Review of 100 consecutive microvascular free flaps

AIM

To analyse the outcome of microvascular free flap reconstructions in Middlemore Hospital (South Auckland, New Zealand).

METHOD

100 consecutive free flap reconstructions from January 2004 to April 2010 were identified from the Middlemore Hospital Theatre Coding List. Basic patient demographics and indication for surgery along with free flap types were recorded and outcomes were analysed.

RESULTS

The free flap success rate was 96%. There were 21 short term complications without any perioperative mortality. The most common complication was flap infection (7/21) followed by vascular thrombosis (6/21 venous and 1/21 arterial). Other complications included partial ischaemic flap (3/21), haematoma (2/21), venous congestion (1/21) and partial wound dehiscence (1/21). Fourteen flaps needed salvage procedures in the operating theatre including eight cases for re-anastomosis of vessels. The overall successful salvage rate was 71% resulting in four failures. The successful salvage rate following re-anastomosis of vessels was 63%.

CONCLUSION

Overall success and salvage rates for free flap reconstructions at our plastics and reconstruction centre are comparable to that of international literature. Diligent postoperative monitoring and early return to theatre for re-exploration is the key to ensuring maximal free flap success.

Various doses of fractioned irradiation modulates multidrug resistance 1 expression differently through hypoxia-inducible factor 1α in esophageal cancer cells

To evaluate the effect of different regimen of radiotherapy on multidrug resistance 1 (MDR1) expression and analyze the role hypoxia-inducible factor 1α (HIF1α) played in the whole process. Fifty-four cell lines established from 96 esophageal cancer biopsy samples were given various doses of fractioned irradiation. The mRNA and protein levels of HIF1α and MDR1 post-irradiation were measured by quantitative reverse transcription-polymerase chain reaction and Western blot analysis, respectively. HIF1α-siRNA was used to verify the effect of HIF1α on radiation-mediated MDR1 modulation. In esophageal cancer cells surviving 28 Gy irradiation (2 Gy/f, 14 fractions), MDR1 mRNA expression increased 65.27 ± 5.58%, and HIF1α was elevated by 27.21 ± 2.25%. Interestingly, their expression decreased by 54.38 ± 11.53% and 32.08 ± 4.75% after 7 Gy irradiation (0.5 Gy/f, 14 fractions). HIF1α expression showed a positive correlation with MDR1 expression in the whole process (P < 0.05). Silencing of HIF1α decreased MDR1 expression and blocked changes in MDR1 and HIF1α expression induced by fractioned irradiation. These results indicate that MDR1 is differentially modulated by different doses of fractionated radiation, which should be taken into account when combining radiotherapy and chemotherapy for patients with esophageal cancer.

Valproate versus diazepam for generalized convulsive status epilepticus: a pilot study

BACKGROUND AND PURPOSE

Evidence-based data to guide the management of status epilepticus (SE) after failure of primary treatment are still scarce and the alternate needs to be found when phenytoin (PHT) is not available or contraindicated. Comparison of intravenous (IV) valproate (VPA) and diazepam (DZP) infusion has not been conducted in adults with SE. This prospective randomized controlled trial is thus designed to evaluate the relative efficacy and safety of IV VPA and continuous DZP infusion as second-line anticonvulsants.

METHODS

After failure of first-line anticonvulsants treatment, patients with generalized convulsive status epilepticus (GCSE) were randomized to receive either IV VPA or continuous DZP infusion. Primary outcome was the proportion of patients with effective control. Side effects were also evaluated.

RESULTS

There were 66 cases enrolled, with the mean age of 41 ± 21 years. Seizure was controlled in 56% (20/36) of the DZP group and 50% (15/30) of the VPA group (P = 0.652). No patient in the VPA group developed respiratory depression, hypotension, or hepatic dysfunction, whereas in the DZP group, 5.5% required ventilation and 5.5% developed hypotension. Time (hour) for regaining consciousness after control was near-significantly longer in the DZP group [13(3.15-21.5)] than in the VPA group [3(0.75-11)] (P = 0.057). Virus encephalitis and long duration of GCSE were independent risk factors of drug resistance.

