The Free Superficially Based Low-Abdominal Mini Flap for Oncoplastic Breast Reconstruction

SUMMARY

Volume replacement in oncoplastic breast reconstruction most commonly uses pedicled flaps. In thin patients with small breasts, free-tissue transfer may be better suited to preserve breast size. Evidence on microvascular oncoplastic reconstruction is limited, and reconstruction has often required sacrifice of potential future donor sites. The free superficially based low-abdominal mini (SLAM) flap uses a narrow strip of lower abdominal tissue based on superficial perfusion of the abdominal wall that is anastomosed to chest wall perforators to preserve the ability to perform future abdominally based autologous breast reconstruction. Five patients underwent reconstruction with SLAM flaps for immediate oncoplastic reconstruction. Their mean age was 49.8 years, and their mean body mass index was 23.5. Tumor location was most commonly in the lower outer quadrant (40%). Average lumpectomy weight was 30 g. Two flaps were based on the superficial inferior epigastric artery, and three, on the superficial circumflex iliac artery. Recipient vessels included internal mammary perforators (40%), serratus branch (20%), lateral thoracic vessel branch (20%), and lateral intercostal perforators (20%). All patients underwent radiation therapy without delay and maintained volume, symmetry, and contour at an average period of 11.7 months after surgery. There were no cases of flap loss, fat necrosis, or delayed wound healing. The free SLAM flap allows for immediate oncoplastic breast reconstruction in thin, small-breasted patients with limited regional tissue without sacrificing future potential donor sites for autologous breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Extreme Limb Salvage: The Thin SCIP Flap for Distal Amputation Coverage in Highly Comorbid Patients

INTRODUCTION

Limb length preservation is correlated with overall survival. Successful free flap coverage of fore-, mid- and hind-foot amputations can prevent more proximal below-knee amputations but is challenging in patients with multiple comorbidities. The thin superficial circumflex iliac artery perforator (SCIP) flap is well-suited for these patients as it provides thin, pliable tissue from a favorable donor site.

METHODS

A retrospective review of all patients with distal amputations requiring coverage with a thin SCIP flap between 2016 to 2022 was performed. Patient demographics, amputation levels, and wound characteristics as well as flap and microsurgery details were analyzed. The primary outcome was limb salvage. Secondary outcomes included partial flap necrosis, flap revision rate and additional postoperative complications.

RESULTS

Thirty-two patients (mean age 57.3) underwent reconstruction of fore-, mid- and hindfoot amputations with thin SCIP flaps (mean follow-up 36 months). Twenty-eight patients (87.5%) had diabetes, 27 (84.4%) had peripheral artery disease and 15 (46.9%) were dialysis-dependent. Average flap size was 59.5cm2 and average flap thickness was 5.7mm. Successful limb salvage was achieved in 27 patients (84.3%). Three cases (9.4%) had total flap loss. Twenty-one flaps (65.6%) had partial necrosis of which 12 (57.1%) healed with conservative management and seven (33.3 %) healed after late revision.

CONCLUSION

The thin SCIP flap is a useful option for coverage of distal pedal amputations in patients with significant comorbidities. Despite higher rates of partial flap necrosis, free flap reconstruction allowed for high rates of limb salvage in a challenging patient population.

Artificial Intelligence for Predicting and Diagnosing Complications of Diabetes

Artificial intelligence can use real-world data to create models capable of making predictions and medical diagnosis for diabetes and its complications. The aim of this commentary article is to provide a general perspective and present recent advances on how artificial intelligence can be applied to improve the prediction and diagnosis of six significant complications of diabetes including (1) gestational diabetes, (2) hypoglycemia in the hospital, (3) diabetic retinopathy, (4) diabetic foot ulcers, (5) diabetic peripheral neuropathy, and (6) diabetic nephropathy.

Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer

BACKGROUND

In 2007, we reported a summary of data comparing diabetic foot complications to cancer. The purpose of this brief report was to refresh this with the best available data as they currently exist. Since that time, more reports have emerged both on cancer mortality and mortality associated with diabetic foot ulcer (DFU), Charcot arthropathy, and diabetes-associated lower extremity amputation.

METHODS

We collected data reporting 5-year mortality from studies published following 2007 and calculated a pooled mean. We evaluated data from DFU, Charcot arthropathy and lower extremity amputation. We dichotomized high and low amputation as proximal and distal to the ankle, respectively. This was compared with cancer mortality as reported by the American Cancer Society and the National Cancer Institute.

RESULTS

Five year mortality for Charcot, DFU, minor and major amputations were 29.0, 30.5, 46.2 and 56.6%, respectively. This is compared to 9.0% for breast cancer and 80.0% for lung cancer. 5 year pooled mortality for all reported cancer was 31.0%. Direct costs of care for diabetes in general was $237 billion in 2017. This is compared to $80 billion for cancer in 2015. As up to one-third of the direct costs of care for diabetes may be attributed to the lower extremity, these are also readily comparable.

