Primary lipofilling as an adjunct in transverse upper gracilis flap breast reconstruction.

In many centres, the myocutaneous transverse upper gracilis (TUG) flap represents an alternative choice in autologous breast reconstruction when abdominal tissue is unavailable. However, a single TUG flap may be volume deficient, particularly in the upper pole. We describe the application of simultaneous lipofilling to the pectoralis major muscle at the index procedure and present our decision-making algorithm, technique and outcomes. A retrospective review of all TUG flaps between January 2011 and May 2021 was conducted. Patient demographics, volume of primary and any subsequent fat grafting and complications were recorded. A total of 183 patients (242 TUG flaps) were included in this study. Of these; 130 patients were reconstructed with single TUG flaps, 16 patients received a single TUG flap with immediate lipofilling, and 37 patients underwent stacked, double TUG flap reconstructions. Of the 242 flaps, there were 2 flap losses (<1%), neither of which occurred in the immediate lipofilling cohort. Among the 130 single TUG patients, 28 (21.5%) required a cumulative total of 40, and a mean of 1.4, secondary lipofilling procedures. The immediate lipofilling patients were injected with a mean of 42 ml fat (range: 20-80 ml). In this group, only 2 of 16 patients required secondary lipofilling. The mean follow-up was 67 months (17-141). Primary lipofilling may reduce the need for secondary revisional procedures and appears safe at the index operation, adds little operative time and has negligible donor site morbidity. In patients where a second (stacked) flap would add unnecessary volume and complexity, it can be considered a useful adjunct.

Chronic sciatic nerve compression secondary to arteriovenous malformation: case discussion and literature review.

Sciatic nerve symptomatology may arise from both intra- and extra-neural pathology, at any point along descent from the sacral plexus to its bifurcation. The potential aetiology is broad, ranging from degenerative spinal disease to muscle, bony and vascular pathology. We present an extremely unusual case of position and exercise-induced nerve compression secondary to arteriovenous malformation and review the potential extraspinal causes, many of which may be ameliorated by surgical excision or decompression. We further discuss the usefulness of diagnostic imaging, specific clinical tests and histopathological tools that may aid in management.

Managing Ruptured Splenic Ectopic Pregnancy Without Splenectomy: Case Report and Literature Review.

Splenic ectopic pregnancy is extremely rare but carries a high risk of uncontrollable life-threatening bleeding. Our aim is to try to diagnose those cases earlier and to include splenic preservation as good alternative for selected cases. Extensive review of the literature has been performed. Thirty-one case reports were identified, of which 4 have been excluded because they were not written in English. A 36-year-old woman presented to the Emergency Department with haemorrhagic shock. Despite the levonorgestrel intrauterine system (LNG-IUS) being in situ for 4 months, urinary and serum tests were both positive for pregnancy, and an ultrasound scan revealed haemoperitoneum suggestive of a ruptured ectopic pregnancy. An emergency Pfannenstiel laparotomy was performed and a diagnosis of spontaneous tubal abortion was made and the abdomen was subsequently closed. Following a period of cardiovascular instability on the Intensive Care Unit postoperatively, an urgent CT scan was performed which revealed bleeding from the spleen. A midline laparotomy was performed by the general surgeon, which involved resection of the gestational sac and splenorrhaphy. Twenty-seven cases were reviewed, and 73% of them presented as an emergency and 21 cases (81%) had been managed with splenectomy. CT scan had been used in eight of the previous case reports of splenic ectopic pregnancy with 100% diagnostic accuracy rate. Non-tubal ectopic pregnancies are very rare. Splenorrhaphy is a safe alternative to splenectomy in cases of splenic ectopic pregnancy. CT abdomen and pelvis with intravenous contrast can be very helpful in relatively stable patients with a vaginal ultrasound demonstrating an empty uterus, no clear adnexal masses or free fluid.

Publication rates from BAPRAS meetings: where are we now?

