Leptomeningeal Metastasis from Non-Small Cell Lung Cancer and Current Landscape of Treatments

Leptomeningeal metastasis (LM), also known as leptomeningeal carcinomatosis (LC), is a devastating complication of metastatic cancer that occurs when neoplastic cells invade the meningeal space. Diagnosis of LM remains challenging given the heterogeneous signs and symptoms at presentation and requires thorough neurological examination, cerebrospinal fluid (CSF) analysis, and MRI of the brain and spine with gadolinium. Detecting neoplastic cells in the CSF is the gold standard for diagnosing leptomeningeal metastases; however, it has low sensitivity and may require multiple CSF samples. New emerging technologies, such as liquid biopsy of CSF, have increased sensitivity and specificity for detecting circulating tumor cells in CSF. The management of LM in patients with NSCLC requires an individualized multidisciplinary approach. Treatment options include surgery for ventricular shunt placement, radiation therapy to bulky or symptomatic disease sites, systemic or intrathecal chemotherapy, molecularly targeted agents, and, more recently, immunotherapy. Targeting actionable mutations in LM from NSCLC, such as EGFR tyrosine kinase inhibitors or anaplastic lymphoma kinase gene rearrangement inhibitors, has shown encouraging results in terms of disease control and survival. Although there are limited data regarding the use of immunotherapy in LM, immunotherapy has produced promising results in several case reports. In this review, we focused on the epidemiology, pathophysiology, clinical presentation, diagnosis, and current treatment strategies, with a special emphasis on novel agents, including targeted therapies and immunotherapy of LM in patients with NSCLC.

Home-based geriatric oncology care: A feasibility study

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Background: The Comprehensive Geriatric Assessment (CGA) improves the outcomes of older patients with cancer, and by identifying of geriatric impairments the CGA can guide the development of supportive interventions. However, the implementation of these interventions in a real-world setting can be burdensome for patients, particularly when additional visits are required in an often frail population. Therefore, our team developed a collaborative model for home-based delivery of CGA-guided interventions. Methods: We performed a retrospective review of community-dwelling patients aged ≥ 70 years with an active cancer diagnosis who were deemed to be frail by a CGA and who received home-based CGA-guided supportive interventions under a collaborative care model established by the geriatric oncology and the palliative home care teams at Hartford HealthCare Cancer Institute between October 2020 and April 2022. The collaboration is based on multidisciplinary discussion of the CGA results / interventions and weekly rounds to discuss patient’s progress and emerging needs. Results: A total of 182 patients received a CGA during the study period, 54% (n = 99) were determined to be frail based on impairment in ≥ 7 geriatric domains. Among all eligible patients, 19 patients (19%) were included in the collaborative model. The median age of enrolled patients was 84 years (74-90), 12/19 (63%) had metastatic cancer, 7/19 (37%) received systemic treatment, and 8/19 (42%) received radiation. The average number of geriatric impairments per patients was 9.5 (7-12). Geriatric impairments addressed at home were skilled nursing (19/19), physical therapy (18/19), occupational therapy (12/19), speech-language-pathology (2/19), nutrition (5/19), or social worker (11/19) support at home. The average number of unplanned hospitalizations was 1.16 per patient (range 0-4), and the average unplanned emergency room visit was 0.89 per person (range 0-4) during study time. Transition to hospice occurred in 8/19 patients (42%), the median time to transition to hospice was 33.5 days (15-167). Conclusions: This study demonstrates the feasibility of a collaborative model for home-based geriatric oncology care in a real-world setting to help reduce the burden of care on patients and ensure patient-centered delivery of CGA-guided interventions. Findings underscore the need for future work to evaluate the impact of this novel geriatric oncology care model on patient outcomes.

Peritoneal Carcinomatosis as an Initial Presentation of Gastrointestinal Stromal Tumor: A Case Report and Review of the Literature

Gastrointestinal stromal tumors (GISTs) are a rare type of tumor with a high risk of malignant transformation. The majority of GISTs are asymptomatic. Surgical resection remains the mainstay of treatment given that GIST is resistant to traditional chemotherapy and radiotherapy. In the last two decades, the discovery of targeted therapy with tyrosine kinase inhibitor therapy (TKI) and widespread mutation analysis of tumors have transformed the treatment of GIST. We present a case of a patient in whom imaging findings were consistent with carcinomatous peritonitis concerning a gynecological malignancy but who was later found to have an unresectable GIST which locally regressed with TKI.

Impact of a shared-care model between community and academic centers for facilitating access to allogeneic and autologous stem cell transplantation

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Background: Despite curative or disease-controlling roles in AML/MDS and MM, access to allogeneic (allo) and autologous (auto) hematopoietic stem cell transplantation (SCT) remains far from universal. Socioeconomic status (SES) and geographic distance from SCT centers have been shown to be barriers to SCT access. In 2016, Hartford HealthCare (HHC) and the Memorial Sloan Kettering Cancer Center (MSK) pioneered a Shared-Care Model (SCM) to streamline access to allo and auto SCT at MSK, featuring a dedicated nurse SCT coordinator, shared hematology tumor boards, MSK-led didactics for HHC providers, and an electronic health record sharing pipeline. We sought to determine if this has improved access to SCT for HHC patients. Methods: A retrospective chart review was conducted of HHC patients aged 18-70 with new diagnoses of AML, MDS, and MM between 2016 and 2020. Socioeconomic status (SES) was estimated by 9-digit zip-code using the Area Deprivation Index (ADI), shown to be a surrogate for healthcare access. Referral or not to a SCT center, referral to MSK through the SCM, and reasons for non-referral were abstracted from the medical record. For patients referred for SCT at MSK, we also captured the number of peri-SCT days in New York City (NYC) and number of subsequent MSK and HHC clinic visits/hospitalizations within 1-year post-SCT. Results: A total of 126 patients was included, with 81 (64%) treated for AML/MDS and 45 (36%) for MM. The median age was 60 years (interquartile range [IQR]: 53-66). The majority were white (n = 101, 80%) followed by 10% (n = 13) Black/African American; 10% (n = 12) were of Hispanic ethnicity. The median ADI percentile was 38 (IQR: 20-51; higher percentiles reflect decreased SES). The median ADI for MSK SCT referrals from New York, New Jersey, and Connecticut 2016-2020 for the same indications was 19 (IQR: 10-30, p < 0.001). A total of 90 patients (71%) were referred to SCT centers. Leading reasons for no referral were favorable-risk disease (n = 10), goals of care (n = 9), and death prior to referral (n = 5); 3 patients were not referred due to comorbidities/performance status. No differences were found between patients referred to MSK vs. other centers. Thirty-four HHC patients were referred to MSK (21 AML/MDS, 13 MM), vs. 3 between 2010 and 2015. Twelve patients underwent allo SCT, with median 97 days in NYC (range: 68-247); 8 underwent auto SCT, with median 21 days in NYC (range: 15-48). Conclusions: Our findings show the feasibility of a shared-care model between a non-SCT-providing large regional hospital system and a major academic transplantation center. Close collaboration between institutions may minimize time patients spend away from home. The SES of HHC referrals was lower than the general MSK population, suggesting that a shared-care model may facilitate access to SCT for patients with previous barriers for this potentially curative therapy.

