Function and biochemistry of the dorsolateral prefrontal cortex during placebo analgesia: how the certainty of prior experiences shapes endogenous pain relief

Prior experiences, conditioning cues, and expectations of improvement are essential for placebo analgesia expression. The dorsolateral prefrontal cortex is considered a key region for converting these factors into placebo responses. Since dorsolateral prefrontal cortex neuromodulation can attenuate or amplify placebo, we sought to investigate dorsolateral prefrontal cortex biochemistry and function in 38 healthy individuals during placebo analgesia. After conditioning participants to expect pain relief from a placebo "lidocaine" cream, we collected baseline magnetic resonance spectroscopy (1H-MRS) at 7 Tesla over the right dorsolateral prefrontal cortex. Following this, functional magnetic resonance imaging scans were collected during which identical noxious heat stimuli were delivered to the control and placebo-treated forearm sites. There was no significant difference in the concentration of gamma-aminobutyric acid, glutamate, Myo-inositol, or N-acetylaspartate at the level of the right dorsolateral prefrontal cortex between placebo responders and nonresponders. However, we identified a significant inverse relationship between the excitatory neurotransmitter glutamate and pain rating variability during conditioning. Moreover, we found placebo-related activation within the right dorsolateral prefrontal cortex and altered functional magnetic resonance imaging coupling between the dorsolateral prefrontal cortex and the midbrain periaqueductal gray, which also correlated with dorsolateral prefrontal cortex glutamate. These data suggest that the dorsolateral prefrontal cortex formulates stimulus-response relationships during conditioning, which are then translated to altered cortico-brainstem functional relationships and placebo analgesia expression.

Evaluation of the methodological quality of articles on autologous breast reconstruction

BACKGROUND

Breast cancer remains the most common cancer among women worldwide. Autologous breast reconstruction may contribute toward restoring body image and improving quality of life after mastectomy. This systematic literature review describes differences in the quality and type of studies investigating autologous breast reconstruction techniques over time.

METHODS

MEDLINE was searched for articles related to the surgical techniques, namely, TRAM, LADO, DIEP, and SGAP/IGAP, for the periods 1970 to 2007 and 2008 to 2010. The quality and type of studies were compared across the two time periods. Full-texts were evaluated according to prespecified quality criteria.

RESULTS

The MEDLINE searches yielded 1,057 articles for review; of them, 517 articles were excluded, and 314 had a completed quality criteria checklist and hence were included; of these 314 articles, 206 articles investigated TRAM flaps, 85 investigated LADO flaps, 74 investigated DIEP flaps, and 6 investigated SGAP/IGAP flaps. A total of 218 articles were published between 1970 and 2007 compared to 96 articles published between 2008 and 2010. The comparison of quality scores between the two time periods showed a shift toward higher scores in the period 2008 to 2010. The DIEP technique was investigated more frequently between 2008 and 2010 than between 1970 and 2007, whereas the percentage of articles focusing on the TRAM flap decreased. The percentage of articles investigating the LADO and SGAP/IGAP techniques remained constant across the time periods.

CONCLUSIONS

Results relating to the methodological quality of articles on breast reconstruction with autologous tissue show that the quality of publications has improved with time, whereas research interests concerning the type of surgical technique investigated have changed in focus.

[Free axillary flaps: a versatile area for harvesting of plicable flaps with a nearly undetectable scar]

BACKGROUND

This article is about 7 cases of free axillary flaps based on the lateral thoracic vessels.

PATIENTS AND METHODS

Preoperative ultrasound markings were performed. Indications were defects which needed very smooth and plicable flaps for coverage with a short and well detectable scar.

RESULTS

Flap loss was not noticed, dissection was demanding due to the very small venous drainage of the flaps and took all over 6.5 hours. A comparison with standard flaps of the subscapular vascular system is given.

CONCLUSIONS

The authors recommend the free axillary flap based on the lateral thoracic vessels as a versatile flap for special indications.

