The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects.

Myocutaneous (MC) free flaps are useful for many reconstructive indications. Perforator flaps have become standard of care. The anterolateral thigh flap (ALT) donor site is popular. With the ALT flap varying sizes of vastus lateralis (VL) muscle can be harvested as a MC flap. The skin islands of these flaps have a great range of freedom when dissected on their perforator. It was hypothesised that the VL-ALT perforator flap would offer adequate tissue volume combining maximal freedom in planning with minimal donor site morbidity. From November 2001 to February 2003 a free partial VL with ALT perforator flap was used in 11 patients to reconstruct large defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps were planned as standard ALT flaps, after which three types of dissection were performed: I. true MC flap; II. muscle flap with a skin island on one perforator, which could be rotated up to 180 degrees ; III. chimera skin perforator flap with muscle being harvested on a separate branch from the source vessel or on a side branch of the skin perforator. Mean skin size of the MC-ALT flaps was 131 cm2. Mean muscle part size of the MC-ALT flaps was 268 cm3. Muscular parts were custom designed for all defects. No total or partial flap failures were seen. Colour mismatch was seen in 6 of 8 patients, when skin was used in the facial area in this all white population. Excessive flap bulk was found in 8 of 11 patients at 6 weeks, however, only in 2 of 11 patients after 6 months. Patients were satisfied with the functional result (8 of 11 patients) as well as the cosmetic result of their reconstruction (7 of 11 patients). All less satisfied patients had received their flap for external facial skin reconstruction. Donor site morbidity was minimal. The combined free partial VL with ALT perforator flap proved valuable as a (chimera type) MC flap with maximal freedom of planning to meet specific reconstructive demands and minimal donor site morbidity.

CD31 staining in epithelioid sarcoma.

We report an unusual case of epithelioid sarcoma. The tumour occurred in the finger of a 27-year-old female. The clinical history, histology and the electron microscopy of the lesion were typical for epithelioid sarcoma. However, immunohistochemical analysis showed strong membranous CD31 staining, a finding hitherto not described. All other robust vascular markers, including factor-VIII-related antigen (FVIIIrag) were negative. The findings were compared with the available literature data, leading us to conclude that there is insufficient evidence for endothelial derivation of epithelioid sarcoma, but in the differential diagnosis with vascular tumours CD31 may stain and to rule out angiosarcoma FVIIIrag is a useful antibody.

Reconstructive techniques for the repair of oral and maxillofacial oncological procedures: what are they, how do they work and what do they look like?

BACKGROUND: There are many different ways to reconstruct the oral and maxillofacial region post tumour ablation. In the past, the resection of oral tumours had been associated with significant disfigurement and loss of function. Modern techniques aim to restore function and improve cosmetics. This paper aims to describe the techniques used in patients treated at the Austin and Repatriation Medical Centre and to answer the more common questions associated with reconstructive techniques. METHODS: A review of techniques of oral reconstruction used by our unit over the last nine years and a review of the literature. RESULTS: Various techniques of reconstruction gained from our experience in treating patients with oral cancer are documented. There are a variety of techniques including grafts, local flaps, regional flaps and free vascularized flaps. Metallic implants such as osseointegrated dental implants may also be used for dental rehabilitation. CONCLUSIONS: There are many different methods of reconstruction in patients who have had resection for oral tumours. It is important for general dental practitioners who may be involved with the care of such patients to have an understanding of the modern techniques of reconstruction that may be used.

How EverCare nurse practitioners spend their time.

OBJECTIVES: To describe how nurse practitioners (NPs) employed by EverCare, a Medicare HMO serving exclusively nursing home residents, spend their working days. DESIGN: A descriptive study based on structured self-reports. SETTING: Nursing homes. PARTICIPANTS: Seventeen NPs employed by EverCare in five sites. MEASUREMENTS: Self-reports of time spent over a 2-week period and specific reports of how time was spent on selected cases. RESULTS: NPs spend about 35% of their working day on direct patient care and another 26% in indirect care activities. Of the latter, 46% of the time was spent interacting with nursing home staff, 26% with family, and 15% with the physicians. The mean time spent on a given patient per day was 42 minutes (median 30); of this time 20 minutes was direct care (median 15). CONCLUSIONS: NPs' activities are varied. Much of their time is spent communicating with vital parties, an important function that supports the physicians' primary care role and should enhance families' satisfaction with care.

Rapid 5' nuclease (TaqMan) assay for detection of virulent strains of Yersinia enterocolitica.