Not a Statin-Induced Myopathy: Metastatic Pancreatic Adenocarcinoma Presenting As Paraneoplastic Myositis

Polymyositis is an inflammatory disease that causes bilateral proximal muscle weakness; unlike dermatomyositis, it is not usually associated with malignancy. However, there are a handful of case reports documenting polymyositis in patients with lymphoma, breast, lung, and bladder cancer. Here we report a case of metastatic pancreatic adenocarcinoma disguised by presenting as polymyositis. Clinical presentation, laboratory values, muscle biopsy, and imaging were all diagnostic of paraneoplastic polymyositis. The patient has significantly improved in symptoms are receiving systemic steroids and pancreaticoduodenectomy.

An evaluation of patient workflow in hematology clinics at a university hospital referred for the workup of monoclonal gammopathy of undetermined significance (MGUS)

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Background: Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant condition that can be a precursor to multiple myeloma and lymphoproliferative disorders. There exists no best practice for the workup of MGUS, despite the number of patients diagnosed every year. We evaluated the workup of MGUS patients at a University Hospital Hematology clinic before and after implementation of an algorithm based on the Mayo Clinic Risk Stratification Model. Methods: This was a single-center IRB-approved retrospective study. Charts of 132 patients referred for MGUS were reviewed across two groups (A: June 2019 -May 2020 and B: June-Dec 2020). Use of the Mayo Clinic Risk Stratification Model for MGUS was implemented in May 2020. Data regarding initial work up, bone marrow studies and imaging were collected. Statistical analyses were performed using R software for computing (4.0.4). Results: Patient demographics and those who did not need further work up per the algorithm are summarized in table. All 86 new (100%) referrals had an initial CBC, creatinine, calcium, SPEP, and IFE while 7(8.1%) did not have an FLC assay. 43(50%) patients had a 24-hour urine protein electrophoresis. 65.1% (56/86) [group A: 26; group B: 30] met the criteria for no extended workup; 39.3% of these (22/56) underwent imaging while 7.1% (4/56) underwent bone marrow exam. After implementation of the algorithm, the number of patients who underwent imaging studies decreased from 50% (13/26) to 30% (9/30). Skeletal survey was the most ordered imaging modality (90.1%,20/22). Conclusions: Our study highlights the overutilization of imaging studies in low-risk MGUS patients. Approximately 50% of patients with MGUS are low risk with a lifetime risk of progression being less than 2%. In these patients avoiding extensive testing will minimize costs without adversely affecting clinical outcomes. We recommend a dedicated MGUS clinic to improve workup and monitoring of these patients. [Table: see text]

Targeting the αv integrin/TGF-β axis improves natural killer cell function against glioblastoma stem cells

Glioblastoma multiforme (GBM), the most aggressive brain cancer, recurs because glioblastoma stem cells (GSCs) are resistant to all standard therapies. We showed that GSCs, but not normal astrocytes, are sensitive to lysis by healthy allogeneic natural killer (NK) cells in vitro. Mass cytometry and single-cell RNA sequencing of primary tumor samples revealed that GBM tumor-infiltrating NK cells acquired an altered phenotype associated with impaired lytic function relative to matched peripheral blood NK cells from patients with GBM or healthy donors. We attributed this immune evasion tactic to direct cell-to-cell contact between GSCs and NK cells via αv integrin-mediated TGF-β activation. Treatment of GSC-engrafted mice with allogeneic NK cells in combination with inhibitors of integrin or TGF-β signaling or with TGFBR2 gene-edited allogeneic NK cells prevented GSC-induced NK cell dysfunction and tumor growth. These findings reveal an important mechanism of NK cell immune evasion by GSCs and suggest the αv integrin/TGF-β axis as a potentially useful therapeutic target in GBM.

Doege-Potter Syndrome with a Benign Solitary Fibrous Tumor: A Case Report and Literature Review

Doege-Potter syndrome is a rare paraneoplastic syndrome that is often diagnosed incidentally during the workup of hypoglycemia of unclear etiology. It is characterized by a non-islet cell tumor hypoglycemia secondary to excessive production of partially processed IGF-II hormone from a solitary fibrous tumor (SFT). Often these tumors are intrathoracic, benign, and asymptomatic. Occasionally they present as a paraneoplastic event; hypertrophic osteoarthropathy in Pierre-Marie-Bamberger syndrome and hypoglycemia in Doege-Potter syndrome. The NAB2-STAT6 gene fusion is the hallmark of the SFT. Complete surgical resection of the tumor often results in resolution of symptoms and cure in most cases. Here we present the case of an 83-year-old non-diabetic female with recurrent syncopal events who was diagnosed with the Doege-Potter syndrome secondary to a SFT of pleura. Her tumor was positive for NAB2-STAT6 gene fusion on RT-PCR. Following the resection of the giant tumor mass, she became symptom-free within 24 h, and has remained asymptomatic at 4 months follow-up.