In the UK the BAPRAS (British Association of Plastic, Reconstructive and Aesthetic Surgeons) meetings have always represented the ideal platform for disseminating new information in the field of plastic surgery. Previous studies have suggested the publication rate for these meetings has been falling. Our aim was to re-assess the conversion rates of presented abstracts to publications. All abstracts from BAPRAS meetings between Winter 2014 and Summer 2016 were included. PubMed and Google Scholar databases were used to search for full publications. A database was collated, this included; time to publication, journal of publication and impact factor of journal. A total of 500 abstracts were presented during the study period for which the publication rate was 28.4%. The average time to publication was 16.8 months. The most common publication journal was the Journal of Plastic, Reconstructive and Aesthetic Surgery (JPRAS) (34%). Free papers were published in journals with significantly greater impact factors (p = 0.046). Publication rates were similar to previous literature for BAPRAS meetings and have increased since 2007. A continued downward trend of publication rates for BAPRAS meetings is not seen in our data. A reduction in the number of publications in JPRAS may be explained by a rise in the impact factor of the journal or increasing competitiveness for publications. When variations in methodology are accounted for publication rates are similar to other specialties. In order to continually assess the quality of papers presented at BAPRAS meetings, the conversion to publication should be regularly re-audited.

Reanimation surgery in patients with acquired bilateral facial palsy.

Acquired bilateral facial palsy is rare and causes difficulty with speech and eating, but dynamic reanimation of the face can reduce the effect of these problems. Of 712 patients who had these procedures during our study period, two had an acquired bilateral facial paralysis. In both, reanimation was completed in a single operation using a free-functional transfer of the latissimus dorsi muscle that was coapted to the masseteric branch of the trigeminal nerve. Both patients achieved excellent non-spontaneous excursion and an improvement in function. Careful evaluation of the available donor nerves including thorough examination and electromyographic testing should always be completed before operation.

Rare case of accidental fire and burns caused by e-cigarette batteries.

E-cigarettes have become very popular among adult smokers, and many users carry e-cigarette devices and their components on their person. We present a case of a 35-year-old man who was admitted to our regional burns unit after his clothing was set-alight following the self-combustion of an e-cigarette lithium battery that was in his pocket. The patient had sustained a 1.5% mixed depth burn to the lateral aspect of his right thigh. Ward debridement under local anaesthetic was performed to remove clothing residue and reduce the risk of tattooing. Following conservative management with outpatient dressings, the burn wound healed by day 56.

Prophylactic venous cannulation of the pedicled TRAM flap in breast reconstruction.

Since its inception nearly 30 years ago, the pedicled TRAM flap has remained a reliable technique of breast reconstruction. However, venous congestion of the flap in the early postoperative period is well recognised and may lead to partial or total flap loss. This study describes a simple technique routinely employed by the senior author over 15 years involving intraoperative cannulation of the deep inferior epigastric vein and externalisation into an ileostomy bag, in order to facilitate drainage and reduce the likelihood of venous congestion. In addition to its role in breast reconstruction, this technique may be a useful adjunct to any form of free or pedicled tissue transfer.

Control of Mycobacterium tuberculosis growth by activated natural killer cells.

We characterized the underlying mechanisms by which glutathione (GSH)-enhanced natural killer (NK) cells inhibit the growth of Mycobacterium tuberculosis (M. tb) inside human monocytes. We observed that in healthy individuals, treatment of NK cells with N-acetyl cysteine (NAC), a GSH prodrug in conjunction with cytokines such as interleukin (IL)-2 + IL-12, resulted in enhanced expression of NK cytotoxic ligands (FasL and CD40L) with concomitant stasis in the intracellular growth of M. tb. Neutralization of FasL and CD40L in IL-2 + IL-12 + NAC-treated NK cells resulted in abrogation in the growth inhibition of M. tb inside monocytes. Importantly, we observed that the levels of GSH are decreased significantly in NK cells derived from individuals with HIV infection compared to healthy subjects, and this decrease correlated with a several-fold increase in the growth of M. tb inside monocytes. This study describes a novel innate defence mechanism adopted by NK cells to control M. tb infection.

Plantar fasciitis and the calcaneal spur: Fact or fiction?

BACKGROUND: Plantar fasciitis is a common diagnosis in patients presenting with heel pain. The presence of co-existing calcaneal spurs has often been reported but confusion exists as to whether it is a casual or significant association. METHODS: The lateral heel radiographs of nineteen patients with a diagnosis of plantar fasciitis and nineteen comparison subjects with a lateral ankle ligament sprain matched for age and sex, were reviewed independently by two observers. Objective measurements of calcaneal spur length and a subjective grading of spur size were recorded. RESULTS: There was a significantly higher prevalence of calcaneal spurs in the cases than the comparison group (89% versus 32%; McNemar chi-square=9.09, df=2, p=0.00257). There was good inter- and intra-observer agreement. CONCLUSION: The current study has demonstrated a significant association between plantar fasciitis and calcaneal spur formation. Further research is warranted to assess whether the association is causal.

Coil migration--a rare complication of endovascular exclusion of visceral artery pseudoaneurysms and aneurysms.

