Detection of Eimeria acervulina using the polymerase chain reaction.

A polymerase chain reaction (PCR)-based assay was developed for the detection of Eimeria acervulina. Primers were designed to amplify a fragment of the EASZ240/160 sporozoite antigen gene. The PCR assay detected as few as 10 E. acervulina oocysts in a mixed population containing a total of 10(6) oocysts. No nonspecific reaction was observed with any other species of avian Eimeria known to occur in Australia. PCR products from genomic DNA were 237 bp larger than predicted from previously reported cDNA sequences. Sequencing of the product revealed the presence of a probable intron. This work demonstrates the potential of PCR-based assays for identification and detection of avian Eimeria. Potential uses include identification of minor species present in mixed infections and quality control in the production of live vaccines.

Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience.

OBJECTIVE: The purpose of the study is to define those patient variables that contribute to morbidity and mortality of median sternotomy wound infection and the results of treatment by debridement and closure by muscle flaps. BACKGROUND: Infection of the median sternotomy wound after open heart surgery is a devastating complication associated with significant mortality. Twenty years ago, these wounds were treated with either open packing or antibiotic irrigation, with a mortality approaching 50% in some series. In 1975, the authors began treating these wounds with radical sternal debridement followed by closure using muscle or omental flaps. The mortality of sternal wound infection has dropped to < 10%. METHODS: The authors' total experience with 409 patients treated over 20 years is described in relation to flap choices, hospital days after sternal wound closure, and incidence rates of morbidity and mortality. One hundred eighty-six patients treated since January 1988 were studied to determine which patient variables had impact on rates of flap closure complications, recurrent sternal wound infection, or death. Variables included obesity, history of smoking, hypertension, diabetes, poststernotomy septicemia, internal mammary artery harvest, use of intra-aortic balloon pump, and perioperative myocardial infarction and were analyzed using chi square tests. Fisher's exact tests, and multivariable logistic regression analysis. RESULTS: The mortality rate over 20 years was 8.1% (33/49). Additional procedures for recurrent sternal wound infection were necessary in 5.1% of patients. Thirty-one patients (7.6%) required treatment for hematoma, and 11 patients (2.7%) required hernia repair. Among patients treated since 1988, variables strongly associated with mortality were septicemia (p < 0.00001), perioperative myocardial infarction (p = 0.006), and intra-aortic balloon pump (p = 0.0168). Factors associated with wound closure complications were intra-aortic balloon pump (p = 0.0287), hypertension (p = 0.0335), and history of smoking (p = 0.0741). Factors associated with recurrent infection were history of sternotomy (p = 0.008) and patients treated for sternal wound infection from 1988 to 1992 (p = 0.024). Mean hospital stay after sternal wound reconstruction declined from 18.6 days (1988-1992) to 12.4 days (1993-1996) (p = 0.005). To clarify management decisions of these difficult cases, a classification of sternal wound infection is presented. CONCLUSIONS: Using the principles of sternal wound debridement and early flap coverage, the authors have achieved a significant reduction in mortality after sternal wound infection and have reduced the mean hospital stay after sternal wound closure of these critically ill patients. Further reductions in mortality will depend on earlier detection of mediastinitis, before onset of septicemia, and ongoing improvements in the critical care of patients with multisystem organ failure.

Endoscopically assisted plastic surgical procedures in the pediatric patient.

Endoscopically assisted surgery has gained wide popularity in plastic surgery. Its major uses have been in aesthetic procedures. In this article we demonstrate the safety and utility of these techniques to a pediatric population. All patients younger than 20 years who underwent an endoscopically assisted plastic surgical procedure by one of the authors were pooled and their medical records reviewed. Complications were determined. For those children having an excision of a forehead mass, the duration of the procedure, length of incision, specimen size, and length of hospital stay were determined. Additionally, parents of these children were contacted by telephone after the excisions to determine satisfaction with the procedures. Sixteen patients' records were reviewed. Patients' ages ranged from 6 months to 15 years (mean, 5.8 years). The procedures performed included removal of forehead mass (n = 9), placement of tissue expanders (n = 5), excision of gynecomastia (n = 1), and malar soft tissue elevation (n = 1). All procedures were completed with endoscopic assistance. One procedure had to be converted to an open technique. No hematomas were observed. For forehead mass excisions, the average duration of the procedure was 46.9 min. Incision length was 1.1 cm, and specimen volume was 0.5 cm3. Parent satisfaction with the endoscopic procedures was high, with 100% responding favorably. No significant complications were observed. Many of the procedures were performed as outpatients. Parental acceptance of and satisfaction with the endoscopic techniques was high. Our experience supports the use of endoscopic techniques in the pediatric plastic surgical patient.

