Inferior-based pharyngeal flap for correction of stress velopharyngeal incompetence in musicians: case reports and review of the literature.

Stress velopharyngeal incompetence (SVPI) is a special form of velopharyngeal incompetence observed in musicians who play wind and brass instruments. Due to high intraoral pressures generated while playing, the velopharyngeal structures fail to seal off the nasopharynx properly, resulting in unwanted nasal air leakage or noises. We present two young female professional clarinetists who experience symptoms of SVPI that preclude the development of their professional career. Both musicians underwent an inferior based pharyngeal flap, a well-known flap frequently used in cleft palate surgery. Both musicians were symptom-free after surgery and remain free of nasal noises while playing the clarinet after 2 and 4 years of follow-up. We present a review of literature of management of SVPI and show that the inferior-based pharyngeal flap is a feasible option for management of these potentially career ending symptoms.

[Successful breastfeeding after reduction mammaplasty]. / Succesvolle borstvoeding na borstverkleining.

OBJECTIVE: To determine if it is possible to successfully breastfeed after reduction mammaplasty with intact continuity between papilla and glandular tissue. DESIGN: Retrospective by use of a written questionnaire. METHOD: Between 1986 and 2000, 994 women under the age of 35 underwent a reduction mammaplasty at the Medical Centre in Leeuwarden, The Netherlands. They were all sent a questionnaire of which 585 were completed correctly and returned. RESULTS: Of the 585 women, 215 had had one or more children and 90 had started breastfeeding, 57 of whom were successful (63%). In non-operated women this figure is 69%. The advice to try to breastfeed was associated with a higher percentage of success than the advice not to try--78% and 42% respectively. CONCLUSION: It appears to be justified to encourage women who have had a breast reduction to attempt to breastfeed after the birth of a child.

Facial reconstruction on the abnormal skull model of a living patient.

OBJECTIVE: The concept of using a skull as the armature upon which to reconstruct a face has been understood for many years. The objective of this study was to blindly test this technique by using a skull that was reconstructed from the computed tomography (CT) scans of a living 48-year-old man. DESIGN: The patient had a bilateral cleft lip, alveolus, and palate. A model of the complete skull produced by a computer-controlled milling machine that used data from the CT scans was used for the reconstruction. Surgery was then performed, and new dental prostheses were also constructed. After surgery, a second model of the relevant part of the skull was made and the reconstruction modified accordingly. CONCLUSION: Despite having no information about the patient apart from that which could be gleaned from the model skull, the reconstructions demonstrate the approximate appearance of the face before and after surgery. Even without the extra information routinely available in forensic cases, a face broadly similar to that of the living patient could be achieved.

Immunogenicity of in vitro folded outer membrane protein PorA of Neisseria meningitidis.

In vitro folded and the denatured form of PorA P1.6 from Neisseria meningitidis strain M990 were used for immunization studies in mice. Previously, the antigen was isolated from cytoplasmic inclusion bodies, folded and purified. Its immunogenicity without adjuvant appeared to be low. The addition of the adjuvant QuilA, but not of galE lipooligosaccharide, considerably enhanced the immunogenicity. Moreover, when immunized with folded PorA P1.6 plus QuilA, a clear switch towards the IgG2a subclass of antibodies and concomitantly, the appearance of serum bactericidal activity, which is believed to be important for protective immunity, was observed. Hence, a tool for preparing vaccines against serogroup B meningococci devoid of endotoxin is available.

Sequence variability of the meningococcal lactoferrin-binding protein LbpB.

The lactoferrin receptor of Neisseria meningitidis consists of two proteins, LbpA and LbpB. LbpB is considered a promising vaccine candidate, and therefore its sequence variability was studied. LbpB from five different strains exhibited 70-80% mutual identity at the amino acid level. Most sequence variability was found in two stretches with a high content of negatively charged amino acids. These stretches were sequenced from six additional strains. One of the stretches is of variable length and is missing in some of the strains. The other stretch is present in all strains, but varies considerably in its exact amino acid sequence. The high degree of variability is disadvantageous for vaccine development, but may be useful for epidemiological studies.

Molecular characterization of LbpB, the second lactoferrin-binding protein of Neisseria meningitidis.

