The distally based superficial sural artery island flap: clinical experiences and modifications

The coverage of defects of the Achilles tendon, malleoli, and heel remains a challenge to reconstructive surgeons. The distally based superficial sural artery island flap is vascularized by the median superficial sural artery, posterolateral septal perforators originating from the peroneal artery, neurovascular arteries of the sural nerve, and combinations of these systems as suprafascial plexus. We used distally based superficial sural artery island flaps for the reconstruction of defects of ankle, malleolus, and heel in 17 patients between 1991 and 1997. The largest flap we have used until today was 12 cm in width and 15 cm in length. All flaps have survived. However, we observed venous congestion and edema in two flaps. Also, marginal necrosis occurred in two flaps for which we had not taken the sural nerve with the flap. After these complications, we made some modifications. We left a skin extension over the fasciovascular pedicle and used it as a roof of the tunnel. We took the sural nerve and the deep fascia in all cases. The main advantage of this flap is a constant and reliable blood supply without sacrifice of a major artery. In addition, this is a one-stage, safe and easy procedure that can be used for large defects.

Environmental contamination during a carbapenem-resistant Acinetobacter baumannii outbreak in an intensive care unit

During a three-month period in 1999, 25 strains of carbapenem resistant Acinetobacter baumannii were isolated from 12 of 170 hospitalized intensive care unit (ICU) patients, of which 16 were considered to be clinically significant. These strains were indistinguishable by biotyping and antibiograms, but genotyping was not performed. Appropriate antibiotic treatment, isolation precautions, and infection control education of the staff failed to halt the outbreak. Environmental contamination was therefore investigated, and A. baumannii was found out in 22 (39.3%) of 56 environmental samples obtained by swabbing. Different antibiotic sensitivity patterns were obtained in the majority of these isolates, but four (7.1%) of the strains were found to have the same sensitivity pattern as the strain causing the outbreak. As a result the ICU was closed, equipment and the environment cleaned, with hypochlorite and terminal disinfection carried out. No bacteria were grown on repeat environmental cultures. Environmental contamination has an important reservoir role in outbreaks of A. baumannii in ICUs and must be eradicated in order to overcome such outbreaks.

Association between minimum inhibitory concentration, beta-lactamase genes and mortality for patients treated with piperacillin/tazobactam or meropenem from the MERINO study

INTRODUCTION

This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial.

METHODS

Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations.

RESULTS

320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam non-susceptible breakpoint (MIC > 16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% CI 2.8 - 87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3% - 15%) and 8% (95% CI 2% - 15%) for the original PA population and the post-hoc MA populations, which reduced to 5% (95% CI -1% - 10%) after excluding strains with piperacillin/tazobactam MIC values > 16 mg/L. Isolates co-harboring ESBL and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-mortality of 14% (95% CI 2% - 28%).

CONCLUSION

After excluding non-susceptible strains, the 30-day mortality difference was from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA co-harboring ESBLs suggests meropenem remains the preferred choice for definitive treatment of ceftriaxone non-susceptible E. coli and Klebsiella.

Bronchiectasis: still a problem

The prevalence of bronchiectasis (BR) has decreased significantly in industrialized countries, but is still commonplace in developing countries. We evaluated the causes and clinical features of BR in 23 children (13 boys (57%) and 10 girls (43%), with a mean age of 8.45 +/- 4.02 years). Infection was the major cause of BR in our region. In 8 patients, BR developed after tuberculosis or pneumonia, was associated with immune deficiency syndromes in 4 children, and with asthma in 4. Cystic fibrosis was diagnosed in 4 cases and ciliary dyskinesia in 3. In 10 patients, only one lobe was involved. Bronchiectatic lesions were most commonly found in the left lower lobe and were observed in 7 patients. Multilobar involvement was found in 13 patients. The initial treatment was primarily medical, but in 2 patients whose medical therapy failed, pulmonary resection was carried out. Three patients died from severe pulmonary infection and respiratory failure.

