Outcome analysis of breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps

QUESTIONS UNDER STUDY: With the reduction in breast cancer mortality in recent years the aesthetic outcome after treatment has gained increasing attention. The aim of this study was to assess the outcome quality of our single institution concept of free TRAM flap breast reconstruction with the aim of providing data to assist the patient's decision-making when breast reconstruction is an option. PRINCIPLES/METHODS: Thirty-two consecutive patients receiving immediate (n = 14) or delayed (n = 18) breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps were included. The selection of patients was based on their own wish and the availability of abdominal tissue, without excluding patients at risk for wound healing complications. Patient data were assessed prospectively and the aesthetic outcome was rated after the final result had been achieved. RESULTS: Ten patients sustained wound healing complications (4 of 9 smokers, 8 of 16 patients with a BMI over 25 kg/m2), 8 of them requiring revisional surgery. An average of 1.06 corrective procedures were performed per patient. The aesthetic outcome was judged to be good by 20 patients, fair by 5 and poor by 1 patient who sustained severe tissue loss. CONCLUSIONS: Our results revealed that a large measure of satisfaction is achievable from breast reconstruction with free TRAM flaps, in spite of the invasive nature of the procedure and the inclusion of patients at risk for wound healing complications. These data may be used in the decision-making process by patients eligible for breast reconstruction after mastectomy.

Virtopsy: forensic traumatology of the subcutaneous fatty tissue; multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) as diagnostic tools

Traumatic lesions of the subcutaneous fatty tissue provide important clues for forensic reconstruction. The interpretation of these patterns requires a precise description and recording of the position and extent of each lesion. During conventional autopsy, this evaluation is performed by dissecting the skin and subcutaneous tissues in successive layers. In this way, depending on the force and type of impact (right angle or tangent), several morphologically distinct stages of fatty tissue damage can be differentiated: perilobular hemorrhage (I), contusion (II), or disintegration (III) of the fat lobuli, and disintegration with development of a subcutaneous cavity (IV). In examples of virtopsy cases showing blunt trauma to the skin and fatty tissue, we analyzed whether these lesions can also be recorded and classified using multislice computed tomography (MSCT) and magnetic resonance imaging (MRI). MSCT has proven to be a valuable screening method to detect the lesions, but MRI is necessary in order to properly differentiate and classify the grade of damage. These noninvasive radiological diagnostic tools can be further developed to play an important role in forensic examinations, in particular when it comes to evaluating living trauma victims.

Evidence based check-up: the general medical point of view

Check-up is a frequent motivation for patients to see their general practitioner. The challenge lies in the choice of screening tools to accomplish an efficient, individual and age-adapted approach. In this article we review evidence-based screening methods, whose efficacy has been demonstrated by randomized clinical trials, as well as their application in clinical practice. While cardiovascular check-up has a high grade of evidence for nearly all patients, counselling to lifestyle change except for smoking cessation has been proved with lower evidence. In contrast, relatively new is the fact that ultrasound to screen for an abdominal aortic aneurysm is useful among men smokers or past smokers between 65 and 75 years old.

Quantification of coronary artery stenosis with high-resolution CT in comparison with histopathology in an ex vivo study

