Non-random distribution and sensory functions of primary cilia in vascular smooth muscle cells.

Although primary cilia are increasingly recognized to play sensory roles in several cellular systems, their role in vascular smooth muscle cells (VSMCs) has not been defined. We examined in situ position/orientation of primary cilia and ciliary proteins in VSMCs and tested the hypothesis that primary cilia of VSMCs exert sensory functions. By immunofluorescence and electron microscopic imaging, primary cilia of VSMCs were positioned with their long axis aligned at 58.3 degrees angle in relation to the cross-sectional plane of the artery, projecting into the extracellular matrix (ECM). Polycystin-1, polycystin-2 and alpha 3- and beta1-integrins are present in cilia. In scratch wound experiments, the majority of cilia were repositioned to the cell-wound interface. Such repositioning was largely abolished by a beta1-integrin blocker. Moreover, compared to non-ciliated/deciliated cells, ciliated VSMCs showed more efficient migration in wound repair. Lastly, when directly stimulated with collagen (an ECM component and cognate ligand for alpha 3beta1-integrins) or induced ciliary deflection, VSMCs responded with a rise in [Ca(2+)](i) that is dependent on the presence of cilia. Taken together, primary cilia of VSMCs are preferentially oriented, possess proteins critical for cell-ECM interaction and mechanosensing and respond to ECM protein and mechanical stimulations. These observations suggest a role for primary cilia in mechanochemical sensing in vasculature.

Do general practitioners disclose correct information to their patients suspected of dementia and their caregivers? A prospective observational study.

This study describes what general practitioners (GPs) tell persons who appear to have dementia and their caregivers after assessment and to estimate the number of (in)correct disclosures and their determinants. In a prospective observational study 64 GPs were instructed to use the Dutch national dementia guideline on all consecutive elderly (55+) patients, newly suspected of dementia. Patients were referred to a multi-disciplinary memory clinic team that served as a diagnostic reference standard. Both GPs and the memory clinic team registered their findings and actions on a predefined form. A total of 107 possible cases of dementia were recorded, and 83 were accompanied by their caregiver. After assessment, dementia was considered present in 69 persons, absent in 29, and uncertain in nine. The GPs told the diagnosis to 42% of people with probable dementia and to 74% of their caregivers. The caregivers' experiences were noted in most cases but specific advice was provided in less than half. Only increased severity of dementia was related to more disclosure to patients and caregivers. Disclosures by GPs were correct in most cases. The GPs were much more reluctant to tell the probable dementia diagnosis to patients than to (family) caregivers. The GPs disclosed incorrect diagnoses to two people without dementia, and two with dementia according to the memory clinic diagnosis.

A novel technique for intraaortic balloon pump placement via the left axillary artery in patients awaiting cardiac transplantation.

In order to circumvent the problems associated with long-term femoral intraaortic balloon pump (IABP) placement we have developed and used a new technique of IABP placement. Over the past three years 13 patients awaiting cardiac transplantation have had placement of IABP via a vein cuff sewn to the left axillary artery. Thirteen patients have undergone IABP placement using this technique. The average duration of IABP support was 37 days (range 10-86 days). Ten patients were successfully transplanted. All patients were allowed to sit, stand and ambulate with assistance. No neurologic complications occurred. There were no episodes of sepsis related to balloon or insertion site. No patient had limb ischemia during IABP counterpulsation. Left axillary artery IABP insertion via a vein cuff portal is a straightforward technique with minimal complications. This method serves as a bridge to cardiac transplantation in a gravely ill group of patients while preserving patient mobility during the waiting period for a donor heart.

Changes in compliance predict pulmonary morbidity in patients undergoing abdominal plication.

The incidence and severity of the effects of pulmonary compliance changes were investigated in patients undergoing abdominal plication surgery. A total of 20 healthy adults scheduled for abdominal plication surgery who had no significant history of pulmonary disease and 20 adults scheduled for nonabdominal, nonthoracic surgery (control group) underwent general endotracheal anesthesia; neuromuscular blockade was confirmed with electrical twitch monitoring. Before abdominal plication, the mean airway compliance was measured under total neuromuscular blockade at 33.4 +/- 2.1 ml/cm water, which was not significant when compared with control patient values. After abdominal plication was performed, the mean airway compliance was remeasured under total neuromuscular blockade; it was significantly decreased at 24.0 +/- 1.8 ml/cm water when compared with values for control patients (32.6 +/- 1.6 ml/cm) and with preplication values. Patients with airway compliance changes of less than 4 ml/cm water (when compared with preplication pulmonary mechanics) had far less incidence of atelectasis, requirements for supplemental oxygen at 24 hours or longer, or hypoxia when compared with patients with compliance changes of greater than 4 ml/cm water. Patients with compliance changes greater than 9 ml/cm water had the highest incidence of pulmonary morbidity. These data suggest that significant changes in pulmonary compliance occur after abdominal plication and that these airway compliance changes are associated with a clinically increased incidence of pulmonary morbidity in the postoperative period.

An instrument to measure the attentional demands of community-dwelling elders.

The capacity to direct attention (CDA) is a pivotal facet of cognitive functioning that allows people to focus on trains of thought, complex tasks, and the daily business of life. According to a theoretical framework of directed attentional fatigue (DAF) and restoration, excessive demand for attention depletes CDA, a condition called DAF. Attentional demands are factors such as feelings of loss and worries that require intense or prolonged use of CDA and thus can lead to DAF. The purposes of this study were to determine reliability and validity for an instrument to measure attentional demands, the Attentional Demands Survey (ADS). The ADS was administered to 197 (142 females, 50 males) community-dwelling elderly (ages 65-98 years, M = 77). A factor analysis revealed 4 factors/subscales consistent with theorized domains. Internal consistency for each subscale ranged from .87 to .90 and test-retest reliability was .91. The ADS can be used to explore the relationships among attentional demands, CDA, and interventions to support and restore attentional functioning for elders.