CONCLUSIONS

  Both IV VPA and continuous DZP infusion are effective second-line anticonvulsants for GCSE. IV VPA was well tolerated and free of respiratory depression and hypotension, which may develop in the DZP group. Outcome parameters were not significantly different between groups.

Seeing patients first: creating an opportunity for practice nurse care?

INTRODUCTION

Practice nurses see patients in both a planned (i.e., scheduled appointment) and an unplanned (i.e., opportunistic) manner. This study aimed to investigate how often and why New Zealand practice nurses see patients prior to the general practitioner and whether they organise their care to support unplanned, opportunistic activity.

METHOD

National postal survey from a random sample of 500 general practices, requesting a response from one nurse per practice. Semi-structured telephone interviews with a purposeful sample of respondents.

FINDINGS

Responses came from 225 nurses (51% of practices confirmed to be eligible). Nearly all (92%) said their work role was the same as that of others in their practice. Only 13% of nurses routinely saw patients prior to the doctor, while 24% would choose to do so it they could, and 65% thought it important. Positive and negative aspects of seeing patients first are presented. Constraints included time, their role assisting practice workflow and perceptions of patient expectations. Few organised their work to create opportunities for lifestyle interventions.

CONCLUSION

The current working environment of practice nurses in New Zealand does not readily support them routinely seeing patients before the general practitioner. We suggest this is a lost opportunity for patient-centred preventive care.

Seeing patients first: creating an opportunity for practice nurse care?

INTRODUCTION: Practice nurses see patients in both a planned (i.e. scheduled appointment) and an unplanned (i.e. opportunistic) manner. This study aimed to investigate how often and why New Zealand practice nurses see patients prior to the general practitioner and whether they organise their care to support unplanned, opportunistic activity. METHOD: National postal survey from a random sample of 500 general practices, requesting a response from one nurse per practice. Semi-structured telephone interviews with a purposeful sample of respondents. FINDINGS: Responses came from 225 nurses (51% of practices confirmed to be eligible). Nearly all (92%) said their work role was the same as that of others in their practice. Only 13% of nurses routinely saw patients prior to the doctor, while 24% would choose to do so it they could, and 65% thought it important. Positive and negative aspects of seeing patients first are presented. Constraints included time, their role assisting practice workflow and perceptions of patient expectations. Few organised their work to create opportunities for lifestyle interventions. CONCLUSION: The current working environment of practice nurses in New Zealand does not readily support them routinely seeing patients before the general practitioner. We suggest this is a lost opportunity for patient-centred preventive care. KEYWORDS: Practice nursing roles; opportunistic interventions; work organisation; primary health care; chronic conditions

A systematic review on endoscopic detection rate, endotherapy, and surgery for pancreas divisum

BACKGROUND AND STUDY AIMS

The rates for endoscopic detection of pancreas divisum at routine endoscopic retrograde cholangiopancreatography (ERCP) vary worldwide, and the sample sizes in the reported studies on endoscopy and surgery for pancreas divisum are very small and variable. The aim of this study was to systematically analyze the pooled data and determine endoscopic detection rates for pancreas divisum and pain relief rates in patients with pancreas divisum after endotherapy or surgery.

MATERIALS AND METHODS

A search for published data was performed by using the Medline database (1950 to 1st May 2008) with "pancreas divisum" as the keyword. Publications, mainly on endoscopic detection rate, endotherapy, or surgery for pancreas divisum, were deemed relevant, and were further fully reviewed and analyzed.

RESULTS

A total of 615 abstracts were retrieved from Medline; 17 articles on endoscopic detection rate, 15 articles on endotherapy, and 13 articles on surgery were included in the review and analysis. The overall endoscopic detection rate for pancreas divisum was 2.9% (899/31,413), with the rate being significantly higher in the United States (5.8%) and Europe (6.0%) than in Asia (1.5%) (both P < 0.001). The pooled overall response rates (i. e. complete and partial pain relief rates after treatment) to endotherapy (69.4%, 361/520) and surgery (74.9%, 203/271) were similar (P = 0.106). In addition, there were significant differences in the combined response rates (for endotherapy and for surgery) between patients with pancreas divisum of acute recurrent pancreatitis (ARP)-type (81.2 %) compared with chronic pancreatitis-type (68.8%), and between ARP-type and pain-type (53.1%) (both P < 0.05).