PURPOSE To investigate the ex vivo performance of high-resolution computed tomography (CT) for quantitative assessment of percentage diameter stenosis in coronary arteries compared to histopathology. MATERIALS AND METHODS High-resolution CT was performed in 26 human heart specimens after the injection of iodinated contrast media into the coronary arteries. Coronary artery plaques were visually identified on CT images and the grade of stenosis for each plaque was measured with electronic calipers. All coronary plaques were characterized by histopathology according to the Stary classification, and the percentage of stenosis was measured. RESULTS CT depicted 84% (274/326) of all coronary plaques identified by histology. Missed plaques by CT were of Stary type I (n=31), type II (n=16), and type III (n=5). The stenosis degree significantly correlated between CT and histology (r=0.81, p<0.001). CT systematically overestimated the stenosis of calcified plaques (mean difference - 11.0 ± 9.5%, p<0.01) and systematically underestimated the stenosis of non-calcified plaques (mean difference -6.8 ± 10.4%, p<0.05), while there was no significant difference for mixed-type plaques (mean difference -0.4 ± 11.7%, p=0.85). There was a significant underestimation of stenosis degree as measured by CT for Stary II plaques (mean difference -14 ± 9%, p<0.01) and a significant overestimation for Stary VII plaques (mean difference 9 ± 10%, p<0.05), but there was no significant difference in stenosis degree between both modalities for other plaque types. CONCLUSIONS High-resolution CT reliably depicts advanced stage coronary plaques with an overall good correlation of stenosis degree compared to histology, however, the degree of stenosis is systematically overestimated in calcified and underestimated in non-calcified plaques.

Diagnostic performance of high-sensitive troponin T in patients with renal insufficiency

In the present study, we wanted to (1) evaluate whether high-sensitive troponin T levels correlate with the grade of renal insufficiency and (2) test the accuracy of high-sensitive troponin T determination in patients with renal insufficiency for diagnosis of acute myocardial infarction (AMI). In this cross-sectional analysis, all patients who received serial measurements of high-sensitive troponin T from August 1, 2010, to October 31, 2012, at the Department of Emergency Medicine were included. We analyzed data on baseline characteristics, reason for referral, medication, cardiovascular risk factors, and outcome in terms of presence of AMI along with laboratory data (high-sensitive troponin T, creatinine). A total of 1,514 patients (67% male, aged 65 ± 16 years) were included, of which 382 patients (25%) had moderate to severe renal insufficiency and significantly higher levels of high-sensitive troponin T on admission (0.028 vs 0.009, p <0.0001). In patients without AMI, high-sensitive troponin T correlated inversely with the estimated glomerular filtration rate (R = -0.12, p <0.0001). Overall, sensitivity of an elevated high-sensitive troponin for diagnosis of AMI was 0.64 (0.56 to 0.71) and the specificity was 0.48 (0.45 to 0.51). The area under the curve of the receiver operating characteristic for all patients was 0.613 (standard error [SE] 0.023), whereas it was 0.741 (SE 0.029) for patients with a Modification of Diet in Renal Disease estimated glomerular filtration rate >60 ml/min presenting with acute chest pain or dyspnea and 0.535 (SE 0.056) for patients with moderate to severe renal insufficiency presenting with acute chest pain or dyspnea. In conclusion, the diagnostic accuracy for presence of AMI of a baseline measurement of high-sensitive troponin in patients with renal insufficiency was poor and resembles tossing a coin.

Implantation of Prophylactic Nonabsorbable Intraperitoneal Mesh in Patients With Peritonitis Is Safe and Feasible

BACKGROUND: Patients with peritonitis undergoing emergency laparotomy are at increased risk for postoperative open abdomen and incisional hernia. This study aimed to evaluate the outcome of prophylactic intraperitoneal mesh implantation compared with conventional abdominal wall closure in patients with peritonitis undergoing emergency laparotomy. METHOD: A matched case-control study was performed. To analyze a high-risk population for incisional hernia formation, only patients with at least two of the following risk factors were included: male sex, body mass index (BMI) >25 kg/m(2), malignant tumor, or previous abdominal incision. In 63 patients with peritonitis, a prophylactic nonabsorbable mesh was implanted intraperitoneally between 2005 and 2010. These patients were compared with 70 patients with the same risk factors and peritonitis undergoing emergency laparotomy over a 1-year period (2008) who underwent conventional abdominal closure without mesh implantation. RESULTS: Demographic parameters, including sex, age, BMI, grade of intraabdominal infection, and operating time were comparable in the two groups. Incidence of surgical site infections (SSIs) was not different between groups (61.9 vs. 60.3 %; p = 0.603). Enterocutaneous fistula occurred in three patients in the mesh group (4.8 %) and in two patients in the control group (2.9 %; p = 0.667). The incidence of incisional hernia was significantly lower in the mesh group (2/63 patients) than in the control group (20/70 patients) (3.2 vs. 28.6 %; p < 0.001). CONCLUSIONS: Prophylactic intraperitoneal mesh can be safely implanted in patients with peritonitis. It significantly reduces the incidence of incisional hernia. The incidences of SSI and enterocutaneous fistula formation were similar to those seen with conventional abdominal closure.

