Forced vital capacity paired with Framingham Risk Score for prediction of all-cause mortality

Forced vital capacity (FVC) measures lung function and predicts coronary heart disease (CHD); whether it provides additive prediction over CHD risk factors has not been established. We examined whether FVC adds to the prediction of all-cause mortality provided by Framingham Risk Score (FRS) alone. We examined 5,485 (61.1 million projected) nonsmoking adults from the USA who were aged 20-79 yrs. Subjects were from the Third National Health and Nutrition Examination Survey, were without obstructive lung disease, had FVC measurements and had ≤ 12 yrs (mean 8.8 yrs) mortality follow-up. We performed Cox regression analysis to examine whether FVC and forced expiratory volume in 1 s (FEV(1)) (categorised as low ≤ 85% predicted, borderline 86-94% predicted and normal ≥ 95% predicted) within FRS groups (10-yr risk of cardiovascular disease low <10%, intermediate 10-20%, high 20%) predict mortality. Receiver operator characteristic analysis examined whether FVC and FEV(1) added to the prediction provided by FRS. Low-, intermediate- and high-risk FRS groups had 79.5% (n = 4,361), 10.1% (n = 555) and 10.4% (n = 569) persons, respectively. Only the intermediate FRS group showed a graded increase in mortality (10.7, 18.2 and 42.8% per 1,000 person-yrs from highest to lowest FVC categories, respectively); those with low FVC had an almost three-fold greater risk of mortality (hazard ratio 2.64; p<0.01) than those with normal FVC. FVC provided incremental additive value for predicting mortality in addition to FRS for only this group (area under curve 0.65 versus 0.58; p<0.05). Similar results were obtained for FEV(1). Evaluation of lung function may be useful to improve risk stratification in persons with intermediate CHD risk where it adds to prediction of mortality over global risk assessment.

Intraoperative near-infrared fluorescence imaging in perforator flap reconstruction: current research and early clinical experience

Despite recent advances in perforator flap reconstruction, there can be significant variability in vessel size and location. Although preoperative evaluation may provide valuable information, real-time intraoperative methods have the potential to provide the greatest benefit. Our laboratory has developed the Fluorescence-Assisted Resection and Exploration (FLARE) near-infrared (NIR) fluorescence imaging system for intraoperative visualization of details of the underlying vasculature. The FLARE system uses indocyanine green, a safe and reliable NIR fluorophore already FDA-approved for other indications. The system has been optimized in large-animal models for the identification of perforator size, location, and perfusion and has also been translated to the clinic for use during breast reconstruction after mastectomy. In this article, we review our preclinical and clinical data, as well as literature describing the use of similar NIR fluorescence imaging systems in plastic and reconstructive surgery.

Treatment of facial scarring: lasers, filler, and nonoperative techniques

Many techniques have been described to improve facial scars. In this review we address nonoperative strategies to manage facial scarring. Scar characteristics and anatomic location are discussed. The following nonoperative techniques are comprehensively examined: pulsed dye laser (PDL), subcision, fat transplantation, collagen injection, dermabrasion, steroid injection, and fillers. The PDL is advocated to flatten and decrease the volume of hypertrophic scars while improving texture and pliability. Dermabrasion is used to blend acne scars into the surrounding facial skin by subtly improving their contour. Fat transplantation, collagen, and filler injection is recommended in the treatment of acne depressed scars and traumatic scars with resulting contour deformity.

A review of local and regional flaps for distal leg reconstruction

Reconstruction of defects or wounds of the distal third of the leg with exposed bone, tendon, or hardware is challenging. Free tissue transfer has allowed limb salvage in many cases but requires a relatively healthy and stable patient, long operative times, and a significant expense. Small and moderate-size wounds of the distal leg may be better served by the use of local and regional flaps. Due to a better understanding of leg vascular anatomy and angiosomes, as well as more sophisticated and varied flap designs, local and regional flaps have been described and successfully used in distal leg wounds. The goal is choosing the most appropriate flap given the patient's anatomy and wound characteristics. The following review will detail the available local and regional flaps for reconstruction of the distal third of the leg with an emphasis on decision making, anatomy, flap design, and technique.