Targeting a cytokine checkpoint enhances the fitness of armored cord blood CAR-NK cells

Immune checkpoint therapy has resulted in remarkable improvements in the outcome for certain cancers. To broaden the clinical impact of checkpoint targeting, we devised a strategy that couples targeting of the cytokine-inducible Src homology 2-containing (CIS) protein, a key negative regulator of interleukin 15 (IL-15) signaling, with fourth-generation "armored" chimeric antigen receptor (CAR) engineering of cord blood-derived natural killer (NK) cells. This combined strategy boosted NK cell effector function through enhancing the Akt/mTORC1 axis and c-MYC signaling, resulting in increased aerobic glycolysis. When tested in a lymphoma mouse model, this combined approach improved NK cell antitumor activity more than either alteration alone, eradicating lymphoma xenografts without signs of any measurable toxicity. We conclude that targeting a cytokine checkpoint further enhances the antitumor activity of IL-15-secreting armored CAR-NK cells by promoting their metabolic fitness and antitumor activity. This combined approach represents a promising milestone in the development of the next generation of NK cells for cancer immunotherapy.

Classification of alveolar bone destruction patterns on maxillary molars by using cone-beam computed tomography

OBJECTIVE

The defective diagnosis of alveolar structures is one of most serious handicaps when assessing available periodontal treatment options for the prevention of tooth loss. The aim of this research was to classify alveolar bone defects in the maxillary molar region which is a challenging area for dental implant applications. To our knowledge, this is the first study of periodontal bone defect prevalence by using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

In this study, the remaining alveolar bone patterns of 669 maxillary molars of 243 patients with periodontal bone loss were investigated on four aspects and the furcation areas of teeth, and then they were classified into six main groups. Combined periodontal-endodontic lesions (CPELs) were also reported in another category.

RESULTS

Following exclusion of 39 (5.8%) teeth with CPEL, the most common group was horizontal bone defects (71.4%) and the least seen group was three-walled vertical bone defects (1.9%) in all alveolar bone sides of teeth. Osseous crater was found at the rate of 6.7% on interdental alveolar bone. Dehiscence and fenestration were detected at rates of 2.7% and 3.3%, respectively. In the assessment of furcation areas, there was no furcation involvement in 61.4% of all teeth and the rate of Grade-II involvements was 26.2%.

CONCLUSIONS

The most appropriate treatment option may be decided through accurate imaging of periodontal defect morphology. CBCT can provide comprehensive information about the remaining alveolar bone structures. In this way, the need for dental implant can be prevented in many cases and be replaced with a more conservative approach on the maxillary molar region.

Effect of enzymes on strawberry volatiles during storage, at different ripeness level, in different cultivars, and during eating

Strawberry samples with enzyme activity and without enzyme activity (stannous chloride added) were measured for real-time formation of lipoxygenase (LOX) derived aroma compounds after 5 min pureeing using selected ion flow tube-mass spectrometry (SIFT-MS). The concentration of (Z)-3-hexenal and (E)-2-hexenal increased immediately after blending and gradually decreased over time, while hexanal concentration increased for at least 5 min in ground strawberries. The formation of hexanal was slower than the formation of (Z)-3-hexenal and (E)-2-hexenal in the headspace of pureed strawberries. The concentration of LOX aldehydes and esters significantly increased during refrigerated storage. Damaging strawberries increased the concentration of LOX aldehydes but did not significantly affect the concentration of esters. The concentrations of many of the esters were strongly correlated to their corresponded acids and/or aldehydes. The concentration of LOX-generated aldehydes decreased during ripening, while fruity esters increased. Different varieties had different aroma profiles and esters were the greatest percentage of the volatiles. The aroma release of some of the LOX-derived aldehydes in the mouthspace in whole strawberries compared to chopped strawberries showed that these volatiles are formed in the mouth during chewing. The persistence of LOX-derived compounds was higher than esters after swallowing. The mouthspace after and before swallowing persistence ratio of esters decreased as the chain length of the acid part of the ester compounds increased in whole strawberries.

PRACTICAL APPLICATION

The storage studies showed that the concentrations of fruity and fresh volatiles increased during ripening and storage while damaging only increases the fresh volatiles. The nose, mouth, and headspace information can be used in the flavor industry to improve the formula of natural strawberry flavor by considering human perception during eating.

A limited and useful approach to determine proximal periodontal health

Previous researchers have shown that there exists an interaction between gingival blood flow and gingival health. The purpose of this study was to compare the papillary blood flow at sites treated by a bridge with the blood flow at untreated sites. Twenty persons with resin-bonded fixed partial dentures were included in the study. The contralateral natural teeth of the site symmetrical to that of the restorations were used as controls. Blood flow was measured from the middle point of the papillae from both test and control sites by Laser Doppler Flowmetry (LDF). The plaque index, papillary bleeding index and probing depth measurements were recorded. There was a statistically significant difference between the test and control sites in papillary blood flow measurements and clinical indices (p < 0.05). Moreover there was statistical significance between gingival blood flow measurements and papillary bleeding index in the experimental group (p < 0.05). In short, there exists an important relationship between resin-bonded fixed partial dentures and papillary blood flow. Although there were no correlations between LDF values and clinical parameters, it can be emphasized, within the limits of the study, that LDF readings have limited diagnostic value, at least when it comes to clinical performance of fixed prosthesis.

Functional reconstruction of the lateral face after ablative tumor resection: use of free muscle and musculocutaneous flaps

BACKGROUND

Wide resection of tumors of the middle third of the face often results in complex three-dimensional defects and facial paralysis either due to removal of the facial nerve within the tumoral tissue or to extensive resection of the facial muscles.