Correlation of serum and urinary matrix metalloproteases/tissue inhibitors of metalloproteases with subclinical allograft fibrosis in renal transplantation

Progressive interstitial fibrosis and tubular atrophy (IF/TA) is a leading cause of chronic allograft dysfunction. Increased extracellular matrix remodeling regulated by matrix metalloproteases (MMPs) and their inhibitors (TIMPs) has been implicated in the development of IF/TA. The aim of this study was to investigate whether urinary/serum MMPs/TIMPs correlate with subclinical IF/TA detected in surveillance biopsies within the first 6months post-transplant. We measured eight different MMPs/TIMPs simultaneously in urine and serum samples from patients classified as normal histology (n=15), IF/TA 1 (n=15) and IF/TA 2-3 (n=10). There was no difference in urinary MMPs/TIMPs among the three groups, and only 1/8 serum MMPs/TIMPs (i.e. MMP-1) was significantly elevated in biopsies with IF/TA 2-3 (p=0.01). In addition, urinary/serum MMPs/TIMPs were not different between surveillance biopsies demonstrating an early development of IF/TA (i.e. delta IF/TA≥1 compared to a previous biopsy obtained three months before; n=11) and stable grade of IF/TA (i.e. delta IF/TA=0; n=20). Next, we investigated whether urinary/serum MMP/TIMP levels are elevated during acute subclinical tubulitis in surveillance biopsies obtained within the first 6months post-transplant (n=25). Compared to biopsies with normal histology, serum MMPs/TIMPs were not different; however, all urinary MMP/TIMP levels were numerically higher during subclinical tubulitis (MMP-1, MMP-7, TIMP-1 with p≤0.04). We conclude that urinary/serum MMPs/TIMPs do hardly correlate with existing or early developing IF/TA in surveillance biopsies obtained within the first 6months post-transplant. This could be explained by the dynamic process of extracellular matrix remodeling, which seems to be active during acute tubulo-interstitial injury/inflammation, but not in quiescent IF/TA.

A new rechargeable device for deep brain stimulation: a prospective patient satisfaction survey

Background: Deep brain stimulation (DBS) is highly successful in treating Parkinson's disease (PD), dystonia, and essential tremor (ET). Until recently implantable neurostimulators were nonrechargeable, battery-driven devices, with a lifetime of about 3-5 years. This relatively short duration causes problems for patients (e.g. programming and device-use limitations, unpredictable expiration, surgeries to replace depleted batteries). Additionally, these batteries (relatively large with considerable weight) may cause discomfort. To overcome these issues, the first rechargeable DBS device was introduced: smaller, lighter and intended to function for 9 years. Methods: Of 35 patients implanted with the rechargeable device, 21 (including 8 PD, 10 dystonia, 2 ET) were followed before and 3 months after surgery and completed a systematic survey of satisfaction with the rechargeable device. Results: Overall patient satisfaction was high (83.3 ± 18.3). Dystonia patients tended to have lower satisfaction values for fit and comfort of the system than PD patients. Age was significantly negatively correlated with satisfaction regarding process of battery recharging. Conclusions: Dystonia patients (generally high-energy consumption, severe problems at the DBS device end-of-life) are good, reliable candidates for a rechargeable DBS system. In PD, younger patients, without signs of dementia and good technical understanding, might have highest benefit.