Subfascial endoscopic perforator surgery: new life for an old procedure?

BACKGROUND: Division of incompetent perforating veins has long been regarded as an appropriate approach for treatment of venous stasis ulcers. The development of endoscopic techniques using standard laparoscopic instrumentation has permitted the application of this therapy without the need for long open incisions, fraught with complications. METHODS: We report our experience with 20 cases of subfascial endoscopic perforator surgery (SEPS) in 19 patients. Seventeen limbs had active ulceration at the time of operation. A gas insufflation technique with two 10 mm ports was used in most cases. RESULTS: An average of four perforating veins were divided in each case. Mean operating time was 1.5 hours. At a mean follow-up of eight months, initial complete healing occurred in 14 of 17 ulcers, three ulcers improved, and three healed ulcers at the time of SEPS have remained healed. One patient developed a small area of recurrent ulceration after initial healing. There were no thromboembolic complications. One procedure was technically unsuccessful because of morbid obesity. One patient developed a wound infection, and one patient required re-exploration for a subfascial hematoma. CONCLUSION: SEPS is a safe, minimally invasive procedure which should become an important part of the surgical armamentarium in treating patients with venous ulcers.

Subcutaneous, video-assisted saphenous vein harvest: report of the first 30 cases.

Harvest of the saphenous vein is a commonly performed procedure in cardiovascular surgery. The incision required for its removal is the longest used anywhere. In this report, the authors describe a minimally invasive technique for removal of the vein. This has been used in 30 patients undergoing peripheral arterial bypass (n = 27), venovenous bypass (n = 2), and a saphenopopliteal fistula (n = 1). There were three perioperative complications: skin necrosis over tunnel (one), bulla (one), and saphenous vein injury (one). Harvest time averaged 1.25 h. There was minimal postoperative discomfort in the harvest site and minimal scarring. Endoscopic harvest of the saphenous vein differs from most laparoscopic procedures because of its linear course. Consequently, visualization and dissection is coaxial rather than triangulation. This study demonstrates the technical feasibility of vein harvest. Development of appropriate instrumentation for opening the optical cavity and vein manipulation will reduce operative times.

Endoscopic abdominoplasty and endoscopically assisted miniabdominoplasty.

Recent developments in abdominal contouring procedures have included the extensive use of liposuction and the use of modified or limited scars, producing in effect a "downsizing" of the operative procedures for many patients. The use of minimally invasive techniques based on endoscopic technology and instrumentation represents a logical extension of this trend. Endoscopic visualization and dissection facilitate musculofascial repair through a very small incision and, combined with liposuction, allows significant improvement in abdominal recontouring in selected patients. Patient selection parameters, instrumentation, operative techniques, and complications of this developing procedure are described.

Autologous breast reconstruction with endoscopic latissimus dorsi musculosubcutaneous flaps in patients choosing breast-conserving therapy: mammographic appearance.

OBJECTIVE: The objective of this study was to define and evaluate mammographic changes in patients treated with breast-conserving therapy and a new reconstructive technique that uses autologous tissue from a latissimus dorsi musculosubcutaneous flap. MATERIALS AND METHODS: Of 20 patients who underwent either immediate or delayed endoscopic latissimus dorsi muscle flap reconstruction after lumpectomy, 13 also had postsurgery mammograms available for review. Radiographic findings assessed included skin thickening, density or radiolucency at the reconstruction site, density around the flap, fat necrosis, calcifications, and the presence of surgical clips. RESULTS: Mammograms for three patients (23%) revealed thickening that we believed was attributable to radiation therapy. No patient had increased density in the flap itself; all flaps were relatively radiolucent centrally (13/13; 100%). Mammograms revealed density around the rim of the flap in four patients (31%). This density was most likely secondary to latissimus dorsi muscle fibers and did not limit radiographic evaluation. One patient had calcifications, probably secondary to fat necrosis. No oil cysts were seen. In the majority of patients (11/13; 85%), surgical clips were visible. CONCLUSION: Endoscopic latissimus dorsi muscle flap reconstruction, previously used only for mastectomy patients, is now being used for improved esthetic outcome in selected patients who desire breast conservation. Our results indicate that the mammographic findings are predictable. The most common findings are relative radiolucency centrally, with or without density from muscle fibers around the edges of the area of tissue transfer. The transplanted musculosubcutaneous flap does not interfere with mammographic evaluation.

