Rapid, single-subject genotyping to predict red blood cell antigen expression.

Genotyping is useful to predict the expression of those RBC antigens for which antisera are difficult to obtain and to determine the probable phenotype of highly transfused patients, and it can be used to test stored DNA when a blood sample is not available. This study assessed a sequence-specific primer (SSP)-based genotyping system for blood group alleles suitable for the rapid testing of a small number of samples and assessed the use of stored whole blood. Genomic DNA was isolated from fresh and 1- and 2-week-old stored blood from 20 donors with known ABO and Rh phenotypes and was used for ABO, RHD, and RHCE genotyping using SSPs. The amplicons were analyzed using gel electrophoresis and a novel microfluidic on-chip electrophoresis system. Analysis of DNA from fresh and 1- and 2-week-old blood by SSP and gel electrophoresis yielded the correct ABO, RHD, and RHCE type in all samples, but with DNA from 2-week-old stored blood the amplicons were more difficult to visualize. Analysis of the same samples with the SSP on-chip electrophoresis assay correctly typed all samples except for one RHCE typing discrepancy of a fresh sample and one RHCE typing discrepancy of a 2-week-old sample. Analysis of amplicons by on-chip electrophoresis required one tenth the DNA that gel electrophoresis did and could be completed within 30 minutes compared with 2 hours with gel electrophoresis. Amplicons were also more readily visualized with on-chip electrophoresis. Fresh and 1- and 2-week-old samples could be ABO and RH genotyped with SSP. Analysis using on-chip electrophoresis was easier and more rapid than that using gel electrophoresis, but test reliability was slightly more variable.

Surgeon perspectives on surgical options for early-stage breast cancer.

To evaluate the practice patterns of general and plastic surgeons regarding patients with early-stage breast cancer, all general and plastic surgeons in Quebec and Maryland were mailed self-administered questionnaires evaluating surgeon demographics, practice patterns, treatment preferences, and satisfaction with the results of lumpectomy and radiation therapy or breast reconstruction. Response rates of 38.3 percent and 26.7 percent were obtained for general surgeons in Quebec and Maryland, respectively. The ratio of reported mastectomies to lumpectomies was 1:2 in Maryland and 1:5 in Quebec. All general surgeons considered lumpectomy an important option. Ninety percent of Maryland surgeons versus 44 percent of Quebec surgeons considered mastectomy important. A total of 53.6 percent versus 24.9 percent of general surgeons in Maryland and Quebec, respectively, considered delayed reconstruction an important option. Additionally, 81.3 percent of Maryland surgeons considered immediate reconstruction important, and 79.6 percent discussed it with all stage I or II patients. More than 75 percent of Quebec general surgeons reported discussing immediate or delayed reconstruction with < or =50 percent of these women. Response rates of 53.6 percent and 48.8 percent were obtained for plastic surgeons in Quebec and Maryland, respectively. In one year Quebec plastic surgeons reported that they performed less than half the number of reconstructions performed by Maryland plastic surgeons (7.2 versus 17.3). In Quebec, 82.3 percent of surgeons reported that they frequently discuss delayed reconstruction, 25.1 percent immediate, 62.5 percent pedicled TRAM, and 51.7 percent nonautogenous options. In Maryland, 74.3 percent of plastic surgeons frequently discuss delayed reconstruction, 95.7 percent immediate, 89.9 percent pedicled TRAM, and 85.9 percent nonautogenous options. For women with early-stage breast cancer, regional variations exist in the surgical options discussed and provided.

Surgical options for the early-stage breast cancer: factors associated with patient choice and postoperative quality of life.