Correlation of urinary nitric oxide concentrations with the development of hip dysplasia in Labrador retrievers

Urinary nitric oxide was determined in terms of the ratio of the concentrations of total urinary nitrite and nitrate:creatinine in 40 juvenile labrador retrievers, and radiographic signs of hip dysplasia and distraction indices were investigated in the same dogs in later life. The ratio was correlated significantly with the Norberg angle and with subchondral sclerosis in both hips, and with the grade of dysplasia in each hip and the dogs' overall grade of hip dysplasia. No correlations were observed between the ratio and the distraction indices or other radiographic criteria for hip dysplasia.

Association of radiographic osteoarthritis, pain on passive movement and knee range of motion: A cross-sectional study

BACKGROUND Knee pain is associated with radiographic knee osteoarthritis, but the relationships between physical examination, pain and radiographic features are unclear. OBJECTIVE To examine whether deficits in knee extension or flexion were associated with radiographic severity and pain during clinical examination in persons with knee pain or radiographic features of osteoarthritis. DESIGN Cross-sectional data of the Somerset and Avon Survey of Health (SASH) cohort study. METHODS Participants with knee pain or radiographic features of osteoarthritis were included. We assessed the range of passive knee flexion and extension, pain on movement and Kellgren and Lawrence (K/L) grades. Odds ratios were calculated for the association between range of motion and pain as well as radiographic severity. RESULTS/FINDINGS Of 1117 participants with a clinical assessment, 805 participants and 1530 knees had complete data and were used for this analysis. Pain and radiographic changes were associated with limited range of motion. In knees with pain on passive movement, extension and flexion were reduced per one grade of K/L by -1.4° (95% CI -2.2 to -0.5) and -1.6° (95% CI -2.8 to -0.4), while in knees without pain the reduction was -0.3° (95% CI -0.6 to -0.1) (extension) and -1.1° (-1.8 to -0.3) (flexion). The interaction of pain with K/L was significant (p = 0.021) for extension but not for flexion (p = 0.333). CONCLUSIONS Pain during passive movement, which may be an indicator of reversible soft-tissue changes, e.g., reversible through physical therapy, is independently associated with reduced flexion and extension of the knee.

Dental fear and satisfaction with dental services in Switzerland.

OBJECTIVES Dental satisfaction is associated with continuity of dental care, compliance with dentist advice, and positive health outcomes. It is expected that people with higher dental fear might have less dental satisfaction because of more negative dental experiences. The objective of this study was to examine satisfaction and reasons for satisfaction with dental practitioners in Switzerland and variations by dental fear. METHODS A national sample of 1,129 Swiss residents aged 15-74 (mean = 43.2 years) completed a personal interview at their home with questions assessing dental fear, dental service use, general satisfaction with their dentist, and reasons for satisfaction or dissatisfaction. RESULTS Overall, 47.9 percent of participants responded that they were satisfied with their dentist and 47.6 percent that they were very satisfied. Satisfaction differed significantly by gender, language spoken, region of residence, and educational attainment. Greater dental fear was significantly associated with greater dissatisfaction with the dentist. The percentage of people who were very satisfied with the dentist ranged from 56.0 percent among people with no fear to 30.5 percent for participants with "quite a lot" of fear but was higher (44.4 percent) for people who stated that they were "very much" afraid of the dentist. The most common reasons attributed for satisfaction with dentists were interpersonal characteristics of the dentist and staff. People with "quite a lot" of fear were found to endorse these sentiments least. CONCLUSIONS Although higher dental fear was associated with more dissatisfaction with the dentist, the level of satisfaction among fearful individuals in Switzerland is still high.

Factors influencing the accuracy of fetal weight estimation with a focus on preterm birth at the limit of viability: a systematic literature review

BACKGROUND Fetal weight estimation (FWE) is an important factor for clinical management decisions, especially in imminent preterm birth at the limit of viability between 23(0/7) and 26(0/7) weeks of gestation. It is crucial to detect and eliminate factors that have a negative impact on the accuracy of FWE. DATA SOURCES In this systematic literature review, we investigated 14 factors that may influence the accuracy of FWE, in particular in preterm neonates born at the limit of viability. RESULTS We found that gestational age, maternal body mass index, amniotic fluid index and ruptured membranes, presentation of the fetus, location of the placenta and the presence of multiple fetuses do not seem to have an impact on FWE accuracy. The influence of the examiner's grade of experience and that of fetal gender were discussed controversially. Fetal weight, time interval between estimation and delivery and the use of different formulas seem to have an evident effect on FWE accuracy. No results were obtained on the impact of active labor. DISCUSSION This review reveals that only few studies investigated factors possibly influencing the accuracy of FWE in preterm neonates at the limit of viability. Further research in this specific age group on potential confounding factors is needed.

