Contemporary postnatal plastic surgical management of meningomyelocele.

BACKGROUND: The goals of this study were to review the outcome of the surgical procedure and hospitalization associated with meningomyelocele repair, and to examine the results of different closure strategies. METHODS: Eighty-three consecutive patients having surgery for meningomyelocele over a ten year period form the basis of this study. Thirty-two closures with a mean defect size preoperatively of 11.5 cm(2) were performed by the neurosurgeon (ADP), and fifty-one closures with a mean defect size of 28.4 cm(2) by the plastic surgeon (MFA). RESULTS: Defects up to 12 cm(2) were closed with local advancement fasciocutaneous flaps. As defect size increased, latissimus muscle flaps were added in 30 (36%) and gluteus muscle in 16 (19%). In recent years, 18 patients (21.6%) with a mean defect of 29 cm(2) were treated with overlapping of deepithelialized fasciocutaneous flaps to add an additional layer of coverage to the dural closure. There were 9 major complications, 6 requiring reoperation. There were 10 minor wound failures managed conservatively. Mean hospital stay was 24.2 days. Re-operation increased length of stay to 45 days (p < 0.0001). Minor wound problems added 6 days to mean hospital stay. Wound failure did not correlate with either defect size or closure technique. Thoracic location was associated with increased wound failure (p < 0.05). Use of a shunt did not increase morbidity. All closures remained durable after discharge. CONCLUSIONS: Location in the thoracic area predicts major wound failure and need for reoperation. Wound complications significantly increase hospital stay. The use of a variety of techniques to achieve multi-layered closures leads to durable coverage for defects of all sizes.

Frequency distribution of cytochrome P450 3A4 gene polymorphism in ethnic populations and in transplant recipients.

CYP 3A4 plays a vital role in the metabolism of many drugs including immunosuppressants. An association between a transition of A --> G at position -290 of the 5'-regulatory region of the CYP 3A4 gene and an effect on the level of transcription has been reported. The CYP 3A4-G variant frequency varies substantially in different populations. In addition it has been demonstrated in association with several disease conditions, including clinical grades of prostate cancer, breast cancer, secondary leukemia, hypercholesterolemia and diabetes. We sought to determine the frequency distributions, in African American (AFAM) and Caucasian (CAU) populations as well as patients with multiple complex diseases, such as those that had undergone cardiac or renal transplantation. Sequence-specific primers and PCR were used to determine genotype variation in 206 AFAM and 108 CAU individuals. CYP 3A4-G genotype was present with a higher frequency in AFAM individuals as compared with CAU (83% vs. 3%, p < 0.0001, RR = 3.9). The homozygous AA allele was predominantly present in CAU (97%) but only 17% in AFAM (p < 0.0001, RR = 2.5). In contrast, the homozygous GG allele was only detected in AFAM group (14.6%). The frequency distribution of homozygous GG and AA alleles were inversely present in male vs. female patients with CTx or RTx. Pre-transplantation clinical conditions demonstrated that hypertension (HTN), hyperlipidemia and to a lesser extent diabetes (DM) were present in CTx and RTx patients with homozygous GG alleles. In addition, 75% of AFAM patients with homozygous GG genotype experienced multiple rejection episodes with severity grades of 3A after cardiac transplantation, and 31.5% of homozygous GG patients with RTx suffered from rejections (p < 0.05; RR = 2.4). In conclusion, CYP 3A4 genotype demonstrated a remarkable interindividual variation between AFAM and CAU populations, and furthermore CTx patients with homozygous GG genotype were at higher risk of developing rejection as compared with RTx patients. This indicates an underlying heterogeneity with regard to the disease characteristics as well as the therapy regimen.

The plastic surgeon's guide to drugs affecting hemostasis.

The plastic surgeon is encountering an unprecedented population of aging individuals who both desire cosmetic or reconstructive surgery and may require the use of medications that alter hemostasis. The increasing use of anticoagulants and platelet inhibitors in particular can create challenges for the plastic surgeon. The purpose of this review is to familiarize the surgeon with the medications that can affect hemostasis and to suggest strategies for their use in the perioperative period. Specific case examples are presented.

Management of women who present with T4 breast cancer.