TRAM flap vascular delay for high-risk breast reconstruction.

The purpose of this study was to evaluate the intraoperative changes in physiologic blood pressure following vascular delay of the TRAM flap. Ligation of the superficial and deep inferior epigastric vessels 2 weeks prior to the TRAM flap was performed. The incidence of fat necrosis was 4.3 percent in 23 high-risk patients who underwent 30 immediate breast reconstructions. Direct measurement of blood pressure in the deep inferior epigastric artery and vein was performed in a control group without delay consisting of 13 low-risk patients and in the study group of 7 high-risk patients who underwent vascular delay. Changes in TRAM flap perfusion pressure were examined following the change in location of the flap from the abdomen to the chest. Blood pressure measurements demonstrated that arterial pressure in the proximal stump of the deep inferior epigastric artery was 64 percent in the study group prior to delay and 72 percent in the control group. The physiologic response to vascular delay included an overall increase in arterial pressure with a decrease in venous congestion. TRAM flap perfusion pressure was significantly increased from 13.3 mmHg (control) to 40.3 mmHg (delayed) in the region of the midrectus perforators (p < 0.05). These data suggest that the technique of TRAM flap delay may increase the reliable tissue volume and improve the safety of the TRAM flap.

Instrumentation and setup for endoscopic plastic surgery.

The use of endoscopic techniques mandates the need for basic understanding of endoscopic instrumentation and operating room setup in order to avoid procedural delays and surgeon frustration. The electronic systems for endoscopic surgery-cameras, light sources, monitors, and so on-have been well developed for other specialties and are fully adaptable to endoscopic plastic surgical procedures. Hand instruments, however, are in the early phases of refinement for subcutaneous plastic surgical procedures and will undoubtedly improve over the next several years. Adaptation of existing instrumentation and development of new operating tools continue and promise to make endoscopic plastic surgical procedures of the future more ergonomic and efficient. Similarly, while operating room setup for endoscopic plastic surgical procedures varies depending on individual circumstances, application of a few basic principles will help in making this step quick and simple. The knowledge and experience of scrub technicians and nurses experienced in endoscopic techniques can be invaluable to the surgeon just beginning to use endoscopic techniques in plastic and reconstructive surgery.

Endoscopic techniques in aesthetic breast surgery. Augmentation, mastectomy, biopsy, capsulotomy, capsulorrhaphy, reduction, mastopexy, and reconstructive techniques.

Endoscopy is a new tool in the armamentarium for surgery of the breast. Endoscopic techniques may offer decreased scarring and morbidity rates for a variety of aesthetic and reconstructive procedures. Whereas initial clinical experiences are encouraging, most endoscopic procedures of the breast remain developmental, both in technique and instrumentation. Additional development, refinement, and experience will be required to define fully the utility of endoscopic techniques.

Primary temporal melanoma without diffuse leptomeningeal involvement: a variant of neurocutaneous melanosis.

Plastic surgeons who treat congenital giant nevi should be aware of the neurocutaneous melanosis syndrome and its variants. When neurologic symptoms are present concurrent with MRI evidence of central nervous system involvement, treatment of the cutaneous lesion must be tempered by knowledge of a poor prognosis. In the otherwise asymptomatic patient, the plastic surgeon should consider screening with MRI imaging, realizing that the clinical significance of a positive MRI scan without neurologic symptoms is unknown.

Endoscopic transaxillary subpectoral breast augmentation.

The transaxillary approach to breast augmentation is an established technique that offers the advantage of a remote incision in an aesthetically acceptable area. The main disadvantage to this approach is the lack of visualization of the implant pocket, necessitating blind, blunt dissection of the pectoral muscle origins. Occasionally, this limitation may result in improper implant placement and poor aesthetic results. In order to address this shortcoming, we have explored the use of minimally invasive endoscopic techniques in transaxillary augmentation to allow division of the pectoral muscle origin under direct visualization, effectively lowering the inframammary crease. Initial dissections and instrument development were performed in five unpreserved female cadavers. Subsequently, 103 implants have been placed in 53 patients utilizing the endoscopic transaxillary approach. Follow-up ranges from 2 weeks to 20 months. There have been no hematomas, infections, capsular contractures, or other complications. Aesthetic results have been good, and patient acceptance is high. By providing predictable and reproducible control of the inframammary crease, endoscopic dissection has allowed us to expand our indications for the transaxillary approach to breast augmentation. Surgical technique and brief clinical experience are described.

