Staging of symptomatic primary breast cancer with MR imaging

OBJECTIVE

This study was designed to investigate the accuracy of contrast-enhanced MR imaging in the locoregional staging of symptomatic primary breast cancer and to determine the impact of contrast-enhanced MR imaging in planning surgical management.

MATERIALS AND METHODS

Ninety patients with primary breast cancer (including two bilateral cancers) diagnosed and treated on the basis of conventional triple assessment (clinical, cytologic, and mammographic examination) underwent MR imaging at 1.0 T using a three-dimensional fast low-angle shot T1-weighted pulse sequence before and after contrast enhancement. A short inversion time inversion recovery sequence was also obtained to evaluate the axilla of each patient. After resection, tumors were histopathologically mapped in detail and correlated with the extent of contrast enhancement on MR imaging.

RESULTS

On the basis of triple assessment, 53 cancers were treated by wide local excision, of which 17 (32%) had positive margins at excision. Residual disease at reexcision was detected in eight of these 17 patients, a finding that correlated accurately with the extent of contrast enhancement on MR imaging. MR imaging was more accurate than mammography in determining invasive tumor size (r2 = .93 versus r2 = .59), in depicting multifocality and extensive intraductal component (sensitivity, 81% versus 62%), and in assessing nipple-retroareolar complex. MR imaging-histopathologic correlation was possible in 75 axillae. Sensitivity and specificity for axillary node metastases were 90% and 82%, respectively.

CONCLUSION

MR imaging of the breast has value in the preoperative locoregional staging of symptomatic primary breast cancer and is useful in planning a single definitive surgical resection in patients with breast cancer.

Clinical study and literature review of nasal irrigation

OBJECTIVES/HYPOTHESIS

Nasal disease, including chronic rhinosinusitis and allergic rhinitis, is a significant source of morbidity. Nasal irrigation has been used as an adjunctive treatment of sinonasal disease. However, despite an abundance of anecdotal reports, there has been little statistical evidence to support its efficacy. The objective of this study was to determine the efficacy of the use of pulsatile hypertonic saline nasal irrigation in the treatment of sinonasal disease.

STUDY DESIGN

A prospective controlled clinical study.

METHODS

Two hundred eleven patients from the University of California, San Diego (San Diego, CA) Nasal Dysfunction Clinic with sinonasal disease (including allergic rhinitis, aging rhinitis, atrophic rhinitis, and postnasal drip) and 20 disease-free control subjects were enrolled. Patients irrigated their nasal cavities using hypertonic saline delivered by a Water Pik device using a commercially available nasal adapter twice daily for 3 to 6 weeks. Patients rated nasal disease-specific symptoms and completed a self-administered quality of well-being questionnaire before intervention and at follow-up.

RESULTS

Patients who used nasal irrigation for the treatment of sinonasal disease experienced statistically significant improvements in 23 of the 30 nasal symptoms queried. Improvement was also measured in the global assessment of health status using the Quality of Well-Being scale.

CONCLUSIONS

Nasal irrigation is effective in improving symptoms and the health status of patients with sinonasal disease.

Preoperative drinking does not affect gastric contents

We have compared the effect of allowing free clear fluids until the time of oral premedication with conventional preoperative fasting. In a prospective, randomized trial, the residual volume and pH of gastric contents after induction of anaesthesia were measured in 100 elective surgical patients allocated randomly to a group in whom the intake of free clear fluids up to the time of premedication was measured (mean 388 ml in 6 h before surgery) or a control group who were fasted for 6 h. Preoperative drinking did not affect either mean (SD) residual gastric volume (22 (21) ml in the study group vs 19 (16) ml in the control group) or pH (study group 2.64 (1.57) vs control group 2.26 (1.45)). The study group experienced less preoperative thirst. Problems with aspiration or regurgitation were not encountered. We believe that allowing elective surgical patients to drink clear fluids until 2 h before anaesthesia may enhance patient comfort without compromising safety.

Androgen-behavior correlations in hypogonadal men and eugonadal men. II. Cognitive abilities

Sex-typed cognitive abilities were assessed in 33 hypogonadal men receiving testosterone replacement therapy, 10 eugonadal men receiving testosterone in a male contraceptive clinical trial, and 19 eugonadal men not administered testosterone. Prior to and following hormone administration, men completed four tests measuring visuospatial ability, three tests measuring verbal fluency, two tests measuring perceptual speed, and a measure of verbal memory. Group differences in testosterone levels were unrelated to performance on most cognitive measures, including visuospatial ability. Relative to other men, hypogonadal men were impaired in their verbal fluency and showed improved verbal fluency following treatment with testosterone. These data suggest that testosterone may enhance verbal fluency in hypogonadal men and support the general hypothesis that current levels of testosterone may influence some aspects of cognitive function.