CONCLUSIONS

The endoscopic detection rate for pancreas divisum is much higher in western countries than in Asian countries. The pooled response rates of patients with pancreas divisum to endotherapy and surgery are similar in the reported series. Patients with ARP-type pancreas divisum respond better to endotherapy or surgery than those with chronic pancreatitis-type and pain-type.

Prospective observational study of acute coronary syndromes in China: practice patterns and outcomes

OBJECTIVE

To describe the investigation and management of patients admitted to hospitals in China with suspected acute coronary syndromes (ACS) and to identify potential areas for improvement in practice.

DESIGN

A multicentre prospective survey of sociodemographic characteristics, medical history, clinical features, in-hospital investigations, treatment practices and major events among patients with suspected ACS.

SETTING

Large urban public hospitals.

PATIENTS

Consecutive patients admitted to in-patient facilities with a diagnosis of suspected acute myocardial infarction (MI) or unstable angina pectoris.

MAIN OUTCOME MEASURES

Myocardial infarction/re-infarction, heart failure, death.

RESULTS

Between September 2004 and May 2005, data were collected prospectively from 2973 patients admitted to 51 hospitals in 18 provinces of China. An initial diagnosis of ST elevation MI, non-ST elevation MI and unstable angina was made in 43%, 11% and 46% of patients, respectively. Diagnosis was inconsistent with objective measures in up to 20% of cases. At both tertiary and non-tertiary centres, there was little evidence that clinical risk stratification was used to determine the intensity of investigation and management. The mortality rate during hospitalisation was 5% overall and similar in tertiary and non-tertiary centres, but reported in-hospital re-infarction rates (8%) and heart failure rates (16%) were substantially higher at non-tertiary centres.

CONCLUSION

This study has identified a number of areas in the management of ACS patients, including diagnosis and risk stratification, which deviate from current guidelines. These findings will help inform the introduction of widely used quality improvement initiatives such as clinical pathways.

First Report of Spirea Witches'-Broom Disease in China

Bumald spirea (Spiarea bumalda Burv.) is an important ornamental tree widely grown in northern China. In August of 2006, spirea plants exhibiting symptoms of witches'-broom, stunting, yellowing, and shoot dieback were found at an incidence of 5 to 15% in Qingzhou City, Shandong Province, China. Total DNA was extracted separately from 0.1 g of phloem tissue from leaf midribs and stems of six symptomatic and six asymptomatic plants with a modified cetyltriethylammonium bromide (CTAB) method (3). Resulting DNA samples were analyzed for phytoplasma DNA by a nested PCR assay using phytoplasma universal 16S rDNA gene primer pairs R16mF2/R16mR1 and R16F2n/R16R2 (2). These primers amplified 1.5- and 1.2-kb products, respectively, from DNA of all symptomatic plants only. Restriction fragment length polymorphism (RFLP) analysis of the 1.2-kb 16S rDNA product using enzymes AluI, MseI, and HhaI indicated that all symptomatic plants contained a group 16SrI (aster yellows group) subgroup B (16SrI-B) phytoplasma strain (4). A 16S rDNA sequence derived from this strain (GenBank Accession No. EF176608) was most similar (99.8 and 99.6%) to those of severe aster yellows (GenBank Accession No. M86340) and Maryland aster yellows (GenBank Accession No. AF322644) phytoplasmas, respectively, thereby confirming strain identity based on RFLP analysis. A phytoplasma (Spiarea stunt phytoplasma, GenBank Accession No. AF190228), which belongs to X-disease group (16SrIII), was reported to infect spirea and probably be lethal to S. tomentosa in New York (1,4). The phytoplasma reported here shared low identity (90.8%) with Spiarea stunt phytoplasma, but also caused dieback of spirea shoots. The epidemiology and economic impact of this disease need further intensive investigation. To our knowledge, this is the first report of spirea witches'-broom disease and of its association with a subgroup 16SrI-B phytoplasma in China. References: (1) H. M. Griffiths et al. Can. J. Plant Pathol. 16:255, 1994. (2) D. E. Gundersen and I.-M. Lee. Phytopathol. Mediterr. 35:144, 1996. (3) Y. Qi et al. Biotechnol. Bull. 4:44, 2004. (4) The IRPCM Phytoplasma/Spiroplasma Working Team-Phytoplasma Taxonomy Group. Int. J. Syst. Bacteriol. 54:1243, 2004.