The lbpA gene of Neisseria meningitidis encodes an outer membrane lactoferrin-binding protein and shows homology to the transferrin-binding protein, TbpA. Previously, we have detected part of an open reading frame upstream of lbpA. The putative product of this open reading frame, tentatively designated lbpB, showed homology to the transferrin-binding protein TbpB, suggesting that the lactoferrrin receptor, like the transferrin receptor, consists of two proteins. The complete nucleotide sequence of lbpB was determined. The gene encodes a 77.5 kDa protein, probably a lipoprotein, with homology, 33% identity to the TbpB of N. meningitidis. A unique feature of LbpB is the presence of two stretches of negatively charged residues, which might be involved in lactoferrin binding. Antisera were raised against synthetic peptides corresponding to the C-terminal part of the putative protein and used to demonstrate that the gene is indeed expressed. Consistent with the presence of a putative Fur binding site upstream of the lbpB gene, expression of both LbpA and LbpB was proved to be iron regulated in Western blot experiments. The LbpB protein appeared to be less stable than TbpB in SDS-containing sample buffer. Isogenic mutants lacking either LbpA or LbpB exhibited a reduced ability to bind lactoferrin. In contrast to the lbpB mutant, the lbpA mutant was completely unable to use lactoferrin as a sole source of iron.

Human B- and T-cell responses after immunization with a hexavalent PorA meningococcal outer membrane vesicle vaccine.

The PorA protein from Neisseria meningitidis, a potential vaccine candidate, induces human bactericidal antibodies which are serosubtype specific. We developed a hexavalent PorA outer membrane vesicle vaccine based on reference strain H44/76. This vaccine contains the six most prevalent PorA serosubtypes as found in many countries. We previously reported on the immune responses of 20 adult volunteers after a single immunization with this vaccine. In this study, the B- and T-cell responses in three adult volunteers were studied after three consecutive immunizations (0, 2, and 11 months). The first immunization induced a strong B-cell response resulting in high immunoglobulin G levels in an outer membrane vesicle enzyme-linked immunosorbent assay. At least a fourfold increase in bactericidal activity was observed against the majority (four to six) of the vaccine antigens compared to prevaccination titers. Immunodominance was observed for one or two of the PorAs in the bactericidal assay with a set of six isogenic H44/76-derived PorA target strains. These strains carry the individual PorAs as present in the vaccine. The second and third immunizations did not induce a further increase in the immune responses. A decline in time with respect to PorA-specific antibodies was observed after each immunization. These observations were reflected by the T-cell proliferation responses. Two additional sets of isogenic H44/76-derived mutant strains were used to study the specificity and/or cross-reactivity of the induced bactericidal antibodies. These target strains differ only in expressing mutant family variants of either PorA P1.7,16 or P1.5,10, both present in the PorA vesicle vaccine. The bactericidal antibody responses found were directed predominantly against the P1.7 (loop 1 of P1.7,16) and the P1.10 (loop 4 of P1.5,10) epitopes. This indicates that different portions of PorA were involved in the induction of bactericidal antibodies depending upon the PorA serosubtype.

Bone grafting the piriform aperture deformity in isolated cleft lip patients: indication, technique, and results.

PURPOSE: This study was undertaken to determine the effect of a bone graft in the piriform aperture on the nasal deformity and orthodontic treatment of the cleft side teeth in isolated cleft lip patients. PATIENTS AND METHODS: All primary cleft lip repair was done 3 months after birth. Nine patients, four female and five male, with a mean age of 12.5 years (range, 8.2 to 24.8 years) and with a repaired cleft lip, were bone grafted between 1992 and 1996. The mean postoperative period was 2 years (range, 1 to 4 years). An iliac crest bone graft was placed in the piriform aperture deformity on the side of the cleft lip. The improvement in the nasal symmetry and angulation of the cleft side teeth were evaluated. The eight growing cleft lip patients (mean age, 11 years; range, 9 to 13 years) were compared with a control group of eight healthy growing children (mean age, 11 years; range, 9 to 13 years). The improvement of nasal symmetry was measured by the formula of the lobule portion of the columella index preoperatively and postoperatively. RESULTS: The mean lobule portion of the columella index preoperatively was 41.8% (SD, 4.4%; SE of Mean, 1.5%) and postoperatively was 44.2% (SD, 4.9%; SE of Mean, 1.6%) (P > .006, t-test for paired samples). The angulation of the cleft side teeth was improved by orthodontic treatment. CONCLUSION: Bone grafting the piriform aperture deformity results in a stable result and improves nasal symmetry and the angulation of the cleft side teeth.

Sequence variability of FrpB, a major iron-regulated outer-membrane protein in the pathogenic neisseriae.

The FrpB protein from pathogenic neisseriae is a 77 kDa iron-regulated outer-membrane protein that belongs to the family of TonB-dependent receptors and may have potential as a vaccine component. Comparison between the frpB gene from three different meningococcal strains and a published gonococcal one revealed that the region from residues 350 to 390 displays pronounced sequence variability. In a model for the topology of FrpB in the outer membrane, this region corresponds to loop 7, the longest of the predicted 13 surface-exposed loops. Binding of four out of a total of eight bactericidal monoclonal antibodies to synthetic peptides corresponding to loop 7 showed that their epitopes are located here. The frpB genes from five additional meningococcal strains were cloned and sequenced in this region. Pairwise comparisons showed different degrees of similarity.