Submental artery island flap for reconstruction of the lower and mid face

Ideal reconstruction of facial defects should be accomplished by like tissue. The submental artery island flap has the same characteristics as facial tissue, consisting of thin, pliable tissue with a perfect color match. The flap can be manipulated in different configurations employing skin, the platysma, the rim of the mandible, and the anterior belly of the digastric muscle to be utilized in the reconstruction of complex defects. The pedicle of the flap is quite reliable and enables a wide range of applicability. We have used this versatile flap successfully for various defects in 14 patients and our results are presented. Ten of the 14 flaps consisted of the skin and platysma, two flaps also included the anterior belly of the digastric muscle, one flap was elevated with the rim of the mandible, and one flap consisted of skin, the platysma, bone and muscle.

Irisin immunohistochemistry in gastrointestinal system cancers

Cancer is the leading cause of morbidity and mortality worldwide. Some studies have shown that high heat kills cancer cells. Irisin is a protein involved in heat production by converting white into brown adipose tissue, but there is no information about how its expression changes in cancerous tissues. We used irisin antibody immunohistochemistry to investigate changes in irisin expression in gastrointestinal cancers compared to normal tissues. Irisin was found in human brain neuroglial cells, esophageal epithelial cells, esophageal epidermoid carcinoma, esophageal adenocarcinoma and neuroendocrine esophageal carcinoma, gastric glands, gastric adenosquamous carcinoma, gastric neuroendocrine carcinoma, gastric signet ring cell carcinoma, neutrophils in vascular tissues, intestinal glands of colon, colon adenocarcinoma, mucinous colon adenocarcinoma, hepatocytes, hepatocellular carcinoma, islets of Langerhans, exocrine pancreas, acinar cells and interlobular and interlobular ducts of normal pancreas, pancreatic ductal adenocarcinoma, and intra- and interlobular ducts of cancerous pancreatic tissue. Histoscores (area × intensity) indicated that irisin was increased significantly in gastrointestinal cancer tissues, except liver cancers. Our findings suggest that the relation of irisin to cancer warrants further investigation.

The prophylactic and therapeutic effects of glutamine- and arginine-enriched diets on radiation-induced enteritis in rats

BACKGROUND

Recent studies indicated that glutamine and arginine support the mucosal barrier in several ways. This experimental study hypothesized that administration of glutamine- and arginine-enriched diets before abdominal radiation therapy would provide a radioprotective effect on intestinal mucosa, and this would augment the therapeutic effectiveness provided by postirradiation administration.

MATERIALS AND METHODS

A rat model of radiation enteritis was designed with a single dose of 1100 cGy to the abdomen. Thirty-five rats were randomized into five groups of seven. A 7-day glutamine-enriched diet for Group I and a 7-day arginine-enriched diet for Group II were administered both pre- and postradiation. For Groups III and IV, the same glutamine and arginine diets were given, respectively, postradiation only. Group V was fed a glutamine- and arginine-free diet and was the control group. The rats underwent laparotomy for culture of mesenteric lymph nodes and removal of segments of ileum, jejenum, and colon for microscopic examination.

RESULTS

Bacterial translocation was significantly higher in Group V (P < 0.05), while intestinal villus count and villus height were significantly higher in all of the groups fed glutamine and arginine when compared with the control group (P < 0.0001 and P < 0.05, respectively).

CONCLUSION

Both arginine- and glutamine-enriched diets have protective effects on gut mucosa in the postirradiation state; however, pre- and postirradiation administration together does not provide superior protection versus postradiation administration alone.

Assessment of DNA strand breakage by comet assay in diabetic patients and the role of antioxidant supplementation

Diabetes patients often show increased production of reactive oxidative species (ROS) together with vascular complications. The presence of these ROS may lead to increased DNA damage in peripheral blood lymphocytes that may be revealed by the comet assay. To test whether DNA is damaged in diabetes, peripheral blood samples were taken from 30 control individuals and 63 diabetic patients (15 insulin dependent (IDDM) and 48 non-insulin dependent (NIDDM)) and the alkaline comet assay was used to evaluate background levels of DNA damage. Significant differences were detected between control and diabetic patients in terms of frequencies of damaged cells. The extend of DNA migration was greater in NIDDM patients by comparison with IDDM patients which might indicate that IDDM patients are handling more oxidative damage on a regular basis. Smoker individuals had higher frequencies of cells with migration by comparison with the non-smokers in both groups. Also, clear differences between patients on placebo and on Vitamin E supplementation for 12 weeks were observed on the basis of the extend of DNA migration during single cell gel electrophoresis.