Functional Total and Subtotal Heel Reconstruction With Free Composite Osteofasciocutaneous Groin Flaps of the Deep Circumflex Iliac Vessels

Functional and esthetic reconstruction of the bony and tendinous structures with a stable, sensate soft tissue integument after complex posttraumatic defects of the heel is demanding. Cases are rare in the literature and hardly comparable due to their heterogeneity. The reconstructive approach has to consider both patient profile and the reconstructive tree, with free microvascular flaps playing a primary role. The goals are the reconstruction of both osteotendinous structures and slender soft tissue lining for proper shoe fitting for ambulation and mechanical and thermal protection. The flap should be sensate in weightbearing areas to optimize gait and to prevent long-term complications by ulcers. The osteofasciocutaneous deep inferior circumflex artery (DCIA) flap is especially suitable for complex heel defects with subtotal or total loss of the calcaneal bone as all components (iliac bone, groin skin, and fascia lata) can have a wide range of size and shape. We operated on 2 cases with this variable composite flap. One patient had a complete heel defect by war shrapnel. The complete calcaneus, soft heel, and Achilles tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and a lateral crush-induced soft tissue defect. In both patients, a stable wound closure, osseous integration, and weightbearing ambulation could be achieved.

[Myosonographic evaluation of rectus abdominis muscle function after DIEP flap breast reconstruction]

Donor-site morbidity following autologous breast reconstruction is a well-known disadvantage of free or pedicled TRAM flaps. Bulging and weakness of the abdominal wall and sometimes even hernias occur. Due to recent technical advances in microsurgery, there are different possibilities for breast reconstruction like the deep inferior epigastric perforator (DIEP) flap which is harvested without rectus muscle. First studies describe good aesthetic results without the complication of hernias and disadvantage of abdominal wall weakness. Myosonography is a new method to test the dynamic rectus muscle function and evaluate the donor-site morbidity after DIEP flap breast reconstruction. This study aims to analyze the value of myosonographic measurements to evaluate the donor-site morbidity following perforator flap elevation of the abdominal wall. Between November 2000 and August 2001, 34 patients at the Markus Hospital in Frankfurt/Main, Germany received breast reconstruction with a DIEP flap. Myosonographic examinations pre- and postoperatively were performed. Furthermore, clinical testing of rectus muscle function with the Janda score in combination with a questionnaire about impairment in daily activities and subjective opinion about discomfort took place. Two months postoperatively, myosonography showed almost identical rectus muscle function at the side of the vessel preparation compared to the contralateral side. Good aesthetic results were also achieved. The absolute muscle thickness at maximum contraction and the difference of muscle thickness between relaxation and contraction were almost identical on both sides. Myosonography is a non-invasive and inexpensive method to test rectus muscle function providing exact and reliable data. Results of this study confirm the hypothesis of lower donor-site morbidity caused by DIEP flaps compared to free or pedicled TRAM flaps. The DIEP flap method for autologous breast reconstruction is highly accepted by patients because of good aesthetic results combined with the lowest possible donor-site morbidity. After more than 180 DIEP flaps with good aesthetic results without abdominal wall hernias this method has become the "gold standard" for autologous breast reconstruction in our department.

[The free gracilis perforator flap for autologous breast reconstruction]

The free gracilis perforator flap is an alternative possibility for autologous breast reconstruction, if previous abdominal operations preclude this donor site, or if there is atypical distribution of fat tissue. The perforator flap is based on the main pedicle of the gracilis muscle. The muscle itself and its innervation can be completely preserved, if the angiosome of this vascular pedicle offers sufficient tissue. In skinny patients however it may be necessary to include the neighbouring angiosome of the second gracilis pedicle by means of the intramuscular anastomosis between both pedicles. In such a case a thin muscle strip with the joining vessel must be included in the flap. The bulk of the gracilis muscle and its motor nerve can, however, still be preserved. Breast reconstruction with this technique was successfully performed on six patients (two bilateral). It is a good alternative to a reconstruction with gluteal, or anteromedial, or lateral thigh perforator flaps.

[Facial reconstruction with microsurgical tissue transfer]

Although regional flaps are the first choice for face reconstructions, large defects require tissue transfer from other parts of the body. Pedicled musculocutaneous flaps or free flaps are then the choice. Retrospective analysis of our cases of 42 pedicled and 58 free flaps between 1990 and 1999 showed a lower complication rate for free flaps. Moreover, free flaps offer the possibility of choosing from a variety of flap types, including thin fasciocutaneous perforator flaps, bulky musculocutaneous flaps and composite flaps with vascularized bone. Complex reconstructions of the face may require chimera and prefabricated flaps. Our choice then is the scapular region, where the subscapular vessels can carry independent tissue blocks of skin, bone and muscle. We demonstrate the reconstruction of the nose, palate and alveolar crest of the maxilla with such a prefabricated chimera flap.