Altered proliferation and differentiation properties of primary mammary epithelial cells from BRCA1 mutation carriers

Female BRCA1 mutation carriers have a nearly 80% probability of developing breast cancer during their life-time. We hypothesized that the breast epithelium at risk in BRCA1 mutation carriers harbors mammary epithelial cells (MEC) with altered proliferation and differentiation properties. Using a three-dimensional culture technique to grow MECs ex vivo, we found that the ability to form colonies, an indication of clonality, was restricted to the aldehyde dehydrogenase 1-positive fraction in MECs but not in HCC1937 BRCA1-mutant cancer cells. Primary MECs from BRCA1 mutation carriers (n = 9) had a 28% greater ability for clonal growth compared with normal controls (n = 6; P = 0.006), and their colonies were significantly larger. Colonies in controls and BRCA1 mutation carriers stained positive for BRCA1 by immunohistochemistry, and 79% of the examined single colonies from BRCA1 carriers retained heterozygosity for BRCA1 (ROH). Colonies from BRCA1 mutation carriers frequently showed high epidermal growth factor receptor (EGFR) expression (71% EGFR positive versus 44% in controls) and were negative for estrogen receptor (ERalpha; 32% ER negative, 44% mixed, 24% ER positive versus 90% ER positive in controls). Expression of CK14 and p63 were not significantly different. Microarray studies revealed that colonies from BRCA1-mutant PMECs anticipate expression profiles found in BRCA1-related tumors, and that the EGFR pathway is up-regulated. We conclude that BRCA1 haploinsufficiency leads to an increased ability for clonal growth and proliferation in the PMECs of BRCA1 mutation carriers, possibly as a result of EGFR pathway activation. These altered growth and differentiation properties may render BRCA1-mutant PMECs vulnerable to transformation and predispose to the development of ER-negative, EGFR-positive breast cancers.

A potential role of EGFR-inhibitors for the prevention of BRCA1-related breast cancer

Abstract #1110

Background: The majority of women who develop a BRCA1-related breast cancer develop an ER-/PR-/HER2- breast cancer. Endocrine prophylaxis does not prevent these ER- breast cancers. Therefore, there is a need to develop novel chemoprevention agents in this population. 67% of BRCA1-associated ER- breast cancers also overexpress epidermal growth factor receptor (EGFR). We therefore examined EGFR as a potential target for chemoprevention&#x2028; Methods: We isolated primary mammary epithelial cells (HMECs) from women with a germline BRCA1 mutation who underwent prophylactic mastectomies and from age-matched controls without a mutation who underwent reduction mammoplasties. We used a three-dimensional matrigel-based colony formation assay to assess clonality and proliferative capacity of these cells as well as their response to EGFR-inhibition. Flow cytometry was used to determine the number of EGF binding sites per cell. As a corresponding mouse model we used conditional MMTV-Cre BRCA1-/-p53+/- mice. Results: HMECs from BRCA1 mutation carriers and from controls express EGFR to a similar extent as HCC1937 BRCA1-associated triple-negative breast cancer cells (5x103 binding sites/cell). In ex vivo 3D-cultures we observed that HMECs derived from BRCA1 mutation carriers showed greater clonal and proliferative capacity when compared to normal controls. However while the HMECs derived from BRCA1 mutation carriers and normal controls were equally sensitive to the growth-inhibitory effect of Erlotinib at concentrations as low as 0.2 μM, the ID50 for HCC1937 breast cancer cells was &gt; 10 μM. Similar findings were observed in murine MECs derived from normal control mice as well as BRCA1-/-p53+/- mice which develop breast cancer at the age of 7 to 8 months. Both groups of murine MECs were equally sensitive to Erlotinib growth inhibition. Conclusion: MECs derived from breast tissue of women and mice with a germline BRCA1 mutation express EGFR and are highly sensitive to growth inhibition with the EGFR inhibitor Erlotinib. In contrast, BRCA1-associated HCC 1937 breast cancer cells are more resistant to Erlotinib inhibition despite EGFR expression. We are now studying whether Erlotinib given via oral gavage daily has the potential to delay or prevent breast cancer in this mouse model of BRCA1-related breast cancer.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1110.

The posterior tibial artery perforator flap: an alternative to free-flap closure in the comorbid patient

Wounds of the distal third of the leg with exposed bone traditionally require free flaps for coverage. Although this often provides good results, patients with multiple comorbidities cannot undergo the long operating times and multiple surgical sites required for these complex procedures. We reviewed the use of posterior tibial (PT) perforator flaps as an alternative to free flaps for distal leg wound coverage in ill patients. Six patients (mean age, 53 years) with multiple comorbidities that precluded free-flap closures were treated with PT perforator flaps to cover complex distal leg wounds. The most common comorbidity was cardiac disease. Five patients had Gustilo grade IIIB open tibial fractures and one had a chronic wound. Mean flap size was 8x5.5 cm with a mean of one perforator per flap. Mean operating room time was 103 minutes. Four flaps were done without general anesthesia. There were no perioperative cardiopulmonary events. With a mean follow-up of 15 months, all flaps survived and all patients were ambulatory. There were no cases of malunion, nonunion, infection, wound breakdown, or partial flap loss. The PT perforator flap is a reliable choice for patients with open leg wounds and comorbidities precluding free-flap closure.