Effects of immunosuppressive drugs on in vitro neogenesis of human islets: mycophenolate mofetil inhibits the proliferation of ductal cells

Assuming that neogenesis contributes to long-term function of islet grafts, it is important to study the effects of immunosuppressive drugs on precursor cell proliferation and differentiation. We examined the effects of low-dose immunosuppressive drugs on these processes in vitro. Immunosuppressive drugs, including sirolimus, tacrolimus, mycophenolate mofetil (MMF), daclizumab and their combinations were tested in parallel culture wells through either the expansion phase (5-7 days) or the entire culture period (4-5 weeks). MMF, alone or in combination with sirolimus or tacrolimus, severely hampered duct-cell proliferation by 8-fold during the expansion period, and significantly reduced the total DNA content by about 40% after 5-week culture. After 4-5 week exposure to different drugs, only sirolimus and daclizumab showed no adverse effects on insulin content, whereas significant reductions of 30-60% in insulin content were seen in all other experimental groups. Only tacrolimus decreased the insulin content per DNA, as well as the proportion of insulin-positive cells. In conclusion, MMF has a potent inhibitory effect on neogenesis primarily through an antiproliferative effect on the precursors, whereas tacrolimus mainly affects beta-cell differentiation. Sirolimus and daclizumab have no adverse effects on these parameters. The immunosuppressive protocol may be an important determinant of long-term clinical islet graft function.

Conversion from cyclosporine to mycophenolate mofetil improves expression of A20 in the rat kidney allografts undergoing chronic rejection

AIMS

Cytoprotective genes have shown to display potent anti-inflammatory and antiapoptotic functions in endothelial and smooth muscle cells. We investigated whether cytoprotective genes, especially A20, were involved in mycophenolate mofetil (MMF)'s ability to ameliorate transplant arteriosclerosis in an experimental chronic rejection model.

METHODS

Sprague-Dawley rat renal grafts were orthotopically transplanted into Wistar rats following the procedure of Kamada with our modification. The recipients were divided into three oral treatment groups: (1) vehicle group (cyclosporine [CsA] 10 mg/kg.d x 10 d followed by vehicle), (2) CsA group (CsA 10 mg/kg.d x 10 d followed by CsA 6 mg/kg.d), (3) MMF group (converted from CsA 10 mg/kg.d x 10 d to MMF 20 mg/kg.d on day 11). At the same time points after transplantation, the rats were sacrificed to harvest the renal allografts. The expression of four cytoprotective genes, A20, heme oxygenase (HO)-1, Bcl-2, and Bcl-XL, was analyzed by quantitative reverse-transcriptase polymerase chain reaction and immunohistochemistry.

RESULTS

The four-cytoprotective genes were all detected in rat kidney allografts undergoing chronic allograft nephropathy. The expression of A20 in grafted kidneys was significantly higher in the MMF than in the CsA or the vehicle group (P < .01). There was no significant difference between the CsA and the MMF groups in the expression of HO-1, Bcl-2, and Bcl-XL.

CONCLUSIONS

We demonstrated that MMF improved the expression of A20 in rat kidney allografts undergoing chronic allograft nephropathy. The correlation between MMF and A20 provide an explanation for the mechanism by which MMF ameliorates transplant arteriosclerosis in an experimental animal model of chronic rejection.

The effects of different immunosuppressants on chronic allograft nephropathy by affecting the transforming growth factor-beta and Smads signal pathways

OBJECTIVE

This study investigated the effects of various immunosuppressants on chronic allograft nephropathy (CAN) by affecting transforming growth factor-beta (TGF-beta) and Smads signal pathway.