INTRODUCTION: We describe a case of metallic, angiographic coil migration, following radiological exclusion of a gastroduodenal artery pseudoaneurysm secondary to chronic pancreatitis. PATIENTS AND METHODS: A 55-year-old man presented to the out-patient clinic with chronic, intermittent, post-prandial, abdominal pain, associated with nausea, vomiting and weight loss. He was known to have chronic pancreatitis and liver disease secondary to alcohol abuse and previously underwent angiographic exclusion of a gastroduodenal artery pseudoaneurysm. During subsequent radiological and endoscopic investigation, an endovascular coil was discovered in the gastric pylorus, associated with ulceration and cavitation. This patient was managed conservatively and enterally fed via naso-jejunal catheter endoscopically placed past the site of the migrated coil. This patient is currently awaiting biliary bypass surgery for chronic pancreatitis, and definitive coil removal will occur concurrently. CONCLUSIONS: Literature review reveals that this report is only the eighth to describe coil migration following embolisation of a visceral artery pseudoaneurysm or aneurysm. Endovascular embolisation of pseudoaneurysms and aneurysms is generally safe and effective. More common complications of visceral artery embolisation include rebleeding, pseudoaneurysm reformation and pancreatitis.

Hip fractures after falls in hospital: a retrospective observational cohort study.

OBJECTIVES: To compare the prevalence and characteristics of hip fractures sustained after inpatient falls (hospital subgroup) to those presenting with a fall in the community (control group). DESIGN: Retrospective observational cohort study. SETTING: University teaching hospital. PARTICIPANTS: 5879 hip fractures occurred over an 8-year period, 327 of these took place after a fall as a hospital inpatient. OUTCOME MEASURES: Comparison of 30-day and 1 year mortality, co-morbidities, length of post-fracture hospital stay, specific complication rates and cognitive function between the hospital and control group. Other specific data on those falling in hospital was also collected. RESULTS: There were significantly higher rates (p<0.001) of cerebrovascular, chronic obstructive airways and renal disease, diabetes, malignancy and polypharmacy in patients suffering falls in hospital. Mini-mental test scores (MTS) were also significantly reduced in this subgroup (p<0.001). 30-day and 1 year mortality rates were 9% and 26%, respectively in the control group and almost double this in the hospital subgroup, being 18% and 47%, respectively (30 days, 95% CI 2.00 (1.54-2.60): p<0.001; 1 year, 95% CI 2.04 (1.73-2.40): p<0.001). There was no statistical difference between post-operative complications or length of stay post-fracture. 55% of falls in hospital took place on medical/geriatric wards with an additional 14% occurring on psychiatric units. DISCUSSION: Patients suffering hip fractures after falls in hospital are frailer with impaired cognitive function and have more co-morbidities than those suffering a fracture in the community. These patients have increased mortality, with almost 50% dead within 1 year of the fall. The majority of hip fractures after falls occur in medical or geriatric wards, but the highest risk group appears to be elderly patients on psychiatric wards. Therefore, falls risk assessment and falls prevention schemes in hospital elderly patients are of paramount importance.

An in vivo microfabricated scaffold for tendon repair.

A new type of in vivo tissue engineering system for tendon repair in situ after cut or crush of a flexor tendon is described. The system is based on the topographical reaction, alignment, migration and perhaps proliferation of tendon cells on micrometrically grooved substrates made in a biodegradable polymer. Macrophage trapping in the structure may also help to prevent inflammation. Tendon damage including crush and section injury is a fairly frequent occurrence. The conventional treatment is surgical repair, however frequently this leads, especially in hand wounds, to attachment of the tendon surface to the surrounding synovium, which is very undesirable. We present an approach based on using a biodegradable device to ensure that the healing of severed or crushed flexor tendons is aided, synovial adhesion prevented and the final result anatomically correct. The biodegradable sheath carries microgrooves fabricated into the polymer by embossing that orient and guide the cells towards each other from either side of the region of damage. After six weeks an apparently normal functional tendon is reformed.

Why fluorescent probes for endoplasmic reticulum are selective: an experimental and QSAR-modelling study.