Laparoscopic incisional hernia repair after transverse rectus abdominis myocutaneous flap reconstruction.

Abdominal wall herniation is a relatively rare but well recognized complication that is known to occur following TRAM flap mobilization. Herein is presented a novel means to approach such a hernia, using the minimally invasive surgical approach to repair the defect with a piece of prosthetic material.

Identifying the attentional demands perceived by elderly people.

The capacity to direct attention is an essential part of life. However, excessive demand for attention produces difficulty in managing everyday activities and stressful life events. This study identified attentional demands of elderly people. Thirty elderly adults were interviewed to ascertain their perceptions of demands on them in four theoretically derived domains. Physical environmental demands included the weather and living space. Informational demands included facing new situations because of a move or the loss of a spouse as well as vision and hearing difficulties. Behavioral demands mentioned were tasks such as exercising, cooking, being able to drive, dealing with finances, and a loss of stamina. Affective demands mentioned were loneliness and worries and sadness about health and the future. A content analysis of the interview data produced items for an instrument to be used during future interventions with elderly people aimed at decreasing the level of demands and restoring the attentional capacity necessary for functioning at an optimal level. This article also discusses the implications of assessing elderly patients.

Breast cancer in reduction mammoplasty: case reports and a survey of plastic surgeons.

A discussion of occult breast carcinomas in breast reduction surgery has not occurred in the last 25 years. My recent experience in discovering two occult breast carcinomas in breast reduction specimens led to the creation of a survey of local plastic surgeons and a review of the literature with the goal being precise recommendations for such occurrences. Our survey of breast reductions performed on 2576 patients shows a 0.16 percent incidence of occult breast carcinoma, significantly lower than the 0.38 percent incidence seen in the Snyderman and Lizardo study of 1959. This decrease in the rate of occult breast carcinomas could be explained by many advances in early detection, improvements in patient education, and more thorough pathologic examination of the surgical specimens. The results of this survey and review suggest that we as plastic surgeons performing breast reduction surgery be well versed in all aspects of breast cancer detection, evaluation, and treatment.

Total ear replantation.

Since the first report of successful microsurgical ear replantation in 1980, there have been 12 other cases reported in the English literature. As the number of trained microsurgeons increases, the opportunity to treat the amputated ear with microsurgical techniques should become more common. The reported cases have involved a variety of different mechanisms of injury and methods of treatment. There have been three techniques used to revascularize the amputated ear successfully: primary vascular repair, vein grafting, and use of the superficial temporal vessels as a pedicled vascular leash. Through our own experience and a review of the literature, we have been able to identify certain clinical characteristics that help dictate which technique to use. We report four cases of successful ear replantation, review the various techniques that have been used successfully, and provide treatment recommendations for future consideration.

Human immunodeficiency virus infection and subsequent melanoma.

Immunosuppression has been known for many years to be associated with the development of skin cancer, particularly squamous cell carcinoma. The association with melanoma is less clear. This report describes 4 patients with known human immunodeficiency virus (HIV) positivity who subsequently developed malignant melanoma. The subtypes and precursors of the tumors vary. Three of 4 patients treated using accepted surgical standards remained disease free an average of 33 months postoperatively. Treatment of the melanoma as in the non-HIV infected melanoma patient is advised. Epidemiological studies remain to be done to determine the significance of this association. In the meantime, melanoma remains a surgical disease and early, aggressive, standard surgical treatment is encouraged for these patients. Despite the immunocompromised state that their HIV status implies, surgical treatment offers local and regional control of disease and possibly cure.

An evaluation of fascial staples (a new technique) in wide fascial plication during reconstructive abdominoplasty.

The purpose of this study is to evaluate the fascial stapler (a new technique) in the plication of the musculoaponeurotic fascia abdominoplasty in comparison to conventional (sutured) techniques. Thirty-eight patients underwent abdominoplasty with rectus sheath plication. Patients were randomized into staple and suture groups. Similar degrees of plicationing were performed in both groups (range, 12-20 cm). Fascial repairs were evaluated postoperatively at approximately 1 month and 6 months. A small, but comparable, subclinical fascial separation was demonstrated immediately in both the stapled and sutured groups. No progression of fascial separation was observed in either group at 1 month and 4 months postoperatively. No complications attributable to the fascial closure were noted in either group. Operative time was considerably less with the stapled technique. The results, although early, suggest that the use of fascial staples for plicationing of the musculoaponeurotic fascia during abdominoplasty is comparable to conventional (sutured) techniques regarding complication rate and disruption rate, but appreciably decreases operative time.

Attentional impairment in persons with multiple sclerosis.

Multiple sclerosis (MS) entails various cognitive and psychological changes. The capacity to direct attention (CDA) is the ability to inhibit competing and distracting stimuli while processing information from the environment. A strong CDA is essential for effective functioning in daily life. The CDA may be reduced by MS lesions and by excessive attention-draining demands imposed by the disease. The purpose of this study was to assess CDA using a one-group descriptive correlational design. The sample consisted of 33 outpatients in symptom remission with relapsing-remitting MS who had virtually no physical disability. As theorized, the MS group presented with attentional deficits of varying severity, despite the presence of few physical symptoms. These deficits were unrelated to depressive symptoms. Findings indicate that nurses need to consider attentional problems even in the most early disease states. Further research is needed to better understand the impact of attentional deficits on daily life functioning and to develop nursing interventions for conservation or restoration of CDA in individuals with relapsing-remitting MS.