We have developed a rapid procedure for the detection of virulent Yersinia enterocolitica in ground pork by combining a previously described PCR with fluorescent dye technologies. The detection method, known as the fluorogenic 5' nuclease assay (TaqMan), produces results by measuring the fluorescence produced during PCR amplification, requiring no post-PCR processing. The specificity of the chromosomal yst gene-based assay was tested with 28 bacterial isolates that included 7 pathogenic and 7 nonpathogenic serotypes of Y. enterocolitica, other species of Yersinia (Y. aldovae, Y. pseudotuberculosis, Y. mollaretti, Y. intermedia, Y. bercovieri, Y. ruckeri, Y. frederiksenii, and Y. kristensenii), and other enteric bacteria (Escherichia, Salmonella, Citrobacter, and Flavobacterium). The assay was 100% specific in identifying the pathogenic strains of Y. enterocolitica. The sensitivity of the assay was found to be >/=10(2) CFU/ml in pure cultures and >/=10(3) CFU/g in spiked ground pork samples. Results of the assay with food enrichments prespiked with Y. enterocolitica serotypes O:3 and O:9 were comparable to standard culture results. Of the 100 field samples (ground pork) tested, 35 were positive for virulent Y. enterocolitica with both 5' nuclease assay and conventional virulence tests. After overnight enrichment the entire assay, including DNA extraction, amplification, and detection, could be completed within 5 h.

Australian experience with the Freehand System for restoring grasp in quadriplegia.

BACKGROUND: The purpose of the present study was to document the value of an implanted multichannel neuroprosthesis (Freehand System) for restoring hand grasp in the first Australians to receive this device. METHODS: Hand function in C5 quadriplegic patients was assessed via measurement of pinch forces, a grasp release test and tests of activities of daily living (ADL). Comparisons were made between presurgery scores and scores recorded after rehabilitation when the neuroprosthesis was and was not in use. RESULTS: A significant difference for both lateral pinch (P = 0.003) and palmar grasp (P = 0.003) was found between forces recorded with and without the use of the neuroprosthesis after rehabilitation, but not between forces recorded presurgery and during rehabilitation without the neuroprosthesis. All subjects were able to grasp, move and release more objects within the 30-s test period with the neuroprosthesis than without it. Collective results for the eight ADL tests for all six subjects show that, in 35 of the 48 (73%) occasions, less physical assistance and/or adaptive equipment was required when the Freehand system was employed compared to when it was not used. In 41 of the 48 (85%) occasions, the six subjects expressed a preference for using the neuroprosthesis to perform these activities of daily living. Twelve months after rehabilitation, five of the six subjects still used the neuroprosthesis daily or every second day. CONCLUSION: The Freehand neuroprosthesis has provided useful hand function with few surgical and technical difficulties in these patients. Regular ongoing use of the device indicates user satisfaction.

Evaluation of AFLP, a high-resolution DNA fingerprinting method, as a tool for molecular subtyping of enterohemorrhagic Escherichia coli O157:H7 isolates.

The amplified fragment-length polymorphism (AFLPTM) technique is based on the selective PCR amplification of restriction fragments. We investigated the utility of AFLP in the molecular subtyping of enterohemorrhagic Escherichia coli serotype O157:H7 isolates. We analyzed a total of 46 isolates of E. coli O157:H7 along with other serotypes, O26:H11, 0114:H19 and 0119:NT. Isolates of E. coli O157:H7 derived from the same outbreak showed an identical AFLP-banding pattern and were subtyped into the same group, giving results almost consistent with those of a pulsed-field gel electrophoresis (PFGE) study, while other serotypes showed clearly different patterns from those of E. coli O157:H7. These results suggest that the AFLP technique has potential as an alternative tool for the molecular epidemiology of E. coli O157:H7.

Prevalence of Escherichia coli O157:H7 in white-tailed deer sharing rangeland with cattle.

OBJECTIVE: To determine the prevalence of fecal shedding of Escherichia coli O157:H7 in white-tailed deer (Odocoileus virginianus) with access to cattle pastures. DESIGN: Survey study. SAMPLE POPULATION: 212 fecal samples from free ranging white-tailed deer. PROCEDURE: Fresh feces were collected on multiple pastures from 2 farms in north central Kansas between September 1997 and April 1998. Escherichia coli O157:H7 was identified by bacterial culture and DNA-based methods. RESULTS: Escherichia coli O157:H7 was identified in 2.4% (5/212) of white-tailed deer fecal samples. CONCLUSIONS AND CLINICAL RELEVANCE: There is considerable interest in the beef industry in on-farm control of E coli O157:H7 to reduce the risk of this pathogen entering the human food chain. Results of our study suggest that the design of programs for E coli O157:H7 control in domestic livestock on pasture will need to account for fecal shedding in free-ranging deer. In addition, the results have implications for hunters, people consuming venison, and deer-farming enterprises.

