Vertical Growth Phase as a Prognostic Factor for Sentinel Lymph Node Positivity in Thin Melanomas: A Systematic Review and Meta-Analysis.

BACKGROUND: The 2010 American Joint Committee on Cancer guidelines recommended consideration of sentinel lymph node biopsy for thin melanoma (Breslow thickness <1.0 mm) with aggressive pathologic features such as ulceration and/or high mitotic rate. The therapeutic benefit of biopsy-based treatment remains controversial. The authors conducted a meta-analysis to estimate the risk and outcomes of sentinel lymph node positivity in thin melanoma, and examined established and potential novel predictors of positivity. METHODS: Three databases were searched by two independent reviewers for sentinel lymph node positivity in patients with thin melanoma. Study heterogeneity, publication bias, and quality were assessed. Data collected included age, sex, Breslow thickness, mitotic rate, ulceration, regression, Clark level, tumor-infiltrating lymphocytes, and vertical growth phase. Positivity was estimated using a random effects model. Association of positivity and clinicopathologic features was investigated using meta-regression. RESULTS: Ninety-three studies were identified representing 35,276 patients with thin melanoma who underwent sentinel lymph node biopsy. Of these patients, 952 had a positive sentinel lymph node biopsy, for an event rate of 5.1 percent (95 percent CI, 4.1 to 6.3 percent). Significant associations were identified between positivity and Breslow thickness greater than 0.75 mm but less than 1.0 mm, mitotic rate, ulceration, and Clark level greater than IV. Seven studies reported on vertical growth phase, which was strongly associated with positivity (OR, 4.3; 95 percent CI, 2.5 to 7.7). CONCLUSIONS: To date, this is the largest meta-analysis to examine predictors of sentinel lymph node biopsy positivity in patients with thin melanoma. Vertical growth phase had a strong association with biopsy positivity, providing support for its inclusion in standardized pathologic reporting.

Anatomy and physiology of perforator flaps of the upper limb.

Perforator flaps are an excellent reconstructive option for a functional upper limb reconstruction. This article explores the physiology and general principles of perforator flaps and their indications for use in reconstruction of the upper extremity. Workhorse perforator flaps of the upper extremity, such as the radial artery perforator, ulnar artery perforator, lateral arm perforator, posterior interosseous artery, first dorsal metacarpal artery perforator and perforator-based propeller flaps, are discussed in greater detail.

Aesthetic and functional reconstruction of fingertip and pulp defects with pivot flaps.

PURPOSE: Sensate reconstruction with glabrous skin is essential for ideal resurfacing of fingertip and pulp defects. The purpose of this study was to examine the palmar pivot flap as a reconstructive option for fingertip and pulp defects. METHODS: We used the palmar pivot flap to repair fingertip and pulp defects in 21 consecutive patients. Outcomes measured included range of motion of the distal interphalangeal and proximal interphalangeal joints, sensation, pain, cold intolerance, and percussion tenderness. We assessed patient satisfaction with the aesthetic outcome using the Michigan Hand Outcomes Questionnaire. RESULTS: All flaps survived. We achieved complete mobility at the distal interphalangeal and proximal interphalangeal joints. Sensory recovery was demonstrated in all flaps within 2 weeks postoperatively. No painful tips were reported at an average follow-up of 11 months. All flaps had mild cold intolerance, and 1 patient reported mild percussion tenderness. All patients were satisfied with the appearance of the reconstructed fingertips. CONCLUSIONS: The palmar pivot flap can provide sensate glabrous skin for the effective reconstruction of fingertip and pulp defects, resulting in aesthetically pleasing and good functional outcomes.

catena-Poly[[bis(pyridine)-lead(II)]bis(µ-penta-fluoro-benzene-thiol-ato)].

The title compound, [Pb(C(6)F(5)S)(2)(C(5)H(5)N)(2)](n), shows the Pb(II) atom in a ψ-trigonal bipyramidal S(2)N(2) bonding environment. Pyridine N atoms occupy axial sites, while thiol-ate S atoms and a stereochemically active lone pair occupy equatorial sites. Very long inter-molecular Pb⋯S inter-actions [3.618 (4) and 3.614 (4) Å] yield a weakly associated one-dimensional polymeric structure extending parallel to [010].

Risk factors influencing transfusion rates in DIEP flap breast reconstruction.

BACKGROUND: As the popularity of deep inferior epigastric perforator (DIEP) flap breast reconstruction grows, there remains little information on the transfusion rate of this more technically challenging procedure. The purpose of this study was to examine the perioperative blood loss and patient characteristics of women undergoing DIEP flap breast reconstruction in an attempt to identify independent risk factors that predict increased blood loss and transfusion requirements. METHODS: A retrospective chart review identified 144 patients who underwent DIEP flap breast reconstruction performed at Queen Elizabeth II Health Sciences Center between January of 2002 and July of 2009. Intraoperative blood loss, hemoglobin and hematocrit drop, length of hospital stay, incidence of perioperative blood transfusions, and complications were reviewed. This study assessed the effects of older age, obesity, bilateral reconstruction, immediate reconstruction, tamoxifen treatment, and length of surgery on the incidence of perioperative blood transfusion and complications. RESULTS: A total of 18.8 percent of patients required perioperative blood transfusions. These patients were older and more obese, underwent more immediate and bilateral reconstructions, and had longer mean operative times and hospital stays. Patients who underwent lengthy bilateral DIEP reconstructions were at increased risk of receiving a perioperative blood transfusion (bilateral: relative risk, 2.4; odds ratio, 4.4; long surgery: relative risk, 3.9; odds ratio, 7.3). Blood transfusion recipients had an increased risk and greater odds of experiencing any postoperative complication (relative risk, 2.3; odds ratio, 3.4). CONCLUSIONS: Bilateral reconstruction and length of surgery were the only factors to significantly increase the risk of perioperative blood transfusion. Patients receiving blood transfusions had an increased risk of experiencing a postoperative complication.

