment of CE on CXR to predict CE by echocardiography has a relatively high specificity and negative predictive value, but a low sensitivity and positive predictive value. The limitations of CXR as a diagnostic test should be understood by clinicians using the test when screening children for cardiac disease.

Magnetic resonance imaging in a child with primary sternal osteomyelitis

Primary sternal osteomyelitis (PSO) is rare. In a 9-year-old boy with Staphylococcus aureus bacteremia, magnetic resonance imaging helped to promptly establish the diagnosis of PSO. Eleven previously reported cases are reviewed, emphasiz ing surgical drainage and antimicrobial therapy for optimal outcome. Magnetic resonance imaging may be superior to other imaging studies for the diagnosis of PSO.

Concomitant infusional paclitaxel and fluorouracil, oral hydroxyurea, and hyperfractionated radiation for locally advanced squamous head and neck cancer

PURPOSE

To improve local disease control and survival with organ preservation, we conducted a phase II multi-institutional trial with a concomitant taxane-based chemotherapy and hyperfractionated radiation regimen.

PATIENTS AND METHODS

Sixty-four patients with locally advanced squamous cancers (stage IV, 98%; N2/3, 81%) were treated on an intensive regimen consisting of 5-day (120-hour) infusions of paclitaxel (20 mg/m(2)/d) and fluorouracil (600 mg/m(2)/d), oral hydroxyurea 500 mg every 12 hours for 11 doses, and radiation 1.5 Gy bid (T-FH2X). Chemoradiation was administered concomitantly on days 1 to 5 of each 14-day cycle. A full treatment course consisted of five cycles during a 10-week period to a total radiation dose of 72 to 75 Gy.

RESULTS

The median follow-up for the group is 34 months. At 3 years, progression-free survival is 63%, locoregional control is 86%, and systemic control is 79%; overall survival is 60%. Seventeen patients died of recurrent cancer, two died of second primary cancers, and four died of other causes. Side effects observed include anemia (22% required transfusion), leucopenia (34%, grade 3 to 4), and mucositis (84%, grade 3 to 4). Organ preservation principles were maintained. At 1 year posttreatment, 61% of patients had severe xerostomia and 47% had compromised swallowing. There was little disturbance of speech quality in 97% of patients at the same follow-up point.

CONCLUSION

T-FH2X is a highly active and tolerable concomitant chemotherapy and hyperfractionated radiation regimen that induces sustained local tumor control and holds promise for improved survival with organ preservation in high-risk patients. Identification of less toxic therapy and improved distant disease control are needed. T-FH2X should be tested in a randomized trial and compared with a less intensive concomitant regimen that uses once-daily radiation fractionation.

Changes in alcoholic patients' coping responses predict 12-month treatment outcomes

Patient subtypes (Types A and B alcoholism), determinants, and outcomes associated with changes in coping responses of 133 alcoholic patients in the year following admission to treatment were examined. In general, patients' use of avoidance coping declined and use of approach coping increased. Type B patients used more avoidance coping than did Type A patients, but the subtypes did not differ in rate of change in coping. As a determinant of coping, cognitive appraisal of threat showed a trend toward predicting avoidance coping at 6- and 12-month follow-ups. Decreased cognitive avoidance coping (e.g., daydreaming) predicted fewer alcohol, psychological, and interpersonal problems. Increased behavioral approach coping (e.g.. taking action) predicted lower severity of alcohol problems. Further study of changes in the cognitive aspects of coping (i.e., appraisals and cognitive avoidance coping) is needed to determine mechanisms underlying cognitive processes associated with treatment outcomes.

A psychiatric epidemiological study of postpartum Chinese women

OBJECTIVE

Epidemiological studies in the 1980s have suggested that depression is rare in the Chinese population and there is no postpartum depression among Chinese women. However, subsequent small-scale studies of postpartum depression in China have yielded contradictory and inconsistent findings. Furthermore, after two decades of profound socioeconomic transformation, depression may no longer be rare in the contemporary population. The authors conducted a psychiatric epidemiological study among postpartum Chinese women using rigorous methodology and a representative sample.

METHOD

A total of 959 consecutive women were recruited at the antenatal clinic of a university hospital in Hong Kong. At 3 months postpartum, the prevalence and incidence rates of depression were measured with a two-phase design. The participants were first stratified by means of the 12-item General Health Questionnaire. Subsequently, all high scorers and 10% of low scorers were assessed with the nonpatient version of the Structured Clinical Interview for DSM-III-R. The 1-month and 3-month prevalence and incidence rates were estimated by using reverse weighting.

RESULTS

The 1-month prevalence rates for major and minor depression were 5.5% and 4.7%, respectively. At 3 months, the corresponding prevalence rates were 6.1% and 5.1%. Together, 13.5% of the participants suffered from one or more forms of psychiatric disorder in the first 3 months postpartum.

CONCLUSIONS

Postpartum depression is common among contemporary Chinese women. A universal postpartum depression-screening program would be useful for early detection. Our data suggest that depression may no longer be rare in the Chinese population.

Mesenchymal stem cells are capable of homing to the bone marrow of non-human primates following systemic infusion

OBJECTIVE

The human bone marrow contains mesenchymal stem cells capable of differentiating along multiple mesenchymal cell lineages. Using a non-human primate model, we sought to determine whether the systemic infusion of baboon-derived mesenchymal stem cells was associated with toxicity and whether these cells were capable of homing to and persisting within the bone marrow.

MATERIALS AND METHODS

Five baboons (Papio anubis) were administered lethal irradiation followed by intravenous autologous hematopoietic progenitor cells combined with either autologous (n = 3) or allogeneic (n = 2) mesenchymal stem cells that had been expanded in culture. In four of these baboons, the mesenchymal stem cells were genetically modified with a retroviral vector encoding either the enhanced green fluorescent protein gene (n = 3) or the human placental alkaline phosphatase gene (n = 1) for tracking purposes. A sixth animal received only intravenous gene marked autologous mesenchymal stem cells but no hematopoietic stem cells or conditioning irradiation.

RESULTS

Following culture, baboon mesenchymal stem cells appeared morphologically as a homogeneous population of spindle-shaped cells that were identified by the monoclonal antibodies SH-3 and SH-4. These cells did not express the hematopoietic markers CD34 or CD45. Baboon mesenchymal stem cells isolated from primary culture were capable of differentiating along both adipogenic and osteogenic lineages. There was no acute or chronic toxicity associated with the intravenous infusion of mesenchymal stem cells. In all five recipients of gene marked mesenchymal stem cells, transgene was detected in post-transplant bone marrow biopsies. In two animals receiving autologous mesenchymal stem cells, including the one non-conditioned recipient, transgene could be detected over 1 year following infusion. In one recipient of allogeneic gene marked mesenchymal stem cells, transgene was detected in the bone marrow at 76 days following infusion.

CONCLUSION

These data demonstrate that baboon mesenchymal stem cells: 1) are not associated with significant toxicity when administered intravenously, 2) are capable of homing to the bone marrow following intravenous infusion, and 3) have the capacity to establish residence within the bone marrow for an extended duration following systemic administration.