Primary hyperaldosteronism in two cats.

A condition of primary hyperaldosteronism resulting from an adrenal tumor in two cats is presented and was characterized by hypertension, hypokalemia, inappropriate kaliuresis, low normal plasma renin activity, and markedly increased serum aldosterone concentration. One of the two cats underwent a laparotomy, and in this case hypertension and hypokalemia resolved following the removal of an adrenal tumor.

Evaluation of TaqMan PCR assay for detecting Salmonella in raw meat and shrimp.

We evaluated the TaqMan Salmonella amplification/detection kit from PE Applied Biosystems, which uses a polymerase chain reaction (PCR) assay for rapid detection of Salmonella in food samples. This system uses the 5' nuclease activity of Taq DNA polymerase, which digests an internal fluorogenic probe to monitor the amplification of the target gene. The system's sensitivity and specificity were evaluated using 42 serotypes of 68 Salmonella strains isolated from fecal samples from patients in Tokyo, Japan, and 39 non-Salmonella strains in 22 genera. There were no false-negative or false-positive results. This PCR assay can detect 3 CFU per PCR tube of Salmonella in pure culture (120 CFU/ml of TSB culture). PCR signals were attenuated with artificially contaminated shrimp, but a similar detection limit was obtained. TaqMan's performance was tested with 100 meat and chicken samples purchased from stores in Tokyo. Overall, two of the DNA extraction protocols (the Chelex and EnviroAmp methods) worked equally well, with some exceptions. Of the 100 samples analyzed, 10 were positive for Salmonella with both conventional culture methods and the kit and 89 were negative with both. One sample was negative by the culture method but positive by the kit assay. These results indicate that TaqMan is a reliable and rapid method for Salmonella analysis in the food industry. With this system, food samples can be analyzed for Salmonella in less than 20 h.

PCR-based DNA amplification and presumptive detection of Escherichia coli O157:H7 with an internal fluorogenic probe and the 5' nuclease (TaqMan) assay.

Presumptive identification of Escherichia coli O157:H7 is possible in an individual, nonmultiplexed PCR if the reaction targets the enterohemorrhagic E. coli (EHEC) eaeA gene. In this report, we describe the development and evaluation of the sensitivity and specificity of a PCR-based 5' nuclease assay for presumptively detecting E. coli O157:H7 DNA. The specificity of the eaeA-based 5' nuclease assay system was sufficient to correctly identify all E. coli O157:H7 strains evaluated, mirroring the previously described specificity of the PCR primers. The SZ-primed, eaeA-targeted 5' nuclease detection assay was capable of rapid, semiautomated, presumptive detection of E. coli O157:H7 when >/=10(3) CFU/ml was present in modified tryptic soy broth (mTSB) or modified E. coli broth and when >/=10(4) CFU/ml was present in ground beef-mTSB mixtures. Incorporating an immunomagnetic separation (IMS) step, followed by a secondary enrichment culturing step and DNA recovery with a QIAamp tissue kit (Qiagen), improved the detection threshold to >/=10(2) CFU/ml. Surprisingly, immediately after IMS, the sensitivity of culturing on sorbitol MacConkey agar containing cefeximine and tellurite (CT-SMAC) was such that identifiable colonies were demonstrated only when >/=10(4) CFU/ml was present in the sample. Several factors that might be involved in creating these false-negative CT-SMAC culture results are discussed. The SZ-primed, eaeA-targeted 5' nuclease detection system demonstrated that it can be integrated readily into standard culturing procedures and that the assay can be useful as a rapid, automatable process for the presumptive identification of E. coli O157:H7 in ground beef and potentially in other food and environmental samples.

Use of a fluorogenic probe in a PCR-based assay for the detection of Listeria monocytogenes.