CD8+ gammadelta T regulatory cells mediate kidney allograft prolongation after oral exposure to alloantigen.

The long term goal of immunological therapy for transplantation is to induce antigen specific unresponsiveness. One approach of significant current interest is the induction of T regulatory (Treg) cells that downregulate immune responses in an antigen specific manner. In this study, we examined the nature of the immunological regulation initiated by oral exposure to alloantigen. We previously demonstrated that feeding of allogeneic donor splenocytes significantly prolongs kidney allograft survival in rats. Purified CD8+ graft infiltrating cells (GIC), but not CD4+ GIC transfer graft prolongation to naïve animals demonstrating the presence of a CD8+ Treg population in the graft. In this study, we provide evidence that is consistent with a hypothesis that the CD8+ Treg generated by oral exposure to alloantigen is an IL-10 secreting, gammadelta TCR+ T cell.

Cyanobacterial psbA families in Anabaena and Synechocystis encode trace, constitutive and UVB-induced D1 isoforms.

Cyanobacteria cope with UVB induced photoinhibition of Photosystem II by regulating multiple psbA genes to boost the expression of D1 protein (in Synechocystis sp. PCC6803), or to exchange the constitutive D1:1 protein to an alternate D1:2 isoform (in Synechococcus sp. PCC7942). To define more general patterns of cyanobacterial psbA expression, we applied moderately photoinhibitory UVB to Anabaena sp. PCC7120 and tracked the expression of its five psbA genes. psbAI, encoding a D1:1 protein isoform characterized by a Gln130, represented the majority of the psbA transcript pool under control conditions. psbAI transcripts decreased upon UVB treatment but the total psbA transcript pool increased 3.5 fold within 90 min as a result of sharply increased psbAII, psbAIV and psbAIII transcripts encoding an alternate D1:2 protein isoform characterized by Glu130, similar to that of Synechococcus. Upon UVB treatment the relaxation of flash induced chlorophyll fluorescence showed a characteristic acceleration of a decay phase likely associated with the exchange from the D1:1 protein isoform encoded by psbAI to the alternate D1:2 isoform encoded by psbAIV, psbAII and psbAIII. Throughout the UVB treatment the divergent psbA0 made only a trace contribution to the total psbA transcript pool. This suggests a similarity to the divergent psbAI gene from Synechocystis, whose natural expression we demonstrate for the first time at a trace level similar to psbA0 in Anabaena. These trace-expressed psbA genes in two different cyanobacteria raise questions concerning the functions of these divergent genes.

Monomeric, one- and two-dimensional networks incorporating (2,6-Me2C6H3S)2Pb building blocks.

The amine coordination of lead(II) has been examined through the preparation and structural analysis of Lewis base adducts of bis(thiolato)lead(II) complexes. Reaction of Pb(OAc)(2) with 2,6-dimethylbenzenethiol affords (2,6-Me(2)C(6)H(3)S)(2)Pb (6) in high yield. The solubility of 6 in organic solvents allows for the preparation of the 1:2 Lewis acid-base adduct [(2,6-Me(2)C(6)H(3)S)(2)Pb(py)(2)](7), and 1:1 adducts [(2,6-Me(2)C(6)H(3)S)(2)Pb(micro(2)-bipy)](infinity](8) and [(2,6-Me(2)C(6)H(3)S)(2)Pb(micro(2)-pyr)](infinity)(9)(where py = pyridine, bipy = 4,4'-bipyridyl and pyr = pyrazine) from reaction with an excess of the appropriate amine. In contrast to 7, reaction of (C(6)H(5)S)(2)Pb (1) with pyridine afforded the 2:1 adduct [(C(6)H(5)S)(4)Pb(2)(py)](infinity)(10). Compounds were characterized via elemental analysis, FT-IR, solution (1)H and (13)C[(1)H](6) NMR spectroscopy, and X-ray crystallography (7-10). The structures of 7-9 show the thiolate groups occupying two equatorial positions and two amine nitrogen atoms occupying axial coordination sites, yielding distorted see-saw coordination geometries, or distorted trigonal bipyramids if an equatorial lone pair on lead is considered. The absence of intermolecular contacts in 7 and 8 result in monomeric and one-dimensional polymeric structures, respectively. Weak Pb...S intermolecular contacts in 9 result in the formation of a two-dimensional macrostructure. In contrast, the structure of , shows extensive intermolecular Pb...S interactions, resulting in five- and six-coordinate bonding environments for lead(II), and a complex polymeric structure in the solid state. This demonstrates the ability of the 2,6-dimethylphenylthiolate ligand to limit intermolecular lead-sulfur interactions, while allowing the axial coordination of amine Lewis base ligands.