CONCLUSION

Diabetic lower extremity complications remain enormously burdensome. Most notably, DFU and LEA appear to be more than just a marker of poor health. They are independent risk factors associated with premature death. While advances continue to improve outcomes of care for people with DFU and amputation, efforts should be directed at primary prevention as well as those for patients in diabetic foot ulcer remission to maximize ulcer-free, hospital-free and activity-rich days.

Interaction of Localized Drivers and Disorganized Activation in Persistent Atrial Fibrillation: Reconciling Putative Mechanisms Using Multiple Mapping Techniques

BACKGROUND

Mechanisms for persistent atrial fibrillation (AF) are unclear. We hypothesized that putative AF drivers and disorganized zones may interact dynamically over short time scales. We studied this interaction over prolonged durations, focusing on regions where ablation terminates persistent AF using 2 mapping methods.

METHODS

We recruited 55 patients with persistent AF in whom ablation terminated AF prior to pulmonary vein isolation from a multicenter registry. AF was mapped globally using electrograms for 360±45 cycles using (1) a published phase method and (2) a commercial activation/phase method.

RESULTS

Patients were 62.2±9.7 years, 76% male. Sites of AF termination showed rotational/focal patterns by methods 1 and 2 (51/55 vs 55/55; P=0.13) in spatially conserved regions, yet fluctuated over time. Time points with no AF driver showed competing drivers elsewhere or disordered waves. Organized regions were detected for 61.6±23.9% and 70.6±20.6% of 1 minute per method (P=nonsignificant), confirmed by automatic phase tracking (P<0.05). To detect AF drivers with >90% sensitivity, 8 to 32 s of AF recordings were required depending on driver definition.

CONCLUSIONS

Sites at which persistent AF terminated by ablation show organized activation that fluctuate over time, because of collision from concurrent organized zones or fibrillatory waves, yet recur in conserved spatial regions. Results were similar by 2 mapping methods. This network of competing mechanisms should be reconciled with existing disorganized or driver mechanisms for AF, to improve clinical mapping and ablation of persistent AF.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02997254.

Neonatal lupus with congenital atrioventricular block and myocarditis

This is a case of a child with neonatal lupus and congenital atrioventricular (AV) block, born to a mother with asymptomatic, systemic lupus erythematosus (SLE). The child, despite pacemaker insertion, died of septicemia and myocarditis at the age of three months. Although the association of neonatal lupus with congenital AV block is well-recognized, there are only few pathologic studies of the conduction system reported in the literature. This is such a study in which we emphasize that, due to an altered immune system in the child, septicemia may be the cause of death in some cases.

IgA deposition in liver in alcoholic liver disease. An index of progressive injury

A retrospective study was done to evaluate the prognostic importance of the patterns of IgA deposition in the liver in alcoholic liver disease. The patterns of IgA deposition in the liver were determined by direct immunofluorescence with fluorescein conjugated rabbit antihuman IgA. Twenty of 40 patients showed a characteristic continuous pattern, and 20 patients showed the nonspecific discontinuous pattern of IgA deposition in the liver. Alcoholic liver disease progressed considerably in 14 (70%) of the 20 patients with an initial continuous pattern and in three (15%) of the 20 patients with an initial discontinuous pattern. Alcoholic liver disease did not progress in six (30%) of 20 patients with an initial continuous pattern and in 17 (85%) of the 20 patients with an initial discontinuous pattern of IgA deposition in the liver.

IgA subclasses in liver tissues in alcoholic liver disease

Examination of liver biopsy specimens from 59 patients with alcoholic liver disease and 21 nonalcoholics by immunofluorescence and immunoperoxidase methods using fluorescein-conjugated and peroxidase-labeled antisera against IgA, IgA1, IgA2, and S-IgA showed that 47 of 59 biopsy specimens from alcoholics and 0 of 21 from non-alcoholics showed a "continuous" pattern of IgA and IgA-subclass deposition (P less than 0.001). Grading the intensity of immunofluorescence on 1-4 scale, biopsies with the continuous pattern showed grade 3-4 activity against IgA2 and S-IgA and only grade 1-2 activity against IgA1. Biopsies with the discontinuous pattern showed only grade 1-2 activity against S-IgA, IgA2, and IgA1. Grade 3-4 activity was persistent in all the 47 specimens with the continuous pattern, despite pretreatment with blocking anti-IgA1, whereas 20 and 38 biopsies showed the same activity after blocking with anti-IgA2 and anti-S-IgA sera, respectively. It is concluded from these studies that IgA2 subclass formed a major subclass component contributing to the continuous pattern of IgA deposition in hepatic tissues and that the major source for this IgA in alcoholics was probably derived from the gastrointestinal tract.