Design and impact of an intraoperative pathway: a new operating room model for team-based practice

BACKGROUND

The concept of a team-based model for delivery of care has been critical at our institution for improving efficiency and safety. Despite these measures, difficulties continue to occur during lengthy operating room procedures. Using a novel team-based practice model, a multidisciplinary team was organized to improve efficiency in microsurgical breast reconstruction. We describe development of an intraoperative pathway for deep inferior epigastric perforator (DIEP) flap breast reconstruction and its impact on various outcomes.

STUDY DESIGN

We evaluated 150 patients who underwent DIEP flap breast reconstruction at Beth Israel Deaconess Medical Center from 2005 to 2008. Patient groups were subdivided into 50 unilateral and 50 bilateral procedures before the intraoperative pathway and 25 unilateral and 25 bilateral procedures after. Outcomes measured included operative time, complications, operating room and hospital costs, proper administration of prophylactic antibiotics and heparin, and staff satisfaction surveys.

RESULTS

Mean operative times decreased after pathway implementation in both unilateral (8.2 hours to 6.9 hours; p < 0.001) and bilateral groups (12.8 hours to 10.6 hours; p < 0.001) and complication rates were unchanged. Mean operating room costs decreased in the unilateral group by 10.2% (p = 0.018). Prophylactic heparin administration showed substantial improvements, although antibiotic administration and redosing of antibiotics trended upward. Staff surveys showed improved interdisciplinary communication, transition guidelines, and enhanced efficiency through standardization.

CONCLUSIONS

Implementation of an intraoperative pathway led to improvements in operative time, cost, quality measures, and staff satisfaction. Refinement of the pathway with team resolution of variances might continue to improve outcomes. Complex, multi-team procedures can derive benefits from standardization and intraoperative pathway development.

Paradoxical venous Doppler signal: a sentinel sign of early venous congestion

We present a case of early venous congestion in a superior gluteal artery perforator flap for breast reconstruction. The case is unique because the early detection was based on a paradoxical handheld Doppler signal. During reexploration, the vessels were compressed with intermittent obstruction on inspiration. The vessels were repositioned and the flap was salvaged with no further complications. The pathophysiology of this paradoxical sentinel sign is discussed, along with other reasons leading to the outflow obstruction.

Life-threatening coagulopathy associated with use of Campath (alemtuzumab) in maintenance steroid-free renal transplant given before surgery

We report a case in which an alarming coagulopathy occurred during the operation in a patient receiving a kidney from his spouse. Campath was used for induction of immunosuppression immediately before surgery. There was catastrophic intra-abdominal bleeding associated with severe hypotension, respiratory failure, prolonged partial thrombin time (PTT), normal prothrombin time (PT) and absence of signs of disseminated intravascular coagulation. Multiple tranfusions of blood and blood products were given. Repeated explorations were carried out to secure hemostasis and removal of intra-abdominal blood clots. The coagulopathy improved after 24 h, but recurred within 3 h after the second dose of Campath, given exactly 24 h after the first dose. The coagulopathy also resulted in graft dysfunction, bilateral basal pneumonia, pleural effusions and prolonged abdominal ileus. In spite of the above, the patient went into diuresis and was discharged well after 3 weeks. He was on Prograf (tacrolimus), the sole maintenance immunosuppressor. The pathogenesis of the Campath-related coagulopathy is unclear. We wish to alert the transplant community to this unusual, but catastrophic, complication. We also advocate administering intravenous Campath following the operation, when surgical wounds are more secure and the patient is in a more stable environment.

Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap

The reconstruction of breast and upper-body deformities in massive weight loss (MWL) patients presents specific challenges to the plastic surgeon. In addition to significant breast ptosis and loss of breast volume, bariatric patients also have excessive lateral axillary and posterior truncal tissue that may require dermolipectomy for correction. A wise-pattern mastopexy was designed with a pedicled fasciocutaneous flap based on the intercostal artery perforators (ICAP) to correct breast ptosis, to restore breast volume, and to eliminate redundant upper truncal tissue. Five MWL patients underwent mastopexy with ICAP flap augmentation. All patients had stable and esthetically pleasing results 1, 3, and 6 months postoperatively. There were no complications of infection, wound dehiscence, seroma, or hematoma. Furthermore, there was no evidence of flap loss or tissue necrosis. Mastopexy with autologous augmentation using the ICAP flap was found to be a reliable method of breast reconstruction in the MWL patient.

Swelling of the Breast Following Augmentation Mammaplasty and Minimally Invasive Cardiac Surgery

Complications following breast augmentation procedures occur in the acute setting, usually in the form of hematoma, seroma, wound breakdown or infection. Late complications of augmentation mammaplasty usually manifest as either a failure of the prosthesis (eg, leak, rupture) or capsular contracture. We present an interesting case of a hematoma following augmentation mammaplasty that occurred 7 years postoperatively. What makes this case particularly intriguing is that in the time period between the augmentation mammaplasty and the late hematoma, the patient underwent minimally invasive cardiac surgery to treat a malfunctioning mitral valve. Ultimately, the breast implant was salvaged and the patient obtained a very satisfactory result. This case is important to report because as more women choose to have breast augmentation procedures and as more people have minimally invasive cardiac surgery, this clinical scenario will be encountered with greater frequency. We also make several suggestions that we feel may help avoid the problems seen with this patient in the future.