Implantable cardioverter-defibrillators and pregnancy: a safe combination?

BACKGROUND

The purpose of this investigation was to evaluate the outcome of pregnancy in women with implantable cardioverter-defibrillators (ICDs).

METHODS AND RESULTS

A multicenter retrospective analysis was performed on women with an ICD who became pregnant. Data were collected on 44 patients. The mean age and ejection fraction at the time of the initial ICD implant were 25.6+/-4.9 years and 49.8+/-9.7%, respectively. The mean follow-up after the ICD implant was 4.8+/-2.8 years. Forty-two women had abdominally implanted generators, and 2 had a prepectoral device. Thirty had epicardial lead sensing systems, and 14 had transvenous. Thirty-six (82%) experienced no complications, and 8 (18%) had a medical or device-related complication. The ICD-related problems included tenderness at the ICD pocket scar (2 patients), generator migration (1), and pericarditis secondary to the epicardial patches (1). Medical complications were pulmonary embolism (1), therapeutic abortion (1), worsening hyperthyroidism (1), congestive heart failure (1), and weight loss (1). Thirty-seven women delivered vaginally, and 7 underwent cesarean section. Thirty-nine babies were born healthy, 1 was stillborn, 2 were small for gestational age, 1 had transient hypoglycemia, and 1 woman had a therapeutic abortion unrelated to the ICD. During pregnancy, 33 women received no ICD therapy, 8 had 1 shock, 1 had 5 discharges, 1 had 11 shocks, and 1 had 5 shocks. The total number of shocks during pregnancy ranged from 0 to 11, with an average of 0.66+/-1.9 discharges. Five women had 7 additional pregnancies without an ICD shock.

CONCLUSIONS

The mere presence of an ICD should not defer a women from becoming pregnant unless she has an underlying structural cardiac disease that is considered a contraindication. Pregnancy does not increase the risk of major ICD-related complications or result in a high number of ICD discharges.

Rapid clinical evaluation of anosmia. The alcohol sniff test

BACKGROUND

Smell impairment affects 1% to 2% of Americans and leads to frequent physician visits. Olfactory testing is available in chemosensory centers, but not as part of a routine cranial nerve examination. The alcohol sniff test (AST), which uses the standard 70% isopropyl alcohol pad, was developed as a quick, reliable measure of olfactory function.

METHODS

Sixty-four patients and 36 healthy control subjects (N = 100) were tested with the AST and with a standard butanol threshold test.

RESULTS

The AST reliably, consistently, and correctly measured olfactory function.

CONCLUSIONS

The AST is a rapid, reliable olfactory test that can be used for screening olfactory function and should be incorporated in the routine cranial nerve examination.

Inductively coupled plasma mass spectrometry and atomic emission spectrometry coupled to high-performance liquid chromatography for speciation and detection of organotin compounds

Inductively coupled plasma mass spectrometry (ICP/MS) is utilized as a detector for several organotin species separated by high-performance liquid chromatography. Detection limits obtained by ICP/MS are 3 orders of magnitude lower than those obtained with inductively coupled plasma atomic emission spectrometry (ICP/AES) detection under the same chromatographic conditions. Chromatographic detection limits are higher than conventional solution nebulization for the same compound by a factor of 20. Ion-exchange chromatography yields linear response over 3 orders of magnitude, while ion pair chromatography gives a linear response of only 2 orders of magnitude as a result of poor resolution. The relative standard deviation for the injection of 20 ng of tin compounds is less than 10%.

Radiation-induced soft-tissue sarcoma

Twenty patients with soft-tissue sarcomas arising within previously irradiated fields have been analysed. The initial radiation dose ranged from 8.8 to 70 Gy, comprising either orthovoltage or megavoltage treatment. The latent interval following radiotherapy ranged from 7 to 45 years (mean 16.8 years). The commonest histological subtype was malignant fibrous histiocytoma. Four patients required forequarter amputation. The 5-year survival was only 14 per cent. The high morbidity and mortality accompanying post-radiation sarcomas must be borne in mind when the choice between therapeutic options for potentially curable cancers is finely balanced.