METHODS

We report the cases of three patients who underwent wide excision of tumors of the cheek region, operations that resulted in tissue defects and facial palsy. Defect reconstruction and facial reanimation was accomplished in one stage through functional muscle transplantation.

RESULTS

Follow-up of more than 1 year showed good symmetry at rest and reanimation of the corner of the mouth in all cases, but one patient, in which the ipsilateral facial main trunk was used as motor nerve supply to the transplanted muscle, developed significant muscle contracture and binding of the cheek skin.

CONCLUSIONS

Every effort should be made to optimize the functional and cosmetic outcomes of neurovascular muscle transfers through precise planning and careful execution of the intricate details of the surgical technique for muscle transplantation.

Chitosan film enriched with an antioxidant agent, taurine, in fenestration defects

A natural polysaccharide, chitosan (poly-N-acetyl glucosaminoglycan), which is a nontoxic and bioabsorbable polymer, has been shown to have hemostatic and antibacterial effects. An amino acid, taurine, is considered to be beneficial for regulating the inflammation process. The purpose of this study was to investigate the synergistic effects of taurine and chitosan in the experimental defects at the vestibular bone of maxillary canine teeth in six dogs. Chitosan films were prepared as delivery system with or without taurine and placed in the randomly chosen defects. Biopsies were performed on the postoperative seventh day and routine histological procedures were performed for light and electron microscopic evaluations. For each group, 30 different microscopic areas were examined and the numbers of macrophages and neutrophils in these areas were counted. The mean numbers of both macrophages and neutrophils were found statistically different between the chitosan film incorporated with taurine and free chitosan groups (p < 0.0001 p > 0.05). In addition to the increase in cell counts in both groups, the cytological alterations were more obvious in the chitosan film group incorporated with taurine. Accordingly, taurine appears to enhance the acceleration effect of chitosan on wound healing at early periods. This effect could be considered beneficial in tissue repair in destructive diseases like periodontitis.

Partial necrosis of an amputated penis following replantation in a heavy smoker: a case report

A case of penile amputation in a heavy smoker who was treated by microsurgical replantation is presented. The penis was cut by a kitchen knife and the ischaemia time until revascularisation was 3 hours. Following successful microneurovascular repair the penis survived. However, a 3 cm portion of the ventral segment, including the corresponding urethral segment, sloughed. The adverse effects of nicotine on vascular anastomotic network in heavy smokers are well known and may be the cause of the partial necrosis in this case.

Osteocutaneous flap prefabrication based on the principle of vascular induction: an experimental and clinical study

Conventional osteomyocutaneous flaps do not always meet the requirements of a composite defect. A prefabricated composite flap may then be indicated to custom create the flap as dictated by the complex geometry of the defect. The usual method to prefabricate an osteocutaneous flap is to harvest a nonvascularized bone graft and place it into a vascular territory of a soft tissue, such as skin, muscle, or omentum, before its transfer. The basic problem with this method is that the bone graft repair is dependent on the vascular carrier; the bone needs to be revascularized and regenerate. The bone graft may not be adequately perfused at all, even long after the transfer of the prefabricated flap. This study was designed to prefabricate an osteocutaneous flap where simply the bone nourishes the soft tissues, in contrast to the conventional technique in which the soft tissue supplies a bone graft. This technique is based on the principle of vascular induction, where a pedicled bone flap acts as the vascular carrier to neovascularize a skin segment before its transfer. Using a total of 40 New Zealand White rabbits, two groups were constructed as the experimental and control groups. In the experimental group, a pedicled scapular bone flap was induced to neovascularize the dorsal trunk skin by anchoring the bone flap to the partially elevated skin flap with sutures in the first stage. After a period of 4 weeks, the prefabricated composite flaps (n = 25) were harvested as island flaps pedicled on the axillary vessels. In the control group, nonvascularized scapular bone graft was implanted under the dorsal trunk skin with sutures; after 4 weeks, island composite flaps (n = 15) were harvested pedicled on the cutaneous branch of the thoracodorsal vessels. In both groups, viability of the bony and cutaneous components was evaluated by means of direct observation, bone scintigraphy, measurement of bone metabolic activity, microangiography, dye injection study, and histology. Results demonstrated that by direct observation on day 7, the skin island of all of the flaps in the experimental group was totally viable, like the standard axial-pattern flap in the control group. Bone scintigraphy revealed a normal to increased pattern of radionuclide uptake in the experimental group, whereas the bone graft in the control group showed a decreased to normal pattern of radioactivity uptake. The biodistribution studies revealed that the mean radionuclide uptake (percent injected dose of 99mTc methylene diphosphonate/gram tissue) was greater for the experimental group (0.49+/-0.17) than for the control group (0.29+/-0.15). The difference was statistically significant (p<0.01). By microangiography, the cutaneous component of the prefabricated flap of the experimental group was observed to be diffusely neovascularized. Histology demonstrated that although the bone was highly vascular and cellular in the experimental group, examination of the bone grafts in the control group revealed necrotic marrow, empty lacunae, and necrotic cellular debris. Circulation to the bone in the experimental group was also demonstrated by India ink injection studies, which revealed staining within the blood vessels in the bone marrow. Based on this experimental study, a clinical technique was developed in which a pedicled split-inner cortex iliac crest bone flap is elevated and implanted under the medial groin skin in the first stage. After a neovascularization period of 4 weeks, prefabricated composite flap is harvested based on the deep circumflex iliac vessels and transferred to the defect. Using this clinical technique, two cases are presented in which the composite bone and soft-tissue defects were reconstructed with the prefabricated iliac osteomyocutaneous flap. This technique offers the following advantages over the traditional method of osteocutaneous flap prefabrication. Rich vascularity of the bony component of the flap is preserved following transfer (i.e. (ABSTRACT

Vaginectomy and laparoscopically assisted vaginal hysterectomy as adjunctive surgery for female-to-male transsexual reassignment: preliminary report

OBJECTIVE

Reassignment surgery of the female-to-male transsexual is a rarely performed surgical procedure that should involve a gynecologist's consultation and expertise. This study examines the experience with this type of surgery at Baskent University Hospital, Ankara, Turkey, from the gynecologists' point of view.