TP53 mutation is an independent prognostic marker for poor outcome in both node-negative and node-positive breast cancer

TP53 gene-mutation and protein expression of p53 are described as being of prognostic importance for the outcome of breast cancer. The present study was therefore carried out to evaluate whether TP53 mutation would be a feasible prognostic marker in the routine diagnostic evaluation of breast cancer, and, in particular, to analyse the relationship between TP53 mutation and nodal status. Tumour material was obtained from women with sporadic early breast cancer. Gene mutations in exon 2-11 were identified using denaturing gradient gel electrophoresis (DGGE) as the initial scanning procedure and characterized by sequencing. All patients were treated according to the guidelines of the Danish Breast Cancer Cooperative Group for the DBCG 89 protocols. The results were correlated with clinico-pathological parameters and the prognosis evaluated by uni- and multivariate analysis using local control, freedom from distant metastasis, disease-free survival, and overall survival as endpoints. The study included 294 patients. TP53 mutations were found in 23% of cases. Mutations were significantly more frequent in tumours from patients who were node-positive and with tumours characterized as being ductal, large of size, with a high degree of anaplasia, and oestrogen receptor negative. Using univariate analysis, it was found that distant metastasis, disease-free, and overall survival were correlated to tumour size, nodal status, degree of anaplasia, oestrogen receptor status, and TP53 mutation. In addition, overall survival was also correlated to age and menopausal status. When analysed according to nodal status, TP53 mutation was found to have a significantly poor survival probability in each of the subgroups. A Cox proportional hazard analysis, including all 294 patients, demonstrated that positive nodal status and TP53 mutation were the only parameters that had an independent poor influence on the risk of developing distant metastasis and reduced recurrence-free survival. The same factors together with postmenopausal status were found to be significantly associated with increased risk of death. TP53 mutation is a strong marker for the prediction of overall and disease-free survival in breast cancer, irrespective of nodal status. A better understanding of the role of the p53 pathway, including analysis of different types of TP53 mutations, is required in order further to investigate the prognostic potential of this marker.

Significance of serotonin transporter gene polymorphism in migraine

OBJECTIVE

To elucidate significance of the serotonin transporter gene (STG) polymorphism in migraine, and to address the polymorphic patterns of STG, both in the migraineurs and healthy people in this country.

STUDY DESIGN

A PCR study of STG in 52 migraineurs and 80 healthy controls.

METHODS

Using the PCR technique, STG polymorphism was studied in the DNA obtained from leukocytes of the patients and healthy controls. Polymorphism of the two regions (VNTR and 5-HTTLPR) of STG was assessed.

RESULTS

VNTR STin 2.10 and STin 2.12 alleles were detected in migraineurs and healthy controls. Both homozygous and heterozygous STin 2.10 allele predominated in the migraine group (p=0.01), while STin 2.12 allele was more frequent in the healthy controls (p=0.02). There was no relationship between the migraine type, family history of migraine and STG polymorphism.

CONCLUSION

STin 2.10 and STin 2.12 alleles of VNTR are frequent in this country. While the presence of STin 2.10 allele increases the risk of migraine, 5-HTTLPR polymorphism is not associated with this risk.

Brain death and donor management in the intensive care unit: experiences over the last 3 years

We sought to examine the frequency of brain death in the ICU, the donation rate, and the problems encountered during donor management between the years of January 2000, the date we began treating patients with neurologic pathologies and traumatic brain injury, and March 2003. Between January 2000 and March 2003, 134 patients diagnosed with brain death in our ICU were studied prospectively for the reason of brain death, the time between admission to ICU, and the diagnosis of brain death, the frequency of diabetes insipidus, the inotrope requirement, hypothermia, electrolyte imbalance, arrhythmia, and cardiac arrest. Among the approximately 2600 patients admitted to the general 24-bed ICU, 940 had cerebral injuries. In this group, the mortality rate was 33.5% (315 out of 940 patients) including brain-dead patients. Donor care was performed in 94 patients with organs suitable for transplantation out of 134 brain-dead patients. Fifty (53.2%) out of 94 patients became organ donors. The donor ratio was 12 per million-population per year as a mean value of the study period, which was approximately 10 times higher than the average ratio in Turkey. Although we observed many life-threatening problems during donor management, none of these patients died or had acute organ dysfunction.