Management of chronic sinusitis in cystic fibrosis

Chronic rhinosinusitis is extremely common in patients with cystic fibrosis. It causes numerous problems in these patients and can put them at risk for life-threatening illness. Potential problems include nasal obstruction, congestion, sinus pain and pressure, infection (usually with Pseudomonas organisms), hyposmia or anosmia, and the seeding of bacteria into the lower respiratory tract. Cystic fibrosis patients with chronically infected sinuses are at increased risk for pneumonia following lung transplantation. A prophylactic protocol has been developed for the management of chronic sinusitis in patients with cystic fibrosis. These patients are fully evaluated at the Nasal Dysfunction Clinic of the University of California, San Diego (UCSD), Medical Center. Based on the results of the evaluation, they are treated with endoscopic sinus surgery, partial middle turbinectomy, septoplasty, and a large middle meatal maxillary antrostomy. Surgery is followed by a rigorous regimen of pulsatile hypotonic saline nasal irrigation to wash away tenacious cystic secretions. Tobramycin (Nebcin) is given once daily in the nasal irrigant to inhibit the growth of Pseudomonas organisms. At the USCD Nasal Dysfunction Clinic, this prepulmonary transplantation protocol is now used in all cystic fibrosis patients with chronic sinusitis.

Testosterone replacement therapy improves mood in hypogonadal men--a clinical research center study

The effect of testosterone (T) replacement on changes in mood was studied for 60 days in 51 hypogonadal men. All patients were withdrawn from their prior T replacement for at least 6 weeks before enrollment. Of these patients, 18 received T enanthate 200 mg im every 20 days, 16 received sublingual T cyclodextrin (SLT) at a dose of 2.5 mg three times daily, and 17 received SLT at a dose of 5.0 mg three times daily. The total treatment period was 60 days. The patients were asked to respond to a questionnaire on 7 consecutive days before the start of treatment and on 7 consecutive days before their visits to the clinic on days 21, 41, and 60 of treatment. The following mood parameters were assessed using a 7-point Likert rating scale: angry, alert, irritable, full of pep (energy), sad/blue, tired, friendly, nervous, and well/good. When compared with the baseline period, T replacement led to significant decreases in anger (P = 0.0045), irritability (P = 0.0009), sadness (P = 0.0033), tiredness (P = 0.0035), and nervousness (P = 0.0291), and significant improvement in energy level (P = 0.0020), friendliness (P = 0.0072), and sense of well-being (P = 0.024) in all subjects as a group. Analyses of the area under the curve (AUC) of baseline serum T levels before T replacement showed significant positive correlations between serum T (AUC) and friendliness (r = 0.29, P < 0.05) and sense of well-being (r = 0.27, P < 0.05), and significant negative correlations with nervousness (r = -0.27, P < 0.05), irritability (r = -0.29, P < 0.05) and tiredness (r = -0.28, P < 0.05). Similar correlations were found between serum dihydrotestosterone (DHT) and some of the mood parameters. After T replacement in the hypogonadal men, these correlations between AUC of serum T levels and the positive and negative mood scores disappeared. These results were corroborated in a subsequent study in which 30 hypogonadal men were supplemented with SLT 5 mg three times daily for 6 months. The patients were less nervous (P = 0.0025) and more alert (P = 0.0004), friendly (P = 0.042), and energetic (P = 0.0001) during the 6-month treatment period compared with baseline. We conclude that T replacement therapy in hypogonadal men improved their positive mood parameters, such as energy, well/good feelings, and friendliness and decreased negative mood parameters including anger, nervousness, and irritability, and direct correlations between serum T and DHT with mood scores were only observed in the baseline period when serum androgen levels were below the normal range. The latter observation suggests that once a minimally adequate serum T/DHT level was achieved by T replacement therapy, further increases in serum T/DHT levels did not further contribute to the improvement in mood variables.

Radiological diagnosis of periapical bone tissue lesions in endodontics: a systematic review

This systematic review evaluates the diagnostic accuracy of radiographic methods employed to indicate presence/absence and changes over time of periapical bone lesions. Also investigated were the leads radiographic images may give about the nature of the process and the condition of the pulp in nonendodontically treated teeth. Electronic literature search included the databases PubMed, Embase and CENTRAL from January 1950 to June 2011. All languages were accepted provided there was an abstract in English. The MeSH terms were 'Cone beam computed tomography (CBCT)', 'Radiography, panoramic', 'Periapical diseases', 'Dental pulp diseases', 'Sensitivity and specificity', 'receiver operating characteristics (ROC) curve', 'Cadaver', 'Endodontics' and 'Radiography dental'. Two reviewers independently assessed abstracts and full text articles. An article was read in full text if at least one of the two reviewers considered an abstract to be potentially relevant. Altogether, 181 articles were read in full text. The GRADE approach was used to assess the quality of evidence of each radiographic method based on studies of high or moderate quality. Twenty-six studies fulfilled criteria set for inclusion. None was of high quality; 11 were of moderate quality. There is insufficient evidence that the digital intraoral radiographic technique is diagnostically as accurate as the conventional film technique. The same applies to CBCT. No conclusions can be drawn regarding the accuracy of radiological examination in identifying various forms of periapical bone tissue changes or about the pulpal condition.