Patients with early-stage breast cancer have three surgical options: lumpectomy with radiotherapy, mastectomy alone, and mastectomy with breast reconstruction. Our objective was to compare women in these three groups with respect to demographics, preoperative counseling, postoperative body image, and quality of life. Women having undergone surgery for stage 1 or 2 breast cancer between 1990 and 1995 were selected by random sampling of hospital tumor registries and were mailed a self-administered questionnaire, which included the Medical Outcomes Survey Short Form 36. Patients were stratified into three mutually exclusive groups: lumpectomy with axillary node dissection and radiotherapy, modified radical mastectomy, and modified radical mastectomy with breast reconstruction. In total, 267 of 525 surveys were returned (50.9 percent). Compared with mastectomy patients, breast reconstruction patients were younger (p < 0.001), better educated (p = 0.001), and more likely Caucasian (p = 0.02). Among mastectomy patients, 54.9 percent recalled that lumpectomy had been discussed preoperatively and 39.7 percent recalled discussion of breast reconstruction. Post-operative comfort with appearance was significantly lower for mastectomy patients. The relationship between type of surgery and postoperative quality of life varied with age. Under 55, quality of life was lowest for mastectomy patients on all but two Medical Outcomes Survey Short Form 36 subscales. Over 55, quality of life was lowest for lumpectomy patients on all subscales (p < 0.05 for all subscales except social functioning and role-emotional). Treatment choice may be related to age, race, education, and preoperative counseling. Whereas the effect of breast cancer on a woman's life is complex and individual, the type of surgery performed is a significant variable, whose impact may be related to patient age.

A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients.

Research indicates that 8.5% of all patients undergoing surgical procedures for more than 3 hours develop pressure ulcers. In some types of surgery, incidence rates in excess of 25% have been reported. An 11-month study was conducted on the safety and efficacy of an experimental alternating air device in comparison with a tertiary care facility's conventional practice. A series of 217 patients undergoing surgical procedures scheduled for a minimum of 3 hours were enrolled. No ulcers developed in the experimental group and 11 ulcers developed in seven patients in the control group (8.75% incidence rate). Of the 11 ulcers, one was Stage I, four were Stage II, and six were unstageable secondary to eschar. The difference between the groups is significant at the P = 0.005 level. Individuals who developed ulcers had a length of stay approximately 7 days longer than the hospital average for comparable patients who did not develop ulcers.

Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures.

The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent). The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience.

Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts.

Necrotizing abdominal wall infections, enteric fistulae, or exposed prosthetic material after ventral hernia repair often results in a loss of abdominal wall integrity. Further surgical reconstruction with prosthetic material is usually contraindicated in the contaminated wound because of the high infection rate necessitating prosthetic removal and further abdominal wall debridement. Consequently, for the past 9 years, we have been using free grafts of autologous fascia lata to replace deficient abdominal wall fascia and muscle in situations where prosthetic material is contraindicated and local tissue rearrangement (i.e., component separation) would be inadequate. Thirty-two patients (mean age 59 years) underwent abdominal wall reconstruction with autologous fascia lata grafts. Indications included exposed mesh (31 percent), enteric fistulae (28 percent), enteric contamination (22 percent), wound infection (13 percent), and immunosuppression alone (6 percent); 31 percent of all patients were immunosuppressed secondary to either a solid organ transplant or a systemic inflammatory disorder. Fascia grafts (mean size 10 x 17 cm) were sutured to the surrounding abdominal wall and covered by local skin flap advancement and/or myocutaneous flap rotation. All abdominal reconstructions were initially successful. Subsequent local abdominal wall complications included cellulitis (n = 3), seroma (n = 2), and skin dehiscence with exposed fascia grafts (n = 7). Five of seven patients with skin dehiscence healed by secondary intention, whereas two had split-thickness skin grafts successfully applied to the granulating fascia. Thigh donor site complications included hematoma (n = 1), skin dehiscence (n = 1), and seroma (n = 2). There have been no cases of lateral knee instability. The average follow-up period is 27 months (range 3 to 106 months). Recurrent hernia has been seen in three patients (9 percent). Interestingly, laparotomy has been performed through an intact fascia lata patch in three patients for unrelated intra-abdominal conditions. In each case, the graft was intact and revascularized, confirming experimental animal data performed in our laboratory. Recurrent hernia has not been observed through the laparotomy site. Our 9-year experience has demonstrated that in the face of large, contaminated abdominal wounds where prosthetic material is contraindicated and local tissue rearrangement would be inadequate, fascia lata autografts are a reliable adjuvant to abdominal wall reconstruction.