Blood coagulation and fibrinolysis in patients with Cushing's syndrome: increased plasminogen activator inhibitor-1, decreased tissue factor pathway inhibitor, and unchanged thrombin-activatable fibrinolysis inhibitor levels

BACKGROUND AND OBJECTIVES

Cushing's syndrome (CS) is associated with an increased cardiovascular mortality and morbidity. Chronic endogenous and exogenous hypercortisolism frequently induce a hypercoagulable and thrombotic condition. Little is known about hemostatic features of patients with CS. To our knowledge, plasma tissue factor pathway inhibitor (TFPI) and thrombin-activatable fibrinolysis inhibitor (TAFI) levels in these patients have not been investigated. Therefore, the main purpose of this study was to evaluate the markers of endogenous coagulation/fibrinolysis, including TFPI and TAFI, and to investigate the relationships between cortisol and these hemostatic parameters and serum lipid profile in patients with CS.

DESIGN AND METHODS

Twenty-four patients with CS and 24 age-matched healthy controls were included in the study. Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, factors V, VII, VIII, IX, and X activities, von Willebrand factor (vWF), antithrombin III (AT III), protein C, protein S, tissue plasminogen activator (t-PA), tissue plasminogen activator inhibitor-1 (PAI-1), TFPI and TAFI, as well as common lipid variables, were measured. The relationships between serum cortisol and these hemostatic parameters were examined.

RESULTS

Compared with the control subjects, platelet count, PT, fibrinogen, AT-III and PAI-1 were significantly increased in patients with CS (p<0.05, p<0.0001, p<0.01, p<0.05, and p<0.0001, respectively), whereas aPTT and TFPI levels were significantly decreased (p<0.0001 and p<0.01, respectively). Plasma TAFI Ag levels did not significantly change in patients with CS compared with the controls. In patients with CS, we showed a negative correlation between serum cortisol: 08:00 h and aPTT (r:-0.469, p<0.05). Serum cortisol: 24:00 h was positively correlated with PAI-1 Ag levels (r: 0.479, p<0.05).

INTERPRETATION AND CONCLUSIONS

In conclusion, we found some important differences in the hemostatic parameters between the patients with CS and healthy controls. Increased platelet count, fibrinogen, PAI-1, and decreased TFPI levels in these patients represent a potential hypercoagulable and hypofibrinolytic state, which might augment the risk for atherosclerotic and atherothrombotic complications. This condition may contribute to the excess of mortality due to cardiovascular disease seen in patients with CS.

Cytokine levels in serum of patients with juvenile rheumatoid arthritis

We investigated serum levels of interleukin (IL)-1beta, IL-6, IL-8, IL-12 and tumour necrosis factor (TNF)-alpha in JRA patients during both active and inactive phases of the disease. The systemic JRA patients had the highest IL-1beta and IL-6 levels during both active and inactive periods. In the systemic group IL-1beta, IL-6 and IL-12 levels during the active period were elevated compared to the inactive period (p = 0.0173, p = 0.0359 and p = 0.0117, respectively). Levels of these cytokines during the inactive stage were still greater than those of controls. IL-8 and TNF-alpha levels during both active and inactive periods were comparable to controls. IL-1beta correlated strongly with CRP and ESR (p = 0.008 and p = 0.031, respectively). IL-6 correlated significantly with CRP (p = 0.002). IL-12 levels were found to be correlated with ESR and CRP (p = 0.03 and p = 0.04, respectively). In active polyarticular JRA patients, IL-6 levels were elevated compared to the inactive phase, and the control (p = 0.001) IL-12 levels decreased significantly with clinical remission (p = 0.018). There was a strong correlation between 11-12 levels and number of joint with limited motion (p = 0). In oligoarticular JRA patients, IL-12 levels during active period were greater than in the controls and there was a marked decrease in IL-12 levels when the patients entered the inactive phase (p = 0.001) In conclusion, IL-1beta, IL-6 and IL-12 may play an important role in JRA and may be used as a marker of disease activity.