A PCR-based assay for Listeria monocytogenes that uses the hydrolysis of an internal fluorogenic probe to monitor the amplification of the target has been formatted. The fluorogenic 5' nuclease PCR assay takes advantage of the endogenous 5' --> 3' nuclease activity of Taq DNA polymerase to digest a probe which is labelled with two fluorescent dyes and hybridizes to the amplicon during PCR. When the probe is intact, the two fluorophores interact such that the emission of the reporter dye is quenched. During amplification, the probe is hydrolyzed, relieving the quenching of the reporter and resulting in an increase in its fluorescence intensity. This change in reporter dye fluorescence is quantitative for the amount of PCR product and, under appropriate conditions, for the amount of template. We have applied the fluorogenic 5' nuclease PCR assay to detect L. monocytogenes, using an 858-bp amplicon of hemolysin (hlyA) as the target. Maximum sensitivity was achieved by evaluating various fluorogenic probes and then optimizing the assay components and cycling parameters. With crude cell lysates, the total assay could be completed in 3 h with a detection limit of approximately 50 CFU. Quantification was linear over a range of 5 x 10(1) to 5 x 10(5) CFU.

Oligonucleotides with fluorescent dyes at opposite ends provide a quenched probe system useful for detecting PCR product and nucleic acid hybridization.

The 5' nuclease PCR assay detects the accumulation of specific PCR product by hybridization and cleavage of a double-labeled fluorogenic probe during the amplification reaction. The probe is an oligonucleotide with both a reporter fluorescent dye and a quencher dye attached. An increase in reporter fluorescence intensity indicates that the probe has hybridized to the target PCR product and has been cleaved by the 5'-->3' nucleolytic activity of Taq DNA polymerase. In this study, probes with the quencher dye attached to an internal nucleotide were compared with probes with the quencher dye attached to the 3'-end nucleotide. In all cases, the reporter dye was attached to the 5' end. All intact probes showed quenching of the reporter fluorescence. In general, probes with the quencher dye attached to the 3'-end nucleotide exhibited a larger signal in the 5' nuclease PCR assay than the internally labeled probes. It is proposed that the larger signal is caused by increased likelihood of cleavage by Taq DNA polymerase when the probe is hybridized to a template strand during PCR. Probes with the quencher dye attached to the 3'-end nucleotide also exhibited an increase in reporter fluorescence intensity when hybridized to a complementary strand. Thus, oligonucleotides with reporter and quencher dyes attached at opposite ends can be used as homogeneous hybridization probes.

The outcomes of elective laparoscopic and open cholecystectomies.

BACKGROUND: The demand for evidence of effectiveness for medical care has prompted the development of epidemiologic approaches to relating the outcomes of care to treatment. This study compares the outcomes of care for patients undergoing the newly introduced laparoscopic cholecystectomy with the results from conventional open cholecystectomies. METHODS: Consecutive cases of elective cholecystectomy from 35 hospitals (all of the metropolitan and selected rural hospitals in Minnesota) were enrolled in the study. Patients were interviewed on admission to establish baseline symptoms and functional status and to confirm risk factors. Their medical records were abstracted to yield information on risk factors, treatment, and hospital complications. To establish outcomes, patients were sent a questionnaire about their symptoms and functional status six months postoperatively. RESULTS: Of 3,448 patients studied, 2,490 (72 percent) had a laparoscopic procedure, including 195 cases that were converted to open cholecystectomies. Functional status data were obtained on 2,481 cases (76 percent). Laparoscopic operation was associated with more operative complications (odds ratio 3.02, p < 0.001), but with fewer general complications (odds ratio 0.32, p < 0.001). The mean time to return to work was 15 days for laparoscopic cases compared to 31 days for open procedures (p < 0.001). The only functional outcome difference between the two procedures was that patients who underwent laparoscopic cholecystectomies were more likely than those with conventional cholecystectomies to be able to perform their usual activities at follow-up evaluation (p < .001). There was evidence of a learning curve; the more laparoscopic procedures a surgeon performed, the fewer the operative (p < 0.01) and general (p < 0.0001) complications. There was no indication that the availability of laparoscopic operation was associated with more operations being performed. CONCLUSIONS: Laparoscopic operation seems to represent a significant advance in getting patients back to a normal life sooner. More attention needs to be given to which patients are most likely to benefit from cholecystectomy of either type. Epidemiologic approaches can be useful in assessing the effectiveness of care. Partnerships between providers and researchers can produce useful effectiveness data by supplementing available clinical records with more detailed outcome data.

Surgical treatment for partial epilepsy among Norwegian adults.