Preservation of facial contour during parotidectomy

Parotid surgery often leaves a facial contour deformity. Free abdominal dermal-fat grafts were used to preserve the facial contour of nine patients undergoing parotid surgery. This procedure is simple to perform and provides an improved cosmetic result without significantly increasing operative time or lengthening hospitalization. No troublesome fat absorption occurred postoperatively. The dermal-fat graft also serves as a barrier to regenerating neurons, thereby preventing postoperative gustatory sweating.

Curved lateral osteotomy for airway protection in rhinoplasty

Lateral osteotomies performed posteriorly enough to avoid step-like prominences at the sides of the nose may allow medial displacement of bone to impinge on the airways. This obstruction near the floor of the nasal passageway is prevented by leaving a triangular piece of bone at the pyriform aperture intact just superior to the level of the inferior turbinate. A curved lateral osteotomy, as described here, cuts bone posteriorly only where aesthetic narrowing is required in rhinoplasty. Techniques providing the recommended curved or angulated lateral osteotomies with osteotomes are demonstrated in the cadaver and in patients.

Prevalence and assessment of qualitative olfactory dysfunction in different age groups

The prevalence of parosmia and phantosmia among 363 chemosensory and nasal/sinus patients was studied, as was the accuracy with which our clinical questionnaire could assess these dysfunctions. We then investigated whether patients with parosmia or phantosmia, matched for odor intensity, perform poorer on odor identification than do patients with no dysosmia. More than 40% of the study group evidenced either parosmia (18.7%) and/or phantosmia (25.6%), a finding that suggests that more attention should be paid by the medical practitioner in addressing qualitative olfactory dysfunction. Furthermore, it appears that assessment of these dysfunctions may aid in differential diagnosis, and that questionnaires can be used with reasonable validity irrespective of the patient's age. Finally, the results imply that parosmia may be reflected in a discrepancy between odor identification and detection.

Anatomy of the superficial temporal artery

The anatomy of the superficial temporal artery was investigated in radiographic and cadaveric studies. The superficial temporal artery divides into an anterior and posterior branch, and the diameters of these vessels are similar. The anatomy of these two vessels is described, and implications for their use in reconstructive flaps are suggested.

Emergency laparotomy in patients with AIDS

The presentation, operative management and final diagnosis were reviewed in 28 patients with AIDS (27 men and one woman) who underwent emergency laparotomy. On clinical and radiological examination, six patients showed features of toxic megacolon, five patients had small bowel obstruction, six patients had localized peritonitis and three had perforated viscus with generalized peritonitis. The most common disease processes were acute colitis in seven patients (associated with cytomegalovirus (CMV) infection in six), intra-abdominal lymphoma in five patients, acute appendicitis in five patients (associated with CMV infection in two), and atypical mycobacterial (MAI) infection in four patients. Two perioperative deaths occurred; one in a patient with acute pancreatitis and a second with generalized peritonitis. Later deaths were due to progression of AIDS, and patient survival at 1 month, 3 months and 6 months was 89 per cent, 64 per cent and 48 per cent, respectively. Lower operative mortality than in previously reported series may be due to earlier intervention in CMV toxic megacolon. Surgery, however, conferred less benefit in patients with acute abdominal pain from MAI infection or lymphoma. With careful patient selection, emergency laparotomy may achieve worthwhile palliation in patients with AIDS.

Effectiveness of curettage and electrodesiccation in the removal of basal cell carcinoma

Basal cell carcinomas are slow-growing malignant skin tumors which have traditionally been successfully treated by curettage and electrodesiccation. Curettage and electrodesiccation is traditionally repeated two or three times, but there are no previous studies documenting the value for the repetitions. This study compares the efficacy of curettage and desiccation once and three times in removing basal cell tumors. The results suggest that these neoplasms have two distinct growth patterns. One is more invasive and incompletely removed by curettage-desiccation. The second pattern is removed by a single cycle of curettage and desiccation. It is hypothesized, based on a review of pertinent literature, that these growth patterns are related to immunologic interaction with tumor cells.