STUDY DESIGN

Eight patients underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy and total vaginectomy, followed by phallic construction. Patients were followed up for 9 to 30 months post-surgery.

RESULTS

The average operative time for total vaginectomy and laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy was 2 h and 20 min. The estimated average blood loss was 250 ml. Other than one bladder perforation, which was repaired immediately and healed uneventfully, we encountered no operative or postoperative complications linked to the gynecologic surgery.

CONCLUSION

Laparoscopy seems to be useful in female-to-male transsexual surgery in allowing the preservation of structures vital for phallic construction, such as inferior epigastric vessels and the rectus abdominis muscle. The application of vaginectomy awaits justification through long-term follow-up studies of transsexuals who have undergone colpocleisis.

Orbicularis oculi myocutaneous flap in reconstruction of postburn lower eyelid ectropion

The management of postburn lower eyelid ectropion is difficult, since the contraction of the skin graft may give rise to secondary deformities especially around the lateral 1/3 of the lower eyelid. In this paper, the results of reconstruction in lower eyelid ectropion with a laterally based orbicularis oculi myocutaneous flap from the upper eyelid in 7 young patients are presented. Satisfactory function and cosmesis were obtained in the evaluation of the patients up to 40 months follow-up. The method proved versatile as the donor scar was well-hidden in the supratarsal fold and the temporally based myocutaneous flap provided additional support to the lower eyelid by exerting an upward pull against the gravity. It is concluded that usage of this flap in postburn ectropion cases is worthwhile to avoid any recurrences. reserved.

Evaluation of initial attachment of human gingival fibroblast cells to biodegradable membranes in vitro by light and scanning electron microscopy

Guided tissue regeneration procedures using resorbable membranes have become accepted therapy for treating periodontal defects. Resorbable collagen and synthetic polylactide and polyglycolide copolymer membranes have been found to support regeneration and preclude the need for surgical removal. This study was undertaken to assess and compare the initial attachment of human gingival fibroblast cells to four collagen-based membranes (fascia lata, fascia temporalis, dura mater, and Type I bovine collagen) and a synthetic polylactic acid-based membrane (resolut). Human gingival fibroblasts were grown from explants of normal tissue obtained during surgical reduction of retromolar tissues. Membrane specimens were placed in separate culture wells and incubated with fibroblasts for one hour. The number of adherent cells was evaluated by light microscopy using an ocular grid system and detailed examination was performed by scanning electron microscopy. The results of evaluation by light microscopy indicated that initial cell attachment was significantly less in the polylactic acid-based membrane group than in the collagen-based membrane groups (P < 0.01). However, no significant differences were found among the collagen membrane groups in terms of fibroblast attachment (P > 0.01). Scanning electron microscopy examination of fibroblasts cultured directly on barrier membranes indicated that the collagen-based membranes appeared to facilitate cell attachment, whereas the polylactic acid-based membrane exhibited a morphology that was not conducive to attachment of human gingival fibroblasts. Based on these limited in vitro results, it appears that collagen-based membranes offer greater potential than polylactic acid-based membranes for guided tissue regeneration at surgical sites.

Perioperative dilation for vessel-size discrepancy using a percutaneous transluminal angioplasty catheter

The problem of vessel-size discrepancy is still unsolved in microvascular-free tissue transfers. In an effort to develop a technique perioperatively to dilate smaller vessel diameters, the authors utilized a catheter customarily used in coronary angioplasties, the percutaneous transluminal coronary angioplasty (PTCA) catheter. Twenty New Zealand rabbits were divided into two groups: Group 1 consisted of 14 experimental animals; Group 2 of six control animals. In both groups, a segmental defect of 2 cm was created in the proximal portion of the femoral artery just below the inguinal ligament, where the vessel diameter is 2.0+/-0.1 mm. In Group 1 animals, an arterial graft was harvested from the superficial femoral artery in the contralateral lower extremity, where the vessel diameter is 1.0+/-0.1 mm. The arterial graft along its entire length was dilated, using a PTCA catheter up to 2 mm in diameter. The duration of dilation was 3 min with pressure applied at 2.5 atm. Before and following dilation, sections were obtained from both ends of the graft for histologic comparison. The grafts were then interposed within the defect and microvascular anastomoses were performed. In the control group, an arterial graft of the same length as in the experimental group was harvested from the contralateral upper femoral region, where the vessel diameter is 2.0+/-0.1 mm. These grafts were then interposed within the defect and microsurgically anastomosed. Seven days later, the patency of the anastomoses was evaluated in both groups. In 13 of 14 rabbits in the experimental group, the anastomoses were patent and the arterial grafts maintained their dilated diameters (2 mm). In all six control animals, the anastomoses were patent. A statistical comparison of vessel patency using Fischer's exact chi-square test showed no significant differences between the experimental and control groups (p = 0.7). Histologically, the dilated arteries demonstrated intact endothelial layers.

Modified adjustable technique to anchor the levator muscle to the flap used in total upper eyelid reconstruction

Total, full thickness loss of the upper eyelid due to trauma, was reconstructed using the Mustardé total upper lid reconstruction method. The immobile flap was then anchored to the avulsed levator muscle at a second stage, using the technique described by Collin and O'Donnell for the correction of eyelid ptosis. We modified the technique by using two rows of anchor sutures instead of one and found it effective in raising the reconstructed eyelid in the traumatic case presented.