Specificity of human bactericidal antibodies against PorA P1.7,16 induced with a hexavalent meningococcal outer membrane vesicle vaccine.

A set of isogenic strains was constructed from the meningococcal reference strain H44/76 (B:15:P1.7,16) which differed only in their outer membrane protein (OMP) compositions. First, three isogenic strains lacking the expression of either class 3 (PorB) or class 4 (RmpM) OMP or both were obtained. Second, three isogenic class 1 OMP loop-deficient strains of H44/76 lacking the predicted loop 1 or 4 or both of class 1 OMP (PorA) were obtained. Third, three isogenic class 1 OMP strains which differed by point mutations in the predicted loop 4 of subtype P1.16 were constructed. Strains were constructed through transformation with gene constructs made in Escherichia coli and their homologous recombination into the meningococcal chromosome. This study describes the contribution of one of the six class 1 OMPs, PorA P1.7,16, in the development of bactericidal antibodies after a single immunization of adult volunteers with 50 or 100 micrograms of protein within a hexavalent PorA outer membrane vesicle vaccine. PorA-, PorB-, and RpmM-deficient isogenic strains were used to define the human immune response against PorA. The loop-deficient isogenic strains were used to define the contribution of loops 1 and 4 of PorA in the development of bactericidal anti-PorA antibodies. The isogenic strains carrying a point mutation in loop 4 were used to study the cross-reactivity of the induced bactericidal antibodies against target strains showing microheterogeneity. The results indicate that a single immunization with the hexavalent PorA vaccine induced a dose-dependent bactericidal immune response, which is directed mainly against PorA. The epitope specificity of antibodies is directed mostly against loop 1, although loop 4 and as-yet-unidentified epitopes of PorA P1.7,16 are also involved.

Internal mammary artery and vein supercharge in TRAM flap breast reconstruction.

To improve the blood supply of the pedicled flap we have performed an additional microvascular augmentation to this type of breast reconstruction procedure since 1991. The ipsilateral deep inferior epigastric pedicle is anastomosed to the internal mammary artery and vein (IMAV supercharge). In 19 of 20 patients this technique proved to be feasible. For the venous anastomoses the 3M microvascular anastomosis system facilitated the procedure. In one patient the venous anastomosis failed due to the small calibre of two internal mammary veins. In a majority of the cases rapid improvement of flap perfusion could be observed as the direct result of the supercharging. The IMAV supercharged flap is quite comparable with the free flap as regards to the operative procedure. Disadvantages are a slightly more extensive dissection and less freedom in positioning the flap due to the presence of the superior muscular pedicle. The main advantage is that the supercharge procedure minimises the risk of total flap loss. Further technical improvement may be obtained by the use of a contralateral vascular pedicle dissected with muscle-sparing techniques.

Construction of Neisseria meningitidis strains carrying multiple chromosomal copies of the porA gene for use in the production of a multivalent outer membrane vesicle vaccine.

Starting with Neisseria meningitidis strain H44/76, a set of strains was constructed for use in production of a multivalent outer membrane vesicle vaccine. The aim was to remove unwanted outer membrane components and at the same time to improve the range of protection. This was accomplished through transformation with plasmid constructs made in Escherichia coli and their homologous recombination into the meningococcal chromosome. Deletion of the cps locus resulted in loss of expression of the group B capsular polysaccharide as well as the lacto-N-neotetraose structure in lipopolysaccharide. Deletion of the porB gene abolished expression of the class 3 outer membrane protein. Additional copies of the porA gene, encoding the immunodominant class 1 outer membrane protein, were inserted into one of the opa genes and into the rmpM gene encoding the class 4 outer membrane protein. This construction was done with three sets of porA alleles, resulting in three trivalent strains, each of which expressed a different combination of class 1 epitopes.

Scalping injuries: dos and don'ts.

Replantation is the treatment of choice in scalping injuries and should always be considered, even in case of a badly damaged scalp. Specific procedures regarding pre-, intra- and postoperative care are crucial to success in replantation. These include: haemodynamic stabilization of the patient without causing damage to possible donor vessels; cooling, cleaning and further proper care of the avulsed specimen; use of antibiotics and haemodilution to optimize the intra- and post-operative situation. The above is illustrated by a case history of successful replantation of a seriously damaged avulsed scalp.

Dividing the fingers in congenital syndactyly release: a review of more than 200 years of surgical treatment.

In three specific eras the approach to the dividing of the fingers in syndactyly release has changed. In the 19th century "straight cutting" or local flaps were used; then in the beginning of the 20th century skin grafts were introduced. After Cronin published work on zigzag incisions, combinations of zigzag incisions, flaps, and grafts came into use. Here, we present a review of the most important technique, given in a historical perspective.