Androgen-behavior correlations in hypogonadal men and eugonadal men. I. Mood and response to auditory sexual stimuli

Mood and response to auditory sexual stimuli were assessed in 33 hypogonadal men receiving testosterone (T) replacement therapy, 10 eugonadal men receiving T in a male contraceptive clinical trial, and 19 eugonadal men not administered T. Prior to and after 6 weeks of hormone administration, men completed a mood questionnaire, rated sexual arousal to and sexual enjoyment of auditory sexual stimuli, and performed a dichotic listening task measuring selective attention for sexual stimuli. Mood questionnaire results suggest that T has positive effects on mood in hypogonadal men when hormone levels are well below the normal male range of values, but does not have any effects on mood when hormone levels are within or above the normal range. However, increased sexual arousal and sexual enjoyment were associated with T administration regardless of gonadal status. Eugonadal men administered T also increased in the bias to attend to sexual stimuli. In contrast, the comparison group of eugonadal men not administered T showed no mood or sexual behavior changes across the two test sessions. These data support a positive relationship between T and sexual interest, sexual arousal, and sexual enjoyment in men.

Vulvo-vaginal melanoma--should radical surgery be abandoned?

A total of 32 patients presenting with melanoma of the vulva and vagina over a 20-year period was reviewed. Primary surgical treatment was by local excision in 14 patients, simple vulvectomy in seven patients and radical resection in 11 patients. Overall 5-year survival was 25% and only one patient was alive at 10 years. Comparison between the groups showed no benefit either in local control, disease-free interval or patient survival according to extent of primary resection. We suggest that, as in anorectal melanoma, radical resection of the primary lesion is unlikely to alter the extremely grave prognosis and its routine use should be abandoned.

Probability of successful defibrillation at multiples of the defibrillation energy requirement in patients with an implantable defibrillator

BACKGROUND

The probability of successful defibrillation has been determined in normal animals but not in patients undergoing defibrillator implantation. Therefore, the purpose of this prospective study was to determine the probability of successful defibrillation in humans on the basis of a step-down defibrillation energy requirement.

METHODS AND RESULTS

Fifty-three consecutive patients underwent five separate inductions of ventricular fibrillation after the defibrillation energy requirement was determined with the use of small decrements and a step-down protocol (20, 15, 12, 10, 8, 6, 5, 4, 3, 2, 1, and 0.8 J). The first shock energy for defibrillation was either 1.0, 1.3, 1.5, 1.7, or 2.0 times the defibrillation energy requirement, and the likelihoods of successful defibrillation were 70+/-27%, 84+/-12%, 86+/-25%, 80+/-29%, and 88+/-32%, respectively (P=.03). The frequencies of uniformly successful defibrillation (5 of 5 defibrillation attempts) were 30%, 27%, 60%, 64%, and 73%, respectively (P=.01). Seven patients in whom the defibrillation energy requirement was <4 J had an overall rate of successful defibrillation of 54+/-20% compared with 86+/-20% in the remaining 47 patients (P=.002). The likelihood of successful defibrillation at twice the defibrillation energy requirement was 98% in the 46 patients with a defibrillation energy requirement of >4 J and 67% in the 7 patients with a defibrillation energy requirement of <4 J (P=.17). An absolute safety margin of 7 J was associated with a 96% probability of successful defibrillation.

CONCLUSIONS

The probability of successful defibrillation is 70% at the defibrillation energy requirement. The probability plateaus at 88%, at twice the defibrillation energy requirement. A 96% probability of successful defibrillation is achieved at an absolute safety margin of 7 J, and a 98% success rate is achieved at energies that are twice the defibrillation energy requirement if the defibrillation energy requirement is >4 J. If the defibrillation energy requirement is <4 J, larger multiples of the defibrillation energy requirement are needed to achieve a high probability of successful defibrillation.

Baker's yeast β-glucan supplementation increases monocytes and cytokines post-exercise: implications for infection risk?