IgA deposits in skin in alcoholic liver disease

IgA deposition in the liver in a characteristic continuous pattern is a consistent finding confirming the diagnosis of alcoholic liver disease. This study demonstrates a correlation between characteristic IgA deposition in the liver and IgA deposition in and around superficial dermal capillaries in alcoholic liver disease. Simultaneous liver and skin biopsies from nineteen patients with established alcoholic liver disease and eight patients with nonalcohol-related diseases of the liver were studied using standard immunofluorescent and immunoperoxidase methods. Fourteen of the nineteen alcoholic patients showed the characteristic pattern of IgA deposition in the liver, twelve of these fourteen patients showed IgA deposits in and around superficial dermal capillaries, and of these twelve patients, nine showed concurrent deposits of C3 in the skin capillaries. None of the eight nonalcoholic control patients showed either characteristic liver IgA deposits or any dermal deposits. Biopsy of clinically normal skin can be of adjunctive aid in the confirmation of alcoholic liver disease.

Patterns of IgA deposition in liver tissues in alcoholic liver disease

Observations in 136 liver biopsies from patients with alcoholic and nonalcoholic liver diseases reveal that IgA deposition in liver tissues appears to have a high degree of morphologic specificity for alcohol injury. Using a direct immunofluorescence technic with fluorescein-conjugated anti-IgG, anti-IgA, anti-IgM, and anti-C1q, four different staining patterns are recognized. These are labelled as "continuous," "discontinuous," "granular," and "pericellular" types depending on their morphologic characteristics and distribution patterns. Fifty of 64 biopsies from alcoholics showed a "continuous" pattern of anti-IgA activity while only three of 72 biopsies from nonalcoholics showed a similar pattern (P less than 0.001). A "pericellular" pattern of anti-IgA activity appears to indicate a more aggressive behavior of alcoholic liver disease. "Continuous" and "pericellular" patterns are seen in "chronic active hepatitis of alcoholics" but not in chronic active hepatitis in nonalcoholics. Anti-IgM activity appears to indicate chronicity of the disease process but does not have any specificity.

Postirradiation malignant fibrous histiocytoma of the lung. Demonstration of alpha 1-antitrypsin-like material in neoplastic cells

A metastasizing fibrous histiocytoma arising in the lung of a patient who received radiation therapy and long-term chemotherapy for malignant lymphoma is presented. Ultrastructural studies revealed fibroblast-like and histiocyte-like cells, cells of intermediate type showing ultrastructural features of both fibroblast-like and histiocyte-like cells, primitive mesenchymal cells, multinucleate tumor cells, and xanthomatous cells. The neoplastic cells showed dilated rough endoplasmic reticula with intracisternal accumulation of electron-dense material forming lattice-like structures. Direct immunofluorescence staining of the neoplastic cells using antihuman alpha 1-antitrypsin showed specific activity, with fluorescent deposits exhibiting interlacing globular formations. These findings and their implications are discussed.

Comparative ultrastructure of tubular carcinoma and sclerosing adenosis of the breast

The innocuous histologic appearance of tubular carcinoma of the breast and its superficial histologic resemblance to sclerosing adenosis will occasionally present diagnostic problems. A comparative ultrastructural analysis of two tubular carcinomas and three cases of sclerosing adenosis was made that showed definite differences in the pattern of myoepithelial cell differentiation and basal lamina deposition in these two entities. Prominent myoepithelial cells and basal lamina reduplication were both conspicuous features of sclerosing adenosis that appeared to be absent in tubular carcinoma. Intracytoplasmic "pseudocysts" were frequently found in sclerosing adenosis, but not in tubular carcinoma. Conversely, intracytoplasmic lumina and incomplete tubular structures were present in tubular carcinoma and seemingly absent in sclerosing adenosis. Such basic ultrastructural differences may help to differentiate these two mammary lesions when diagnostic problems occur at the conventional light microscopic level.

Ultrastructure of the basal cell adenoma of parotid gland

Electron microscopic examination of two classical examples of so-called basal cell adenoma of parotid gland disclosed four distinct cellular types: the squamous epithelial cells with tonofilaments and prominent desmosomes predominantly located at the central portion of neoplastic mass; the basally located secretory cells with numerous secretory granules; the occasional intermediate cells with scanty cytoplasmic microfilaments; and the peripherally situated attenuated myoepithelial cells. The neoplastic clusters are surrounded by highly replicated basal laminae with microfibrils in their interstices. This information about its component cells suggests that basal cell adenoma arises from the secretory duct, in particular the intercalated duct, of the parotid gland. The term basal cell adenoma appears appropriate for its designation. It is interesting that the secretory cells and the multilayered basal laminae illustrated in the present study are reportedly seen in adenoid cystic carcinoma of the salivary gland; this finding would suggest a common cellular origin for these two neoplasms.