[Anatomy of the dorsal mid-hand arteries--anatomic study and review of the literature]

By dissections of 20 cold-preserved hands, we investigated the dorsal metacarpal arteries (DMA) with regard to reliability, origin and anastomoses. The first dorsal metacarpal artery showed a trifurcation with three vessels: Ramus ulnaris (A. metacarpalis dorsalis I), Ramus medialis and Ramus radialis (A. ulnodorsalis pollicis). The DMA II to IV were observed medially in their respective intermetacarpal spaces. The A. metacarpalis dorsalis V was unreliable in reaching the skin of dorsal proximal phalanges as in the DMA IV. Most reliable for reaching the skin of dorsal proximal phalanges were the radial arteries--first, second and third dorsal metacarpal arteries. The dorsal digital arteries originate close to one another at the level of the metacarpophalangeal joints. There was an increase of epifascial position, from radial to ulnar. Irregular palmar intermetacarpal anastomoses were found proximal to the ligamentum metacarpale transversum profundum but nearly consistently in the web space.

[A new method of microvascular anastomosis: clips with a soluble stent]

In this study, we investigated a new method of microvascular anastomosis using titanium clips combined with a soluble intraluminal stent. This method was used to perform anastomoses of the common carotid artery in five NZW rabbits and the abdominal aorta in five rabbits. Five rabbits ears were isolated on their central vascular pedicles. The central ear artery was transected and anastomosed using the stent/clip technique. In five carotid arteries, a conventional sutured anastomosis was performed. All anastomoses were patent at POD 1, 7 and 21. The average time to perform stent/clip anastomoses was significantly (p < 0.001) shorter than conventional sutured anastomoses (2.5 min vs. 9 min). There was no observable side effect from the stent material and no evidence of peripheral emboli. The stent/clip technique is an easy, fast and safe method of microvascular anastomosis.

[Surgical therapy in the second stage after burn injuries with special reference to reconstruction of face and hands]

Surgical reconstruction in the second stage after burn injury requires an individual approach. The possibilities are determined primarily by the extent of the injury. The timing of the surgery is very important, and functional, aesthetic and psychological aspects must be taken into consideration in each case. Plastic surgery is only one part of the rehabilitation of the burn patients. Examples are given of possible reconstructive procedures for the face and hands.

An in vivo screen for the luciferase transgene in zebrafish

A simple and economical large-scale in vivo screen for firefly luciferase expression in transgenic zebrafish is described. The screen is a film assay of luminescence during embryogenesis. Either luciferin substrate can be microinjected into the embryo, or the embryo can be raised in a luciferin solution. In a test of transient expression in the G0 (microinjected) generation, a construct with the human cytomegalovirus (CMV) promoter gave higher levels of expression than three other constructs. Using the CMV promoter, injection of supercoiled or linear DNA led to approximately equivalent amounts of expression. Although G0 transient luciferase expression is high enough to be reliably screened, G1 integrated expression is either low or nonexistent, and therefore unscreenable. In the G1 and G2 generations, low-level expression was increased with application of 5-azacytidine. The fact that both transgene methylation and 5-azacytidine activation of expression occurred suggests that methylation is involved in either reducing or eliminating integrated luciferase expression. This in vivo luciferase screen may be useful for insertional mutagenesis, promoter, gene, or enhancer traps, promoter analysis, and optimization of conditions for gene transfer.

[Chronic reflux esophagitis with endobrachyesophagus and multifocal adenocarcinoma]

In approximately 10% of all cases of endobrachesophagus a malignant degeneration occurs. A frequent endoscopic and bioptic control of the endobrachesophagus is the prognostic decision in order for a developing adenocarcinom to be identified in the early stages. Our casuistry demonstrates the problematic nature of the diagnostic and therapy of a multifocal adenocarcinom in an endobrachesophagus.

The concept of a Clinical Review Secretariat--evolution of a clinical review programme at Dandenong and District Hospital

In 1986 a Clinical Review Secretariat was established at Dandenong and District Hospital. It comprises a Director, co-ordinator and secretary, all on a part-time basis. The main role of the secretariat in the evaluation of patient care is that of a facilitator with the provision of organisational and computer skills with secretarial back-up and co-ordination of clinical review activities. The clinical review programme is continually evolving, however, almost two years after its inception it is felt that much has been achieved.