Palatal fractures: classification, patterns, and treatment with rigid internal fixation.

A classification of palatal fracture types is developed from patterns observed on CT scans, and success with open reduction techniques is correlated with fracture pattern. The six palatal fracture types are as follows: I, anterior and posterolateral alveolar; II, sagittal; III, parasagittal; IV, para-alveolar; V, complex; and VI, transverse. Associated fractures were LeFort I (100 percent), LeFort II and III (55 percent), mandible (48 percent), and dental (55 percent). Large segment, sagittally oriented palatal fractures could be stabilized with rigid internal fixation. Complete rigid fixation of the palate consists of (1) roof of mouth, (2) pyriform or alveolar, and (3) four LeFort I buttress stabilization. Comminuted palatal fractures were managed by standard LeFort I and alveolar buttress fixation, palatal splinting, and intermaxillary, fixation. If complete rigid fixation was employed in the palate in type II, III, and IV fractures, a palatal splint was avoided in 60 percent of these cases. Rigid internal fixation is therefore concluded to facilitate the treatment of certain types of palatal fractures by reduced length of intermaxillary fixation and avoidance of palatal splinting.

The edentulous Le Fort fracture.

A retrospective review of 328 Le Fort fractures has identified 20 (6.1%) of these fractures as edentulous. A review of treatment of the patients was conducted. Conservative (nonsurgical treatment methods) and classic open reductions produce aesthetic and functional results that lead to posterior and oblique positioning of the maxillary occlusal segment in comminuted fractures. Attention to positioning the maxilla by relating it to the mandible through maxillomandibular fixation minimized these deformities. Establishing maxillary-mandibular relationships in edentulous fractures, therefore, seems to have the same importance as establishing occlusion in dentulous patients as an important initial step in the treatment of comminuted Le Fort fractures.

Distribution of FMRFamide-like immunoreactivity in the nervous system of Lumbricus terrestris.

The distribution of FMRFamide-like immunoreactive cell bodies and fibers in the nervous system of the earthworm Lumbricus terrestris has been studied by means of immunocytochemistry. The cerebral ganglion contains 150-170 immunoreactive nerve cells that are organized into six major groups in the rostral and five major groups in the caudal part of the ganglion; 160-180 immunoreactive nerve cells are present in the subesophageal ganglion, and 80-90 in the ventral cord ganglia. Immunoreactive neurons of the subesophageal and the ventral cord ganglia show similar distributions, in that FMRFamide-like immunoreactive cells form a ventromedial and a lateral cell group. Neuropil in all parts of the central nervous system shows intensively stained varicose and non-varicose fibers. Each segmental nerve contains FMRFamide-like immunoreactive fibers that can partly be traced to the two muscle layers of the body wall, and a fine immunoreactive network lies among the muscle fibers. A similar network is found in the wall of the alimentary canal. Immunopositive perikarya and fibers have been detected in the prostomial nerves, in the stomatogastric system. Some epithelial cells of the body wall are also immunopositive. The morphological characteristics and localization of FMRFamide immunoreactive neurons suggest that they may be involved in: (1) central integratory processes; (2) neuromuscular regulation in both the body wall and enteric system; (3) sensory processes.

Effect of a serotonin agonist (sumatriptan) on the peptidergic innervation of the rat cerebral dura mater and on the expression of c-fos in the caudal trigeminal nucleus in an experimental migraine model.