The basis of the selectivity of fluorochromes routinely used to visualize the endoplasmic reticulum (ER) in live cells remains obscure. To clarify this, interactions of living cells with fluorochromes of varied physicochemical properties were analyzed experimentally and numerically using a quantitative structure activity relationship analysis (QSAR). Routine selective ER probes were found to be amphipathic, lipophilic cations with moderate-sized conjugated systems. The moderately lipophilic character permits probe uptake by passive diffusion without nonspecific accumulation in biomembranes. The moderately amphipathic character favors uptake into the ER, perhaps owing to its high concentration of zwitterionic lipid head-groups. The QSAR model rationalizes the impractical character of some ER probes mentioned in the literature, and could permit design of novel ER probes with different emission colors. The possibility of using the QSAR model as a tool to predict the accumulation of xenobiotics in the ER of living cells is illustrated by the localization of certain antipsychotic drugs in cultured cells.

In vivo response of strontium and zinc-based ionomeric cement implants in bone.

In this study the osteoconductive properties of strontium based ionomeric cements (ICs) named, LG125 and LG119, as well as zinc-based ICs, designated by LG130 and LG132, were compared. Wet ICs were surgically implanted into the femora of weaned Wistar rats for 4 weeks. To assess the percentage osseointegration the perimeter of the implant and the perimeter of bone in contact with the implant were measured using a pointer (the length of bone/implant interfacial contact). Osteoconduction was determined by taking six points at random around the perimeter of each ionomeric rod measuring the thickness of newly formed bone. The degree of osteoconduction was taken as the average thickness of new bone produced on the implant surface. It was found that osteoconduction was greatest in the strontium based IC implant LG125. From these studies it can be concluded that the composition LG125 might provide a useful purpose as a bone cement.

Opposite effects of flurbiprofen and the nitroxybutyl ester of flurbiprofen on apoptosis in cultured guinea-pig gastric mucous cells.

The nitric oxide (NO)-donating nitroxybutyl ester of flurbiprofen (NO-flurbiprofen), shows reduced gastro-intestinal toxicity relative to flurbiprofen. NO may exert either pro- or anti-apoptotic effects, while non-steroidal anti-inflammatory drugs may induce apoptosis. The aim of the present work was therefore to compare the effects of flurbiprofen and NO-flurbiprofen on apoptosis in guinea-pig gastric mucous cells. Apoptotic activity was assessed by assay of caspase activity and from the fragmentation and condensation of nuclei. Incubation with flurbiprofen for 24 h produced a concentration-dependent induction of apoptosis in cells attached to the culture plate (caspase 3-like activity increased by 257% at 500 microM), while NO-flurbiprofen inhibited basal apoptosis (caspase 3-like activity decreased by 71% at 500 microM). Caspase activity and nuclear fragmentation were substantially increased in cells that had spontaneously detached from the culture plate. NO-flurbiprofen inhibited caspase activity (55% at 500 microM) but not nuclear fragmentation in these detached cells. NO flurbiprofen inhibited the activation of apoptosis by 25 microM C(6)-ceramide in cells attached to the culture plate. Inhibition of caspase activity by NO-flurbiprofen was detectable after 6 h of incubation with intact cells, but by contrast with the NO-donor S-nitrosyl-N-acetyl-penicillamine, was not demonstrable with cell homogenates. Activation of caspase 3-like activity by flurbiprofen was slow (>6 h incubation needed) and was inhibited by cycloheximide. The presence of a nitroxybutyl ester moiety on flurbiprofen prevents the pro-apoptotic activity of the parent compound and may contribute to the reduced gastro-intestinal toxicity of NO-flurbiprofen.

Relation of deranged neonatal cerebral oxidative metabolism with neurodevelopmental outcome and head circumference at 4 years.

Cerebral oxidative metabolism was studied using phosphorus magnetic resonance spectroscopy during the first week of life and neurodevelopmental outcome was assessed at 4 years in 62 infants who had clinical and/or biochemical evidence consistent with birth asphyxia (critically impaired intrapartum gas exchange). Twenty-one died and the neurodevelopmental status of the 41 who survived was assessed by a range of tests at age 4 years. The minimum recorded values for the cerebral phosphocreatine:inorganic phosphate concentration ratio (an index of oxidative metabolism) were related to outcome. The results showed significant relations between the extent of derangement of neonatal oxidative metabolism and a range of adverse outcomes, including death, and at 4 years reduced head growth and the presence and severity of neuromotor impairments, overall neurodevelopmental impairments, and cognitive functioning. Strong correlations between the extent of derangement of neonatal oxidative metabolism and outcome at 1 and 4 years were also shown. We conclude that the severities of adverse outcomes at 1 and 4 years of age were closely related to the extent of cerebral energy derangement in the first week of life, and we also conclude that primary intrapartum hypoxic-ischaemic cerebral injury was generally responsible for the events that led to death, microcephaly, and impaired