RESUMO
Accurate preoperative localisation of deep inferior epigastric artery perforator (DIEaP) provides optimal surgical planning for DIEaP flaps. Cross-sectional imaging by contrast-enhanced magnetic resonance angiography (CE-MRA) has advantages over previously described techniques for perforator imaging including reduced radiation exposure and better muscle to vessel contrast. A retrospective series of 10 unilateral free breast reconstructions following preoperative CE-MRA of the anterior abdominal wall is presented. Mean age of the patients at the time of surgery was 50.3 years (range 44-63 years). An average of 2.8 perforators per study (range 1-5) was identified. Mean perforator luminal diameter was 2.6mm (1.4-4.0mm) with a mean intramuscular course length of 22.3mm (6.4-51.9 mm). Perforator course length was classified as 17% long intramuscular course (>4 cm), 80% short intramuscular course (<4 cm) and 3% paramedian. In all 10 patients, DIEaP flaps were successfully elevated. In all cases the flaps were elevated on vessels identified in preoperative review of the CE-MRA. There was a significant difference in the rates of conversion from DIEaP to transverse rectus abdominis myocutaneous (TRAM) flaps in the group who underwent CE-MRA in comparison to historical controls from the previous year (P=0.025). CE-MRA is an effective tool for DIEaP flap planning.
Assuntos
Artérias Epigástricas/anatomia & histologia , Mamoplastia/métodos , Cuidados Pré-Operatórios/métodos , Retalhos Cirúrgicos/irrigação sanguínea , Adulto , Feminino , Humanos , Angiografia por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Estudos Retrospectivos , Coleta de Tecidos e Órgãos/métodos , Resultado do TratamentoRESUMO
CT scanning is accepted as a regular component of the investigation of patients with simple craniosynostosis. In a series of 109 cases with simple craniosynostoses treated at Great Ormond Street Hospital for Children, a correct diagnosis on the basis of clinical findings was made in 100% of cases by an experienced clinician. CT scans with 3D reconstructions provided diagnostic confirmation in 100% of the patients when performed, but 91% of patients had already had sufficient confirmation of diagnosis by radiography. The clinical use of the scans for purposes other than diagnosis was examined. CT scanning in simple craniosynostosis in this series did not provide any additional clinical benefit as a screening method for the detection of intracranial abnormalities or for surgical planning. We propose that it may be appropriate to limit CT scanning, both axial images and three dimensional reconstructions, to selected cases where diagnostic uncertainty exists or where, it is used in surgical planning.
Assuntos
Craniossinostoses/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Tomografia Computadorizada por Raios X/métodos , Pré-Escolar , Craniossinostoses/cirurgia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Crânio/diagnóstico por imagemRESUMO
Steroids are often administered to paediatric craniomaxillofacial patients perioperatively to reduce postoperative facial swelling, although there is little evidence of their efficacy. Preoperative tumescent infiltration using 7 ml x kg(-1) of a solution consisting of 0.1 mg x ml(-1) triamcinolone acetate, 0.0125% bupivacaine, 0.025% lignocaine, 3 units x ml(-1) hyaluronidase and 1:1000000 adrenaline in Hartmann's solution was evaluated from a retrospective case controlled study of patients undergoing standard fronto-orbital remodelling for simple craniosynostosis (n = 20). Eye closure (i.e. inability to open the eyes) was used as a marker for severe facial swelling. Patients receiving the tumescent infiltration demonstrated significantly less eye closure (P < 0.005), implying that the tumescent infiltration had a significant effect on facial swelling. The avoidance of eye closure allowed more effective monitoring for neurological and ophthalmological complications, which is a significant clinical benefit. The infiltration solution has the advantage of a lower corticosteroid dose than previously reported dexamethasone-based perioperative regimens, thereby minimising any unwanted metabolic effects. The technique is advocated for the reduction of postoperative facial swelling in craniomaxillofacial surgical patients.