METHODS

Vascular smooth muscle cells (VMSC) from rat aorta were incubated for 6 or 12 hours with various immunosuppressants. Cyclosporine (CsA) (3 microg/mL), FK506 (1 microg/mL), mycophenolate mofetil (MMF) (0.3 microg/mL), rapamycine (Rapa) (10 microg/mL), CsA (1 microg/mL/MMF 0.3 microg/mL). We used the Sprague-Dawley Wistar rat accelerated kidney sclerosis model. Before transplantation, the kidney was preserved 1 hour in 0 degrees C to 4 degrees C heparin sodium chloride solution to reinforce the cold ischemia injury. The rats were divided into eight groups (each group n = 8): group A, pseudo-OP; group B, isotransplantation; group C, CsA 6 mg/kg . d; group D, FK506 0.15 mg/kg . d; group E, MMF 20 mg/kg . d; group F, Rapa 0.8 mg/kg. d; group G, CsA 3 mg/kg . d + MMF 20 mg/kg . d. The serum creatinine levels and pathological changes, according to the Banff scheme, were observed at 2, 4, 6, 8 and 12 weeks posttransplantation. Immunohistochemistry and quantitative fluorescence polymerase chain reactions were used to end localize and quantitate the expression of TGF-beta1 and Smad 2, 3, 7 in VMSC and in the transplanted kidney.

RESULTS

CsA and FK506 stimulated gene expression and protein production of TGF-beta1, smad2, and smad3, but inhibited expression of smad7 both in VSMC and in the transplanted kidney. In contrast, MMF and Rapa down-regulated gene expression and protein production of TGF-beta1, smad2, 3 while up-regulating expression of smad7. There was no significant difference between the CsA group and the FK506 group, as well as the MMF group and the Rapa group. The group treated with CsA + MMF was similar to the MMF and the Rapa groups.

CONCLUSION

Our study suggested that various immunosuppressants affected differentially TGF-beta1 and Smads signal pathways in rat VSMC and kidney grafts. CsA and FK506 can cause CAN, owing to up-regulated expression of smad2 and smad3, and down-regulation of smad7 expression. MMF and Rapa can prevent the CAN progression, because of down-regulation of the expression of smad2 and smad3, with increased smad7 production.

Expression of fractalkine, CX3CR1, and vascular endothelial growth factor in human chronic renal allograft rejection

AIM

Fractalkine/CX3CR1 system may contribute to the pathogenesis of renal allograft chronic rejection (CR). Vascular endothelial growth factor (VEGF) is an endothelial mitogen, which shows increased expression in inflammation and vasculopathy. This study sought describe the expression and distribution of Fractalkine/CX3CR1 and VEGF, and their relationship to human renal allograft CR.

METHODS

Renal tissue from 10 patients with CR was examined for Fractalkine/CX3CR1 and VEGF protein by immunohistochemistry for comparison with patients displaying hyperacute rejection (n = 10), acute rejection (n = 10), and normal kidneys (n = 10). All patients were selected based upon histologically proven diagnoses between 1992 and 2003.

RESULTS

Immunohistochemistry revealed that Fractalkine/CX3CR1 were mostly expressed in the tubulointerstitium and tubular epithelial cell basolateral membrane. Some vessels showed positive staining for Fractalkine/CX3CR1 as well as occasionally glomerular parietal wall cells. Among the CR group, VEGF was mostly expressed in tubular epithelium and the tubulointerstitium. A proportion of glomeruli and vessels had positive staining for VEGF, which was up-regulated most strikingly in the interstitial compartment in CR. There was markedly increased expression of Fractalkine/CX3CR1 and VEGF protein in the interstitium of the CR compared with other groups (P < .05). VEGF colocalized with the expression of Fractalkine/CX3CR1.

CONCLUSION

Fractalkine/CX3CR1 and VEGF may play an important role in the development of interstitial fibrosis via mononuclear cell-induced cytokine production and myofibroblast stimulation in CR. Further studies are necessary to identify the role in the pathogenesis of CR.