The supratentorial cerebral dura of the albino rat is equipped with a rich sensory innervation including nociceptive axons and their terminals, which display intense calcitonin gene-related peptide (CGRP) immunoreactivity both in the connective tissue and around blood vessels. Stereotactic electrical stimulation of the trigeminal (Gasserian) ganglion, regarded as an experimental migraine model, induces marked increase and disintegration of club-like perivascular CGRP-immunopositive nerve endings in the dura. Intravenous administration of sumatriptan, prior to electrical stimulation, prevents disintegration of perivascular terminals and induces accumulation of CGRP in terminal and preterminal portions of peripheral sensory axons. Consequently, immunopositive terminals and varicosities increase in size; accumulation of axoplasmic organelles results in a "hollow" appearance of many varicosities. Since sumatriptan exerts its anti-migraine effect by virtue of its agonist action on 5-HT1D receptors, we suggest that sumatriptan prevents the release of CGRP from dural perivascular terminals by an action at 5-HT1D receptors. In the caudal trigeminal nucleus electrical stimulation of the trigeminal ganglion induces, in interneurons, increased expression of the oncoprotein c-fos which is not prevented by intravenous application of sumatriptan. Disparate findings regarding this effect are partly due to the fact that sumatriptan very poorly passes the blood-brain barrier and partly to different experimental paradigms used by different authors.

Substance P immunoreactive elements in the nervous system of earthworm (Lumbricus terrestris).

Substance P immunoreactive elements were detected in the nervous system of the earthworm, Lumbricus terrestris using peroxidase-antiperoxidase method. Each part of the central nervous system contains immunoreactive perikarya. The central neuropil shows no stained fibers. Immunopositive nerve cells were found in the stomatogastric ganglia as well as nerve cells and fibers in the wall of the alimentary canal. In the body wall, epidermal sensory cells and fibers surrounding the chaetae display immunoreactivity. The results are compared with those described previously by other authors.

Co-localization of serotonin and FMRFamide-like immunoreactivities in the central nervous system of the earthworm, Eisenia fetida.

In the present study co-localization of serotonin and FMRFamide-like immunoreactivities was studied in the central nervous system of the earthworm, Eisenia fetida. Alternate serial sections were stained with antisera raised against serotonin and FMRFamide, using the peroxidase-antiperoxidase method. The immunostained consecutive sections were compared by light-microscopy and on reconstructed images using NIH Image and Neurolucida programs. Although there was a large number of serotonin and FMRFamide-like immunoreactive neurons in the central nervous system of Eisenia, co-localization of immunostaining was relatively rare. In the cerebral ganglion no cells were found that stained for both antisera. In the subesophageal and ventral cord ganglia the neurons reacting for both antisera represented approximately 17-23% and 10-14% of the serotonin- and 7-11% and 9-17% of the FMRF-amide-like immunoreactive cells, respectively. It is suggested, that FMRFamide-related peptides act as neuromodulators and may also influence the activity of serotonergic neurons.

Cigarette smoking, plastic surgery, and microsurgery.

Although tobacco smoking is known to result in coronary heart disease, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, lung cancer, and other smoking cancers, many surgeons believe that smoking also results in impaired wound healing and poor surgical results. Large clinical experiences in several areas of plastic surgery reinforce this suspicion. Procedures that have been noted to be adversely affected by cigarette smoking include rhytidectomy, abdominoplasty, breast reconstruction, free-tissue transfer, and digital replantation. This article reviews the available data, introduces new clinical data, and hypothesizes about the ways in which some procedures are more affected than others.

High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction.

A 17-year experience from 1977 to 1993 with gunshot, shotgun, and high-energy avulsive facial injuries emphasizes the superiority and safety of "ballistic wound" surgical management: (1) immediate stabilization in anatomic position of existing bone, (2) primary closure of existing soft tissue, (3) periodic "second look" serial debridement procedures, and (4) definitive early reconstruction of soft-tissue and bony defects. The series contains 250 gunshot wounds, 53 close-range shotgun wounds, and 15 high-energy avulsive facial injuries. Four general patterns of involvement are noted for both gunshot and shotgun wounds and three for avulsive facial injuries. The treatment algorithm begins with identifying zones of injury and loss for both soft and hard tissue. Gunshot wounds are best classified by the location of the exit wound; shotgun and avulsive facial wounds are classified according to the zone of soft-tissue and bone loss. Treatment, prognosis, and complications vary according to four patterns of gunshot wounds and four patterns of shotgun wounds. Avulsive wounds have not been recommended previously for ballistic wound surgical management. The appropriate management of high-energy avulsive and ballistic facial injuries is best approached by an aggressive treatment program emphasizing initial primary repair of existing tissue, serial conservative debridement, and early definitive reconstruction.