We conducted a retrospective longitudinal self-controlled study of 124 adult patients treated with resective surgery for medically uncontrolled partial epilepsy from 1949 to 1988. Approximately 65% of the patients experienced > 95% reduction in seizure frequency, and 75% had worthwhile improvement of at least 75% seizure reduction. Significant reductions were noted in all major seizure types treatable with resective surgery; complex partial (CPS), simple partial (SPS), and secondarily generalized tonic-clonic seizures (GTC) (all p < 0.05). Tissue pathology and region of resection did not provide significant information with respect to seizure outcome. EEG in the first postoperative year was an important predictor of long-term seizure outcome (p = 0.03). One third of the temporal lobe resected patients had neurologic deficits as a consequence of the resection as compared with 14% of patients with frontal resections (p = 0.03). One third of the deficits among the temporal lobe resected patients were considerable, with possible social implications. Half of the patients with preoperative focal spike activity had a normal EEG postoperatively. One fifth of patients maintained their preoperative epileptic focus after the operation, and about one fifth displayed new foci. Approximately one fourth of the patients were free of medication for a median of 16 years postoperatively, and 60% of patients who were seizure-free were still receiving medication. There was no operative mortality, but the late mortality, as expected, was higher than that of the general population. Two male patients (1.6%) committed suicide.

Surgical treatment for partial epilepsy among Norwegian children and adolescents.

We conducted a retrospective longitudinal self-controlled study of 64 patients aged 4-19 years treated with resective surgery for partial epilepsy from 1952 to 1988. Approximately 60% of patients experienced > 95% reduction in seizure frequency, and 70% had worthwhile improvement of at least 75% reduction. Seizure relief was more frequent among patients who underwent operation after 1978, and significant differences by time period of operation were noted for those with temporal lobe excisions and patients with normal tissue histology. The region of resection and the age at treatment did not provide significant information with respect to seizure outcome. Postresection electrocorticography (ECoG) and EEG of the first postoperative year predicted later seizure outcome. Small neurologic deficits were more common among patients resected in the temporal lobe than in patients resected in the frontal lobe. Half of the patients with preoperative unilateral focal activity and a third of those with bilateral focal activity had normal EEG postoperatively. One fourth had discontinued antiepileptic drug (AED) therapy. As expected, long-term mortality was significantly higher than the mortality of the general population. Seven patients died during follow-up. Two male patients committed suicide.

Predictive factors for success in surgical treatment for partial epilepsy: a multivariate analysis.

We conducted a longitudinal self-controlled study of 131 patients aged 4-60 treated with resective surgery for medically uncontrolled partial epilepsy from 1949 to 1988. Using multivariate logistic regression, we showed that pre- and perioperative variables can be used to predict "success" or "failure" of surgical resective treatment in approximately 79% of cases. If the predicted probability is > 0.75 or < 0.25, the model predicts a correct result in 87% of cases. Eight predictive factors emerged with a backward multivariate logistic regression model with the likelihood-ratio (LR) test to exclude variables from the equation: (a) the influence of the surgical team and surgical procedure, (b) the presence of paresis preoperatively, (c) duration of disease, (d) age at treatment, (e) positive neuroradiologic findings in preoperative investigations, (f) preoperative complex partial seizures (CPS), (g) nonepileptic EEG abnormalities, and (h) generalized spike activity in EEG preoperatively. Sex, age at first seizure, area of resection, presence of simple or generalized seizures preoperatively, preoperative seizure frequency, tissue pathology, use of computed tomography/nuclear magnetic resonance (CT/NMR) in preoperative investigations, degree of preoperative neurologic deficit, perioperative electrocorticographic results, and bilateral EEG spikes did not have predictive value in the model.

Outbreak of Japanese encephalitis on the island of Saipan, 1990.

During October 1990, an outbreak of encephalitis occurred on Saipan. Although no virus was isolated, patients seroconverted to Japanese encephalitis (JE) virus, indicating the first known occurrence of JE on US territory since 1947. Ten cases occurred among a population of 40,000. The prevalence of antibody to JE virus among 234 lifelong Saipan residents surveyed after the outbreak was 4.2%. Age, household crowding, and lack of air conditioning were risk factors for infection. The seroprevalence in pigs, which are important amplifying hosts of JE virus, was 96% (n = 52). None of 288 stored serum specimens from lifelong Saipan residents sampled in 1984 were seropositive. These data suggest that JE virus was recently introduced onto Saipan and that peridomestic factors affected the risk of human infection. Transmission of JE virus probably ended with exhaustion of the supply of susceptible amplifying hosts. Surveillance for human cases and seroconversions in pigs during 1991 revealed no evidence of ongoing JE virus transmission.