An investigation of resorption and tissue reaction after subcutaneous implantation of collagen based membrane materials in rats

This study was undertaken to assess histologically the response to collagen based membrane materials that might be used for guided tissue regeneration (GTR) procedures, using a subcutaneous model on the dorsal surface of the rat. The commercially available materials included absorbable type I bovine collagen barrier, fascia lata, fascia temporalis and dura mater membranes. In the study 20 Wistar rats were used 80 implant materials were placed under general anaesthesia. Animals were sacrificed 7, 14, 28 and 42 days post-implantation. The specimens were assessed histologically for the composition of the tissue surrounding the membranes, the types of cells in infiltrate and the degree of resorption. It was concluded that these membrane materials were well tolerated and were gradually resorbed. Light microscopic examination showed that the type I bovine collagen and fascia lata were resorbed faster but fascia temporalis and dura mater were resorbed more slowly at 42 days. In addition the resorption process was continuing and these materials were evident histologically at 42 days.

Combined use of root conditioning, fibrin-fibronectin system and a collagen membrane to treat a localized gingival recession: a 10-case report

The purpose of this research was to evaluate the effectiveness of combined root surface conditioning with tetracycline HCI, fibrin sealing system, guided tissue regeneration procedure and coronal sliding flap application in the treatment of localized gingival recessions. The present study was conducted on 10 patients with localized facial recessions of at least 3mm. A trapezium-shaped flap was elevated apically to the margin of the bone dehiscence and the root surface was thoroughly scaled by hand instruments and burs. Tetracycline HCI (pH 1.9) solution was then topically applied for 5 minutes and the root surface thoroughly rinsed with sterile saline. A collagen membrane was trimmed and shaped to cover the entire root surface and later removed and a fibrin sealing system injected onto the root surface. Immediately membrane was placed again on the root surface without applying any pressure. The flap was sutured in the coronal position to completely cover the root surface and membrane. Control group patients were treated with only coronal sliding flap operation. Sutures were removed 10 days after surgery. Patients were clinically reevaluated 6 months postoperatively. The mean amount of root surface coverage obtained was similar in the test and control groups (test = 71.7%; control = 68.55%) but the clinical attachment gain (test = 4.21mm; control = 2.86mm) and pocket depth variations (test = 1.14mm reduction; control = 0.07mm reduction) differed significantly (P < 0.001). This study found promising healing of localized gingival recessions to result from a combined use of tetracycline HCI root demineralization, fibrin sealing system application, guided tissue regeneration procedure and coronal sliding flap operation.

Augmentation of random-flap survival by implantation of vascularized fascia allografts and temporary immunosuppression: implications for flap fabrication

The purpose of this study was to explore the possible use of an allogeneic vascular source for flap fabrication. Epigastric fascia with its superficial epigastric vessel pedicle was harvested from the donor rat and microsurgically revascularized in the recipient rat across a major histocompatibility barrier. ACI rats (Rtl-a) served as donors, and Lewis rats (Rtl-1) served as recipients. The recipient rat was immunosuppressed with a daily dose of 2 mg/kg cyclosporin A plus 5 mg/kg prednisone for 4 weeks. Three experiments were performed for skin, muscle, and bone studies. In experiment 1 (20 Lewis rats), placement of the allotransplanted fascia underneath the epigastric skin significantly improved the survival of a random epigastric skin flap raised 3 weeks later (7.35 +/- 0.65 cm2 versus 6.09 +/- 0.90 cm2, p < 0.05). Immunosuppression was discontinued 10 days after flap elevation with no observable additional skin necrosis. In experiment 2 (13 Lewis rats) and experiment 3 (14 Lewis rats), segments of isogeneic muscle and bone were grafted successfully on the allotransplanted fascia, respectively. The survival of these grafts was confirmed by metabolic bone activity, bone labeling, microangiography, and histologic studies and further confirmed 2 weeks after cessation of immunosuppression. An allotransplanted fascia as a vascular source proved in this model its capability to improve the survival of a random skin flap and to accept a free bone or muscle graft with temporary immunosuppression. These findings hold promise for possible use of an allogeneic vascular source in flap fabrication.

The effects of periodontal therapy on serum antibody levels to Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis (part II)

Levels of IgG and IgM antibodies were estimated against Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis were determined by enzyme linked immunosorbent assay (ELISA) in 17 patients with juvenile periodontitis, 15 with adult periodontitis and 24 healthy controls at the beginning of treatment and 3 to 8 months after periodontal therapy. After treatment, antibodies to A. actinomycetemcomitans and P.gingivalis had decreased in patients, but the levels were still significantly higher than in healthy controls. Whether or not an of antibody level against a specific bacteria changes after periodontal treatment is however, still debatable.

Serum antibodies to Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis in juvenile periodontitis and adult periodontitis (part I)

Recent microbiological studies support the concept that specific gram negative bacteria play a major role in the etiology and pathogenesis of human chronic inflammatory periodontal disease. Actinobacillus actinomycetemcomitans has been isolated frequently from juvenile periodontitis and Porphyromonas gingivalis has been shown to be a prominent species in adult periodontitis in humans. The purpose of this study was to determine levels of the specific antibodies to A.actinomycetemcomitans and P.gingivalis in 17 patients with juvenile and 15 patients with adult periodontitis and 24 healthy subjects. IgG and IgM antibody titers against these antigens were determined by enzyme-linked immunosorbent assay (ELISA). The levels of antibodies against A.actinomycetemcomitans were significantly higher in the juvenile periodontitis compared to the adult periodontitis patients and controls. Anti-P.gingivalis antibodies were elevated in adult periodontitis compared to juvenile periodontitis patients and controls.

Sharing the radial forearm flap in reconstruction of two separate defects in the same patient

The radial forearm flap is used extensively to cover defects for which a thin skin flap is needed. It can be used either as a pedicle or a free flap in various designs. In this case report, a new application of this flap is presented in which two flaps were created out of a single radial forearm flap to cover two separate defects. One of the flaps was a distally based reverse island flap. We used this flap to cover a defect developed by releasing a burn contracture on the flexor surface of the thumb. The other flap consisted of the proximal portion of the forearm flap and was transferred to the neck region as a free flap to cover a defect resulting from the release of a burn contracture. The radial artery allows sharing the fasciocutaneous unit of the forearm into two different flaps and transferring them to separate areas. Thus, donor site morbidity is reduced when there is more than one defect to be reconstructed.