A field evaluation of the polymerase chain reaction procedure for the detection of bovine leukaemia virus proviral DNA in cattle.

A polymerase chain reaction (PCR) procedure that detects proviral bovine leukaemia virus (BLV) in peripheral blood mononuclear cell DNA was evaluated. Blood samples from all animals (164) in a commercial dairy herd with a 30% prevalence of BLV infection, and from 194 animals from BLV free herds were tested. The absence of any positive PCR results in animals from BLV free herds confirmed the specificity of the assay. Initial testing of the infected herd using a single amplification PCR (SA-PCR), detected BLV infection in 62 of 72 adult animals that were seropositive by the agar gel immunodiffusion (AGID) test and in one persistently seronegative cow. Infection in this cow was confirmed by sheep bioassay. Subsequent testing of the SA-PCR negative, seropositive animals using a double amplification PCR (DA-PCR) detected proviral BLV in eight of nine animals that were available for retesting. The PCR assay was also able to distinguish BLV infected calves from uninfected calves that were serologically positive because of the presence of colostral antibody. Lymphocytes from all seropositive animals were cultured for determination of BLV antigen expression. Cultures from 37 of 62 SA-PCR positive animals produced detectable quantities of viral antigens. However, antigen expression was not detected in cultures from seropositive animals that were negative in the SA-PCR. In addition, in experimental transmission tests, inoculation of more than 10(6) lymphocytes from these cows was required for sheep to become seropositive to BLV.(ABSTRACT TRUNCATED AT 250 WORDS)

Control of bovine leukaemia virus transmission by selective culling of infected cattle on the basis of viral antigen expression in lymphocyte cultures.

The use of viral antigen expression in lymphocyte cultures to prioritize the culling of bovine leukaemia virus (BLV) infected cattle was evaluated as a means of controlling the spread of infection in heavily infected herds. Selective culling was implemented in five commercial dairy herds containing between 126 and 304 cattle with infection prevalences, based on serological testing using the agar gel immunodiffusion test, of 19.4%, 20.3%, 20.1%, 20.6% and 39%. All seropositive cattle were tested for BLV antigen expression in lymphocyte cultures, and 51% found to express detectable quantities of viral antigens. In the four herds with 19% to 21% infection prevalence, all antigen-positive animals were culled immediately. Antigen-negative animals were retained in the herds for at least 16 months. Only two new infections were recorded in these four herds after antigen-positive animals had been culled, despite the continued presence of the antigen-negative animals. In the herd with 39% infection prevalence, a rapid reduction in the incidence of infection was achieved, even though only those animals with the highest levels of antigen expression were culled initially. Experimental transmissions from seropositive cattle indicated that sheep could be infected from an antigen-positive cow with fewer than 10(3) lymphocytes, whereas more than 10(6) lymphocytes were required to transmit infection from an antigen-negative cow. Estimation of the amount of integrated BLV DNA in serial dilutions of blood from antigen-positive and antigen-negative cattle provided an explanation for the higher infectivity of antigen-positive cattle.(ABSTRACT TRUNCATED AT 250 WORDS)

T lymphocyte responses of sheep to bovine leukaemia virus infection.

Sheep were experimentally infected with bovine leukaemia virus (BLV) by inoculation of peripheral blood lymphocytes (PBL) from BLV infected sheep. Monoclonal antibodies were used to monitor changes in lymphocyte subpopulations in the first few weeks after inoculation. The polymerase chain reaction (PCR) detected BLV DNA in PBL of infected sheep 11-15 days after inoculation, that is, before antibodies to viral structural proteins were detected at 15-39 days post-inoculation. A rise in the number of both B and T lymphocytes coincided with detection of infection by PCR. At this time, an increase in the number of circulation CD8+ lymphocytes resulted in a low CD4: CD8 ratio. It appears that in BLV infection there is a host specific cell-mediated immune response to infected lymphocytes rather than a general immune response to foreign antigens. This response, which is characterized by an increase in the number of circulating CD8+ lymphocytes, precedes seroconversion. There is considerable variation between animals in this cytotoxic T lymphocyte response.