True aneurysms of the digital artery: case report

True aneurysms of the digital arteries are extremely rare; a search of the literature in English yielded only 12 cases. An idiopathic true aneurysm of the radial digital artery of the small finger is described, with its clinical presentation and corresponding arteriogram. Microsurgical repair with an interposition vein graft was performed to re-establish the vascular anatomy. To our knowledge this is the first such reconstruction reported.

Creative Strategies for Updating Knowledge on Sexually Transmitted Diseases

Updating knowledge is important in maintaining effective nursing competency. The hectic pace of health care delivery in the 1990s does not always allow for attending day-long continuing education sessions. This article presents creative teaching-learning strategies that are self-paced, interesting, and less time intensive, designed to update nurses on sexually transmitted diseases.

Injectable cartilage using polyethylene oxide polymer substrates

This study demonstrates that polyethylene oxide gels, which are biocompatible and biodegradable synthetic polymers, can be utilized for the encapsulation of isolated chondrocytes and maintenance of three-dimensional spatial support for new tissue development. Chondrocytes isolated from the glenohumeral and humeroradioulnar joints of a calf were added to a 20% polyethylene oxide solution in Ham's F-12 medium to generate a final cellular density of 10 x 10(6)/mL. The polymer-chondrocyte constructs were injected through a 22-gauge needle in 500-microliters aliquots subcutaneously in 12 nude mice and incubated for 6 and 12 weeks in vivo. Histologic and biochemical analyses including deoxyribonucleic acid and glycosaminoglycan quantitative analyses confirmed the presence of actively proliferating chondrocytes with production of a well-formed cartilaginous matrix in the transplanted samples. Control specimens from eight implantation sites consisting of chondrocytes alone or polyethylene oxide substrates did not demonstrate any gross or histologic evidence of neocartilage formation. These findings demonstrate the potential use of an injectable and moldable polymer substrate that can support cell proliferation and matrix synthesis after subcutaneous transplantation for neocartilage generation. The use of functional biologic tissue substitutes may serve as an alternative solution to current methods of augmentation or reconstruction of structural craniofacial contour deformities.

Direct selection of tetracycline-sensitive Escherichia coli cells using nickel salts

In this report, a new method for the selection of tetracycline-sensitive Escherichia coli cells from a mixed population is described. This method is simpler and more effective than previous methods, does not utilize toxic reagents, and allows selection in liquid as well as solid media. This method should be of considerable aid in molecular cloning procedures involving inactivation of the tetracycline-resistance genes encoding the energy-dependent efflux of the antibiotic, as well as in the study of the function of tetracycline-resistance elements such as transposons and integrons.

High-resolution electron microscopy of technegas and pertechnegas

Once inhaled, technegas remains in the lungs for a long period of time, whereas pertechnegas rapidly disappears. To investigate this difference, the morphology of technegas and of pertechnegas was investigated using high-resolution transmission electron microscopy. The technegas and pertechnegas were generated in an atmosphere of pure argon and in 3% oxygen in argon, respectively, using a commercially available technegas generator. For the technegas, the technetium crystals were observed to be covered with carbon, whereas they were found to have no carbon coating with the pertechnegas. Whether or not the technetium is coated with carbon appears to be responsible for the differences in behaviour of technegas and pertechnegas after deposition on the lung epithelium following inhalation.

Hemoglobins of Kiefferulus, sister genus of Chironomus (Diptera: Insecta): evolution of the Hb VIIB cluster

A genomic clone containing hemoglobin genes was isolated from a species of the chironomid genus Kiefferulus. Eight genes, including an apparent pseudogene, were sequenced and the amino acid sequences of the putative proteins were determined. By comparison to the previously described hemoglobins in the sister-genus Chironomus, they were identified as members of the dimeric Hb VIIB group. The results indicate that the existence of clusters of hemoglobin genes may be a common feature in chironomids and not just confined to Chironomus. The Kiefferulus genes show greatest similarity of amino acid sequence to Hb VIIB-7 from the Chironomus cluster. The results suggest that the ancestral cluster contained at least two gene types, one of which gave rise to VIIB-7 and the Kiefferulus genes while the other gave rise to the other Chironomus VIIB genes. Both clusters appear to have increased in size by duplication or unequal crossing over since the separation of the genera. It also appears that an unrelated gene present in the Chironomus cluster, Hb-Y, arose from a completely independent origin with no apparent equivalent gene anywhere in the genome of Kiefferulus or some other Chironomus species.