Mandatory communication skills training for oncologists: enforcement does not substantially impact satisfaction.

PURPOSE Even though there is evidence that both patients and oncology clinicians are affected by the quality of communication and that communication skills can be effectively trained, so-called Communication Skills Trainings (CSTs) remain heterogeneously implemented. METHODS A systematic evaluation of the level of satisfaction of oncologists with the Swiss CST before (2000-2005) and after (2006-2012) it became mandatory. RESULTS Levels of satisfaction with the CST were high, and satisfaction of physicians participating on a voluntary or mandatory basis did not significantly differ for the majority of the items. CONCLUSIONS The evaluation of physicians' satisfaction over the years and after introduction of mandatory training supports recommendations for generalized implementation of CST and mandatory training for medical oncologists.

Esthetic, Functional, and Everyday Life Assessment of Individuals with Cleft Lip and/or Palate

OBJECTIVES To evaluate the level of satisfaction of individuals with cleft lip and/or palate (CLP) and their parents concerning the esthetic and functional treatment outcomes, the impact of the cleft on everyday life, and potential associations with treatment outcome satisfaction. SUBJECTS AND METHODS The sample consisted of 33 patients (7 CP, 20 unilateral CLP, and 6 bilateral CLP; median age: 17.1, range: 9.0-33.1 years) and 30 parents, who responded to a questionnaire in an interview-guided session. All participants received their orthodontic treatment at the Department of Orthodontics in the University of Athens. RESULTS Patients and their parents were quite satisfied with esthetics and function. Patients with UCLP primarily were concerned about nose esthetics (BCLP about lip esthetics and CP about speech). Increased satisfaction was associated with decreased influence of the cleft in everyday life (0.35 < rho < 0.64, P < 0.05). Parents reported significant influence of the cleft on family life, while patients did not. CONCLUSIONS Despite the limited sample size of subgroups, the main concerns of patients with different cleft types and the importance of satisfying lip, nose, and speech outcomes for an undisturbed everyday life were quite evident. Thus, the need for targeted treatment strategies is highlighted for individuals with cleft lip and/or palate.

The correlation of epicardial adipose tissue on postmortem CT with coronary artery stenosis as determined by autopsy

The goal of this study was to assess whether epicardial and paracardial adipose tissue volumes, as determined by computed tomography (CT), correlate with coronary artery stenosis as determined by autopsy. The postmortem CT data and autopsy findings of 116 adult human decedents were retrospectively compared. Subjects were classified into three groups according to their degree of coronary artery stenosis: ≥50, <50%, and no stenosis. Epicardial and paracardial adipose tissue volumes were calculated based on manual segmentation after threshold based masking. In addition, epicardial adipose tissue thickness was measured using a caliper. All three parameters (thickness of epicardial fat and volumes of both epicardial and paracardial fat) were compared among the three groups and correlated with the degree of coronary artery stenosis. The group with no coronary artery stenosis showed the lowest mean values of epicardial adipose tissue volume, while the coronary artery stenosis ≥50 % group showed the highest volume. All measured variables (thickness of epicardial fat and volumes of both epicardial and paracardial fat) correlated significantly with the grade of coronary artery stenosis, even after controlling for BMI, however, epicardial adipose tissue volume exhibited the strongest correlation. This study reveals that there is an association between the degree of coronary artery stenosis and the amount of epicardial fat tissue: The larger the volume of epicardial fat, the higher the degree of coronary artery stenosis.