Macrodactyly: report of eight cases of a rare anomaly

Macrodactyly or megalodactyly is a rare anomaly of the extremities. Neural factors are involved in the etiology. Presented here are eight cases which comprise five macrodactylous toes and three fingers. The mean age at first referral was 6.8 years. Six patients underwent resection of the proximal phalanges together with bulk reduction of the soft tissue mass. Only soft tissue reduction was performed in the remaining two patients. Skin necrosis was observed in two cases, one of which necessitated amputation at the proximal interphalangeal joint level. The functional outcome was evaluated as poor with limited range of motion and stiffness in the joints. As far as functional results are concerned, macrodactylous toes had a better prognosis than that of fingers. It was concluded that none of the available methods as yet gives ideal functional and cosmetic results in macrodactyly.

Accessory nose associated with unilateral incomplete cleft lip

We describe a 6-month-old Turkish girl who was found to have a mass near her nose at birth and incomplete cleft lip. No other clinical and radiological abnormalities were demonstrable elsewhere in her body. Histological examination of the excised mass showed an organoid structure that was consistent with an accessory nose.

Use of membranes containing 20% chlorhexidine and 40% doxycycline for treatment of chronic periodontal pockets

A study was carried out to compare the effects of subgingival applications of resorbable hydroxypropylmethylcellulose (HPMC) membranes containing 20% chlorhexidine (CHx) and 40% doxycycline (DOXY) placed subgingivally in periodontal pockets greater than 5 mm in depth. Each of 11 patients had at least four pockets. HPMC strips containing CHx and DOXY were inserted into each pocket twice a week for 6 w. One pocket was kept as a control and the other received subgingival scaling and root planing at 0, 1, 3 and 6 w. The microbial flora of 44 pockets from the 11 patients was examined using dark-field microscopy at the baseline and at 1, 3, 6 and 10 w. Clinical parameters including probing depth, crevicular fluid flow, bleeding on probing and gingival shrinkage were also recorded. The CHx and DOXY-administered or root-planed pockets showed marked reduction of both pocket depth and the number of motile organisms. Less bleeding was also observed in CHx and DOXY-inserted pockets.

Comparison of the antibacterial effects on subgingival microflora of two different resorbable base materials containing doxycycline

A study was conducted to evaluate the effects of local drug delivery on subgingival plaque flora using hydroxypropylmethylcellulose (HPMC) and methylcellulose (MC) base material containing 40% doxycycline (DOXY). Eleven patients who had at least four pockets exceeding 5 mm in depth associated with a single rooted tooth were selected from volunteers after an initial examination. Two of the pockets were chosen at random for insertion of the HPMC and MC strips twice a week for 6 w. One pocket received no treatment, and the other was debrided and root-planed only. Baseline and follow-up measurements at 0, 1, 3, 6, and 10w included probing depth, gingival shrinkage, bleeding on probing and crevicular fluid flow. Subgingival bacterial samples were also taken for dark-field microscopy. In vitro drug release from the HPMC strips was greater than that from MC. Significant improvements in many clinical parameters occurred in the pockets treated with HPMC or MC strips, or mechanical debridement. There was a marked decrease in the relative proportions of motile organisms during and after treatment.

Vascularized nerve tube: an experimental alternative for vascularized nerve grafts over short gaps

Multilayered tubes fabricated from human amnion were placed subcutaneously and/or longitudinally in contact with an axial artery and vein in rats. Histologic evaluation at the third postoperative week showed that the tubes had incorporated with the surrounding fibrovascular tissue. New capillary formation within the tube wall was well demonstrated by microangiography. Vascularized amnion tubes were then used to bridge a 1-cm-long femoral nerve gap in an artificially-created, relatively avascular bed in rats. An avascular bed was created by wrapping the corresponding nerve segment with a thin silicone sheet. After 3 months, nerve regeneration was assessed using morphometric analysis. The vascularized amnion conduits showed comparable nerve regeneration to vascularized nerve grafts (p > 0.05), and superior nerve regeneration when compared to nonvascularized amnion conduits and nonvascularized nerve grafts as well (p < 0.05). This suggests that, in the rat model, a conduit can be neovascularized and used as a prefabricated tissue, to bridge short nerve gaps in a compromised bed.

Microvascular ear replantation with no vein anastomosis

In replantation of a totally amputated ear, the artery only was repaired with no vein repair. Venous stasis was successfully prevented by daily skin punctures during the first 4 days postoperatively. The elastic cartilage framework with no internally circulating blood constitutes the major percentage of the auricle mass. Thus the metabolic demand of the ear is relatively small, according to its small caliber nutrient vessels. Although the successful result in this single case report means neither a consistent procedure nor uniformly safe choice of treatment, the potential use of the single-artery repair with no accompanying vein anastomosis in ear replantations, we believe, deserves to be considered.

Ultraviolet-A induced delayed wound contraction and decreased collagen content in healing wounds and implant capsules

Chronic exposure to ultraviolet-A radiation causes changes in the biochemistry of dermal connective tissue. To investigate its effects on wound healing, we irradiated Sprague-Dawley rats for 4 months using a black ray ultraviolet-A radiation source (560 J/cm2). Full thickness skin wounds of 2 cm in diameter were then created on the back of each animal and silicone cubes were implanted subcutaneously into the irradiated area of the back. Wound contraction in the irradiated animals (n = 28) was significantly slower than that of the controls (n = 29) (p < 0.001). Postoperatively, the hydroxyproline content of the contracted wounds and the implant capsules was assessed at 6 and 12 weeks, respectively. In the irradiated animals, it was found to be significantly less than that of the controls (p < 0.001). A delay in wound contraction and a decrease in hydroxyproline content of healing wounds and implant capsules, reflecting an alteration in collagen metabolism, are two effects of prolonged intermittent ultraviolet-A radiation pretreatment.