Use of transformation to construct antigenic hybrids of the class 1 outer membrane protein in Neisseria meningitidis.

The class 1 protein of Neisseria meningitidis is an important component of candidate outer membrane vaccines against meningococcal meningitis. This porin protein contains two variable regions which determine subtype specificity and provide binding sites for bactericidal monoclonal antibodies. To determine the contribution of each of these variable regions in the induction of bactericidal antibodies, a set of isogenic strains differing only in their class 1 epitopes was constructed. This was done by transformation of meningococcal strain H44/76 with cloned class 1 genes and selection of the desired epitope combinations in a colony blot with subtype-specific monoclonal antibodies. When used for the immunization of mice, outer membrane complexes induced bactericidal antibodies only against meningococcal strains sharing at least one of their class 1 epitopes. The results demonstrate that the P1.2 and P1.16 epitopes, normally located in the fourth exposed loop of the protein, efficiently induce bactericidal antibodies independently of the particular sequence in the first variable region. The P1.5 and P1.7 epitopes, normally located in the first exposed loop, were found to induce lower bactericidal titers. Hybrid class 1 outer membrane proteins were constructed by inserting oligonucleotides encoding the P1.7 and P1.16 epitopes into the porA gene. In this way, we obtained a set of strains which carry the P1.5 epitope in loop 1, P1.2 in loop 4, and P1.7 and P1.16 (separately or in combination) in either loop 5 or loop 6. The additional epitopes were found to be exposed at the cell surface. Outer membrane complexes from several of these strains were found to induce a bactericidal response in mice against the inserted epitopes. These results demonstrate that it is feasible to construct meningococcal strains carrying multivalent class 1 proteins in which multiple subtype-specific epitopes are present in different cell surface-exposed loops.

[The treatment of syndactylia and results in 31 children]. / De behandeling van syndactylie en de resultaten bij 31 kinderen.

In recent years there have been some changes in the treatment of congenital syndactyly. Nowadays treatment is started in the first year of life, before the child uses his hands purposefully. In the University Hospital of the Free University of Amsterdam 31 patients with 61 congenital syndactylies in 45 hands were treated between 1971 and 1991. The results were good in 40, fair in 15, moderate in 4 and poor in 2 corrections. Surgery was performed under general anaesthesia and whenever possible on an out-patient basis. To split the fingers zig-zag incisions are used. For web reconstruction two triangular flaps or one rectangular flap are used. Complex syndactyly is treated in two sessions: first two double opposing palmar flaps to cover the tips and to form the nail walls are raised and after two weeks the rest of the syndactyly is corrected. Postoperative treatment consists of a compression bandage for two weeks, followed by bathing and training in warm water until all wounds have healed.

The double opposing palmar flaps in complex syndactyly.

Double opposing flaps on the palmar surface were designed to create nail folds and to cover bony defects of the distal phalanges in the treatment of complex syndactyly. This is a two-stage procedure, and the flaps were used on 10 hands in 8 patients. There were no failures, and the results were satisfactory after a mean follow-up time of 2 1/2 years. The two stages were performed 2 weeks apart, and the surgery can be done as an outpatient procedure.

Ischaemic disease of the colon and rectum after surgery for abdominal aortic aneurysm: a prospective study of the incidence and risk factors.

In a prospective study of 100 patients operated on for an infrarenal localised aortic aneurysm, routine postoperative colonoscopy revealed ischaemic colonic disease, defined as ulceration or necrosis of different degrees in three of 66 patients (4.5%) operated on electively or semi-acute, and in six of 34 patients (17.6%) operated on for a rupture of their aneurysm. Colonoscopic findings were interpreted as transmural gangrene in three patients, extensive superficial necrosis in one, and ulceration in five. Exploratory laparotomy, however, led to a definite diagnosis of transmural gangrene in only one patient. This patient was the only one whose death was directly related to this complication, notwithstanding timely surgical intervention. Four patients had severe and protracted diarrhoea, while four others exhibited no clinical symptoms at all. Ischaemic colonic lesions were found more often in patients who had been exposed to a period of preoperative shock, than in those who were operated on in a stable circulatory state (20.7 vs. 4.2%; P less than 0.05). It was also more common in patients in whom the patency of at least one hypogastric artery could not be preserved (36 vs 5.6%; P less than 0.02). Ligation of a patent inferior mesenteric artery was not in this study related to the development of ischaemic colonic disease, nor was a period of prolonged (greater than 1 h) cross clamping of the aorta. Postoperative diarrhoea was an early warning sign of ischaemic colonic disease in five of nine patients. Other clinical symptoms or signs were of no value at all in this respect.(ABSTRACT TRUNCATED AT 250 WORDS)