The purpose of this study was to review the clinical presentation and outcome of women who present with large or locally invasive (T4) breast carcinoma. This retrospective study was conducted at the University of Mississippi Medical Center, a state tertiary care referral institution. One hundred twenty-nine women between the ages of 28 and 85 years (mean, 55 years) presented with T4 breast carcinoma. Follow-up was available for 128 women. Only 23 women have survived (18%), 5 of whom (21.7%) have metastatic disease. Mean survival for those who died was 21.6 months, compared to 76.3 months for survivors. Survival was not influenced by tumor characteristics (P > 0.5), but was strongly influenced by nodal status (P < 0.001) and by the presence of metastases at the time of diagnosis (P < 0.001). Survival was strongly related to mode of therapy (P < 0.01), but this was principally related to very high mortality rates in women who received no therapy (100%), surgery only (92.3%), or chemotherapy only (95%). The best survival was seen in women who received chemotherapy prior to surgery (40%); their survival was superior to that of women treated initially by surgery, followed by chemotherapy (16.3%, P = 0.04). However, when women who presented with metastatic disease were excluded, survival was not different between these two groups (P = 0.18). Despite public education efforts and the wide availability of screening programs for breast carcinoma, many women still present with locally advanced disease. Outcome can be favorable in the absence of node involvement or metastatic disease, even in the presence of large, fungating tumors. Multimodality therapy gives the best results, but early surgery may be required for progression of disease during chemotherapy or because of extensive ulceration at initial presentation.

Incorporating cytochrome P450 3A4 genotype expression and FT-IR/Raman spectroscopy data as means of identification of breast tumors.

We have evaluated the use of cytochrome P450 (CYP), 3A4 genotype and Fourier transform-infrared (RT-IR)/Raman spectroscopy as diagnostic tools for detection of breast tumors. CYP is involved in catalytic activity of oxidative metabolism of many chemicals in fatty tissues, and it plays a major role in biotransformation and detoxication of environmental contaminants. FT-IR and Raman spectroscopy have been used to develop methods for cancer assessment. Thus, the hypothesis was that a) CYP 3A4 gene expression level may have effect on the clinical presentation of breast cancer; and b) a combination spectroscopy and genotype analysis may strengthen the level of diagnosis. In parallel studies we compared by reverse-transcription-polymerase chain reaction (RT-PCR), the CYP 3A4 mRNA transcript levels, and by FT-IR the pathology of breast tissues. RNA was isolated from human breast biopsies and cultured tumor cells (MCF-7). A comparison of the levels of RT-PCR was made between CYP 3A4 genotype and 1B1, a genotype associated with human tumors, testing 3 normal breast tissues, 2 specimen from breast reduction and 7 breast tumors. Two variants of CYP 3A4 mRNA were observed, of which a 380-bp was displayed in 4 out of 5 pathologically determined tumors, and a 260-bp fragment was associated with normal tissues. The predictive value of the CYP 3A4 for the detection of tumor tissues was greater than that observed with the CYP 1B1. FT-IR signal patterns were distinct for tumor tissues as compared with that of normal tissue. Our findings demonstrated the importance of CYP 3A4 as molecular biomarker for determining the presence of breast tumors. This data in association with FT-IR/Raman spectroscopy and pathology, it can be an ideal test for predicting the clinical presentation of breast cancer.

There is no difference in survival between African-American and white women with breast cancer.

A difference in survival by race in women with breast cancer has been reported. We examined survival of African-American (AA) and white (W) women diagnosed with breast cancer and evaluated variables that may affect survival at a university teaching hospital. A retrospective review of tumor registry data for breast cancer was performed in all AA and W female breast cancer patients diagnosed between the years 1990 and 1999 at a university hospital. Survival between AA and W women diagnosed with breast cancer during that period was compared using Kaplan-Meier analysis. Variables including age and stage of disease at diagnosis, receptor status, treatment, and tobacco exposure were evaluated utilizing Chi-square testing. A P value <0.05 was considered statistically significant. A total of 585 AA and W women were diagnosed with breast cancers between the years 1990 and 1999. Mean ages were 51.8 years for AA and 56.9 years for W (P = 0.001). Overall survival (7.8 years AA and 7.6 years W) and survival by stage were not statistically different between the groups. AA patients were younger (P = 0.001), presented with higher-stage tumors (P = 0.017), more often had positive axillary lymph nodes (P = 0.012), more often were estrogen and progesterone receptor negative (P = 0.004), and more often were premenopausal (P = 0.048). AA women were more likely treated with chemotherapy while W women tended to receive hormone therapy (P = 0.01). Statistical significance was not reached for differences in tumor histology or tobacco exposure. We conclude that despite presenting with worse prognostic indicators AA women experience survival equivalent to their W counterparts.