Assuntos
Anti-Inflamatórios/uso terapêutico , Blefarite/tratamento farmacológico , Craniossinostoses/cirurgia , Edema/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Pré-Medicação , Triancinolona/uso terapêutico , Anestésicos Locais/uso terapêutico , Blefarite/etiologia , Estudos de Casos e Controles , Quimioterapia Combinada , Epinefrina/uso terapêutico , Humanos , Hialuronoglucosaminidase/uso terapêutico , Lactente , Injeções Subcutâneas , Tempo de Internação , Dor Pós-Operatória/etiologia , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Defesa da Criança e do Adolescente/legislação & jurisprudência , Circuncisão Masculina/normas , Competência Mental/legislação & jurisprudência , Consentimento dos Pais , Consentimento do Representante Legal/legislação & jurisprudência , Adulto , Circuncisão Masculina/efeitos adversos , Ética Médica , Humanos , Recém-Nascido , Masculino , Pais , Defesa do Paciente/legislação & jurisprudência , Religião e Medicina , Estados UnidosAssuntos
Circuncisão Masculina , Consentimento Livre e Esclarecido/legislação & jurisprudência , Atitude , Criança , Maus-Tratos Infantis/legislação & jurisprudência , Defesa da Criança e do Adolescente/legislação & jurisprudência , Humanos , Masculino , Religião e Medicina , Reino Unido , Estados UnidosRESUMO
Mental health professionals, like other professionals involved in family matters, feel constrained when advocating for the interests of children by the belief that parents are entitled to custody and control of their children's lives, regardless of what others may think of their parenting behavior, absent severe harm to the children. This belief is morally untenable, and the legal doctrine of parental rights that is its concrete embodiment is consistent with other well-established legal principles and should be abandoned. Children alone should have legal rights in connection with their upbringing, and those rights should include an entitlement to much higher standards of parenting than the law presently imposes.
Assuntos
Poder Familiar , Adolescente , Criança , Defesa da Criança e do Adolescente/legislação & jurisprudência , Pré-Escolar , Humanos , JurisprudênciaRESUMO
The impact of age on hospital mortality, incidence of major hemorrhagic events and transfusion requirements was examined in 756 patients with acute myocardial infarction enrolled in the Thrombolysis in Myocardial Infarction (TIMI) Phase I, open label studies and the TIMI Phase II pilot study. The mortality rate significantly increased with age and was 3.5%, 11.5% and 12% in patients less than 65, 65 to 69 and 70 to 76 years of age, respectively (p less than 0.001). Logistic regression analyses selected female gender, diabetes mellitus, extensive coronary artery disease, history of congestive heart failure, continuing chest pain immediately after recombinant tissue-type plasminogen activator (rt-PA) administration, low systolic blood pressure at the time of admission and advanced age as variables predictive of in-hospital death. The incidence of major hemorrhagic events among patients not undergoing cardiac surgery during hospitalization was 8.7%, 14.5% and 24.7% in patients aged less than 65, 65 to 69 and greater than or equal to 70 years, respectively (p less than 0.001). The majority of hemorrhages were secondary to cardiac catheterization or puncture wounds. Variables related to a major hemorrhagic event included protocol, age, rt-PA dose/kg body weight and elevated diastolic blood pressure on admission. Of five intracranial bleeding events, three occurred in patients greater than 65 years. Transfusion requirements significantly increased with age (p less than 0.001). Reperfusion status at 90 min in the TIMI Phase I and open label studies A to C was similar in the three age groups studied and ranged from 60% to 71%.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Infarto do Miocárdio/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Fatores Etários , Idoso , Transfusão de Sangue , Avaliação de Medicamentos , Feminino , Hemorragia/etiologia , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Reperfusão Miocárdica , Projetos Piloto , Ensaios Clínicos Controlados Aleatórios como Assunto , Ativador de Plasminogênio Tecidual/efeitos adversosRESUMO
The intracellular location of a cytochrome P-450-dependent monoterpene hydroxylase from the higher plant, Catharanthus roseus, has been investigated. By differential and sucrose density gradient centrifugation, utilizing marker enzymes and electron microscopy, the monooxygenase was demonstrated to be associated with vesicles having a membrane thickness of 40-60 nm. The vesicles could be distinguished from endoplasmic reticulum, Golgi apparatus, mitochondria, and plasma membrane and were found in light membrane fractions containing provacuoles. Most definitive results were obtained when seedlings were ground in the presence of sand and in a medium containing sorbitol. Upon subjection of the 20,000-g pellet preparation to linear sucrose density gradient centrifugation, a threefold enrichment in hydroxylase activity was afforded in a yellow band having vesicles varying in size from 0.1 to 0.8 mum in diam and having a density of 1.09 to 1.10 g/cm3. Since the monooxygenase has been implicated in indole alkaloid biosynthesis in this plant, the data suggest the compartmentalization of at least a part of this pathway.