Nerve regeneration in a bony bed: vascularized versus nonvascularized nerve grafts

In a rabbit model, regeneration of the intratemporal facial nerve was studied as vascularized and nonvascularized nerve grafts. Fifteen New Zealand white rabbits weighing 4 to 4.5 kg were used. A 1-cm gap was created in the intratemporal facial nerve. In the vascularized nerve graft group (group 1), the facial nerve was repaired with a vascularized median nerve graft (n = 6), while in the nonvascularized nerve graft group (group 2), the median nerve was used as a nonvascularized graft (n = 6). In group 3, the facial nerve gap was left unrepaired (n = 3). At 3 months postoperatively, electrophysiologic testing, morphologic nerve study, and morphometric muscle analysis were performed. Although the mean numerical values of axonal counting, nerve conduction, and morphometric muscle study results were slightly better in the vascularized nerve graft group, the differences between the two grafted groups were not statistically significant (p > 0.05). Morphometric nerve analysis, i.e., axon diameter and myelin sheath thickness, showed significant differences in nerve regeneration between the two groups (p < 0.05). These results suggest that a bony bed is not optimal for neovascularization of a nerve graft. We conclude that vascularized nerve grafts are superior to nonvascularized nerve grafts when nerve regeneration occurs in a bony recipient bed. This might be of clinical importance in the repair of facial nerve lesions within the temporal bone.

A simple technique for harvesting standardized skin grafts in the rodent

A simple technique for harvesting skin grafts of predetermined size, shape, and thickness in rodents is described. In this technique, the donor skin is immobilized and tensed by means of a tongue depressor, or similar template, inserted into the loose areolar tissue below the panniculus, stretching the overlying skin to permit easy dermatome harvesting of a skin graft.

An anatomical, morphological and electrophysiological study of the rabbit facial nerve in the temporal bone

Anatomical, histological and electrophysiological features of the rabbit facial nerve in the temporal bone are described for research purposes. Based upon the findings the rabbit intratemporal facial nerve is surgically accessible and consists of a constant axon number and myelin sheath thickness. As a valid model the rabbit intratemporal nerve can be readily utilized for research studies in nerve regeneration pertinent to the facial nerve in this region.

Blood flow to human gingiva measured by the 133Xe clearance technique

Blood flow to the maxillary and mandibular gingivae was determined in 9 subjects under both normal conditions and in inflammation using the 133Xe clearance technique. A total of 36 sites (18 healthy and 18 inflamed) were selected for 133Xe injection. The clearance of radioactivity was monitored by a gamma camera. The calculated mean blood flows were 51.1 +/- 11.4 and 48.7 +/- 6.7 ml/100 g/min to the normal maxillary and mandibular gingivae, respectively. In inflamed gingiva, the corresponding mean blood flows were 55.0 +/- 13.0 and 54.7 +/- 11.7 ml/100 g/min, respectively. A statistical comparison of the healthy and diseased sites was done according to the paired t and Student's t tests. The difference between the sites was not significant (p > 0.05) in the maxilla, but significant (p < 0.05) in the mandible. There was no significant difference (p > 0.05) when the total healthy and diseased sites were compared.

A new vascularized nerve graft model in the rabbit

The macro- and microanatomy of the rabbit median nerve were studied for the purpose of developing a vascularized nerve graft (VNG) model. A segment of median nerve was then designed as a vascularized graft to serve as a model. This model consists of a 1-cm long median nerve segment and its accompanying brachial artery and vein 3 cm in length, with an arteriovenous fistula created distally. The model was tested by using the VNG to repair an intratemporal facial nerve defect and proven to be reliable. Its monofascicular pattern and diameter match those of the reconstructed facial nerve, making this model unique, compared to other models previously described.

A new flap model in the rat

Standardized skin flap models in the rat, such as the McFarlane and Finseth flaps, have suggested placement on the rat of only a single flap. The single flap, because of variations in skin vasculature among rats, may be problematic and require prohibitively large numbers of rats to obtain statistically significant results. In this study of 60 Sprague-Dawley rats, we have developed a flap model designed to be paired in a single rat and standardized to serve as the experimental flap and the control. At the level of the symphysis pubis, symmetrical, three-sided, caudally based, bilateral skin flaps, 2 cm in width, were extended to different bony landmarks. Only the length of the flaps was varied. The inferior epigastric pedicle was then divided. The flap length, which optimally produced predictable and persistent necrosis, was found midway between the xiphoid and the sternal notch. The model was pharmacologically manipulated with the injection of superoxide dismutase through the epigastric vein before division of the inferior epigastric pedicle; this scavenger did not effect the survival of the random pattern flaps.

The trauma of suction-assisted lipectomy cannula on flap circulation in rats

The effect of suction-assisted lipectomy on cutaneous blood vessels of inguinal skin flaps was studied and compared in 191 rats. Different types of cannula tips were used; the number of passes was standardized. In one experiment, following suctioning, 3 X 2 cm groin island flaps based on inferior epigastric pedicles were raised and then reattached. Fluorescein dye study and microangiography were performed to evaluate flap viability. Flap survival was determined clinically and by histologic examination on the fifth postoperative day. Three-sided inguinal random-pattern flaps were raised in a second experiment and reattached following suctioning. On the fifth postoperative day, surviving flap areas were measured using standard photographs and an imaging computer and were compared with controls. Results showed that cannula passes accompanied by vacuum are harmful to vessels, while those unaccompanied by vacuum are not. The greater the number of suctioning passes, the more trauma there is to vessels and the greater is the likelihood of flap necrosis. Conical and spatula tips were more harmful to vessels than spherical, cobra, keel cobra, or Fournier tips. These results support the conclusion that suction-assisted lipectomy enhances the possibility of skin necrosis by traumatizing the vascular pedicle of a flap, especially when it is used as an adjunct to flap elevation.