Silicon tissue assays in nonaugmented cadaveric patients: is there a baseline level?

Microscopic silicone in various tissues in the bodies of females with breast implants has led to the possible incrimination of these implants with connective-tissue disorders. Current technology precludes accurate silicone measurements, but all compounds containing the element silicon (which would include silicone) may be measured accurately. Direct positive correlations of silicon assays with silicone measured levels were confirmed by adding known amounts of silicone oil as a control. With the ubiquitous nature of organosilicons (food containers, syringes, etc.), we hypothesized that baseline silicon levels could be detected in tissues of cadavers without silicone breast augmentation. Ten cadavers were examined. Tissue samples were derived from subcutaneous fat, nipple, breast tissue, liver, spleen, and axillary nodes. Nine of 10 cadavers had silicon levels in various tissues. Measurements were performed by direct current atomic emission spectroscopy. The baseline data were compared with those from four augmented patients who underwent capsulectomies and implant removal. Silicon levels were fivefold higher in the augmented patients than in the nonaugmented cadavers. No difference in levels was noted if the patient had an intact or ruptured implant and/or was symptomatic versus asymptomatic for immunologic disease. This study was designed to measure baseline silicon levels in the normal population. It also has established an accurate level of measurement of tissue silicone.

Quantitation of sensibility in gigantomastia and alteration following reduction mammaplasty.

A vibrometer and Semmes-Weinstein monofilaments were used to delineate the sensory threshold for quickly and slowly adapting fibers in 13 women with gigantomastia (bra size D or greater) as compared with small-breasted women (bra size A or B). It was found that the mean thresholds for gigantomastia patients were significantly higher (i.e., they were less sensitive) for vibration (p < 0.001) and pressure (p < 0.02). After amputation and free nipple grafting (six patients) or a McKissock-type breast reduction (four patients), six patients had improved sensation, two patients were less sensitive, one patient was unchanged, and one patient was lost to follow-up. These results suggest (1) that preoperatively, there is a chronic traction injury to the fourth, fifth, and sixth intercostal nerves in women with gigantomastia (this is corrected after breast reduction, and sensation improves), (2) that breast reduction surgery itself divides some intercostal nerve fibers, the number dependent on the extent and type of skin and glandular resection (this decreases sensation), and (3) that postoperatively, reinnervation from intercostal and supraclavicular nerves occurs (this improves sensation with time). The postoperative sensory outcome of the breast depends on a combination of these factors; the majority of our patients with gigantomastia have improved sensation after breast reduction.

The sensational transverse rectus abdominis musculocutaneous (TRAM) flap: return of sensibility after TRAM breast reconstruction.

Normal breast sensation was objectively quantitated with a biothesiometer, Semmes-Weinstein monofilaments, and two-point discrimination in 10 patients. Ten patients, 2 to 7 years after pedicled transverse rectus abdominis musculocutaneous flap (TRAM) breast reconstruction, were tested in a similar manner. The majority of these patients were found to have recorded measurable sensibility in the TRAM reconstruction. Recovered sensation was best in the medial and superior quadrants and improved with time. Although sensibility was present, it was still significantly different from normal sensory thresholds. A method to improve sensation by intercostal nerve repair is described. Three patients who have undergone this reconstruction have better sensibility in the reinnervated breast compared with the control breast. Sensory reeducation programs may also improve subsequent sensibility return.

Technical modifications for on-site nipple-areola reconstruction.

There have been numerous techniques and refinements for nipple-areola reconstruction described that have required the use of distant donor sites. A further modification of the skate flap is described, whereby the entire reconstruction can be performed on site, thus avoiding a second scar and any subsequent morbidity. This technique is easy to perform and has all the advantages of the skate flap as described by Little.

Radioactive cell membrane labelling.

Building upon earlier studies with fluorescent probes, the authors describe a new cell tracking compound, PKH95, with a radioactive signal, which has been developed specifically for high-sensitivity cell tracking and biodistribution studies.