Strenuous aerobic exercise is known to weaken the immune system, and while many nutritional supplements have been proposed to boost post-exercise immunity, few are known to be effective. The purpose of the present study was to evaluate whether 10 d of supplementation with a defined source of baker's yeast β-glucan (BG, Wellmune WGP®) could minimise post-exercise immunosuppression. Recreationally active men and women (n 60) completed two 10 d trial conditions using a cross-over design with a 7 d washout period: placebo (rice flour) and baker's yeast BG (250 mg/d of β-1,3/1,6-glucans derived from Saccharomyces cerevisiae) before a bout of cycling (49 ± 6 min) in a hot (38 ± 2°C), humid (45 ± 2 % relative humidity) environment. Blood was collected at baseline (before supplement), pre- (PRE), post- (POST) and 2 h (2H) post-exercise. Total and subset monocyte concentration was measured by four-colour flow cytometry. Plasma cytokine levels and lipopolysaccharide (LPS)-stimulated cytokine production were measured using separate multiplex assays. Total (CD14⁺) and pro-inflammatory monocyte concentrations (CD14⁺/CD16⁺) were significantly greater at POST and 2H (P<0·05) with BG supplementation. BG supplementation boosted LPS-stimulated production of IL-2, IL-4, IL-5 and interferon-γ (IFN-γ) at PRE and POST (P<0·05). Plasma IL-4, IL-5 and IFN-γ concentrations were greater at 2H following BG supplementation. It appears that 10 d of supplementation with BG increased the potential of blood leucocytes for the production of IL-2, IL-4, IL-5 and IFN-γ. The key findings of the present study demonstrate that BG may have potential to alter immunity following a strenuous exercise session.

PET/CT in the Evaluation of Response to Treatment of Liver Metastases from Colorectal Cancer with Bevacizumab and Irinotecan

The present approach at our institution for the treatment of patients with colorectal (CRC) cancer and with liver metastases planned for metastasectomy is the neoadjuvant administration of Bevacizumab with Irinotecan based therapy. Metabolic imaging of tumor viability with 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET), and simultaneous anatomic localization provided by low-dose non-enhanced computed tomography (CT), can be obtained in a combined modality FDG-PET/CT scan. The purpose of this study was to evaluate the possible contribution of FDG-PET/CT as a surrogate marker to evaluate treatment response of liver metastases in vivo. This is a retrospective evaluation of 18F-FDG PET and CT findings in the first seven consecutive patients. FDG-PET/CT scans were performed before the start of the neoadjuvant and after four cycles of therapy, just prior to surgery. Results were compared to concurrent contrast-enhanced CT, when required, and pathology. Response to treatment was determined according to RECIST size criteria obtained from data from thin (3–5mm) slice CT, and changes in uptake of 18F-FDG uptake on PET.

A total of 20 liver lesions were evaluated in seven patients. Overall, 6/7 patients had favorable response to treatment, and only one had progression of disease. One patient was found to be inoperable at surgery. Biopsy was obtained in 1/4 lesions in this patient, while pathology was unable for the remaining three lesions. As such, pathologic validation of findings was available for 17/20 lesions. Complete response (CR) was evident on FDG-PET in 10/17 (58%) lesions, whereas only 4/17(23%) were deemed CR by CT. Similarly, only 1/17 (6%) lesion appeared stable by FDG-PET criteria, whereas three (18%) were termed stable disease (SD) according to size on CT.

FDG-PET findings correlated better than CT with pathology, and were more indicative of pathology. Overall PET/CT correctly predicted necrosis at pathology in 70% vs. 35% by CT. Our results suggest that 18F-FDG PET may be instrumental for predicting the pathologic response to Bevacizumab based therapy.

The thirty degree transposition flap

The rhomboid and other 60 degrees transposition flaps have theoretical and practical disadvantages for many applications. A better flap for these is one having an angulation of 30 degrees at its distal end. When this 30 degrees flap is combined with the M-plasty, a versatile and cosmetically favorable repair is provided for many surface defects. In fact, over the years, it has become our most useful method of closure with flaps. Fundamentally, it allows sharing of tensions of closure better than does the rhomboid flap, produces less level disparities or protrusions than does any 60 degrees flap, and its resulting scar length is only fractionally longer than that of the rhomboid flap. Rhomboid and other 60 degrees angle flaps have been exceedingly valuable tools to many surgeons; the 30 degrees flap combined with M-plasty should be significantly more useful.

Applications of the biomechanical behavior of cartilage to nasal septoplastic surgery

The biomechanics of septal cartilage as they apply to septoplasty are studied. The original investigations on septal cartilage are reviewed and summarized. Biomechanical principles of the behavior of cartilage are reviewed and applied to the principles of septoplasty surgery. Using pigs' ears, theoretical predictions are investigated and verified. Incorporating this information, an approach to septoplastic surgery is described.