The current use of tissue expanders in breast reconstruction: device design, features, and technical considerations.

INTRODUCTION: The use of tissue expanders (TE) in post-mastectomy breast reconstruction is a widely accepted practice, especially in patients desiring implant-based breast reconstruction. It has become the standard of care to perform a two-staged breast reconstruction using tissue expanders for the past 50 years due to its reliability, safety, cost-effectiveness, and versatility. Due to its popularity, there are numerous types and features of breast tissue expanders and various surgical approaches available for plastic surgeons. AREAS COVERED: In this article, we will review the role of tissue expanders in breast reconstruction, the types and features of breast tissue expanders, and technical considerations. EXPERT OPINION: The use of tissue expanders in breast reconstruction offers significant advantages of preserving the breast skin envelope and reestablishing the breast mound. With evolving approaches to breast reconstruction, tissue expander design, and application underwent several refinements and modifications. Due to these advances, studies on its long-term efficacy and safety profile typically fall behind and more studies with higher levels of evidence are needed to better evaluate the efficacy and safety profile of tissue expanders. With increased understanding, reconstructive surgeons can minimize complications and maximize reconstructive, aesthetic outcomes with high patient satisfaction.

Boosting the Biocontrol Efficacy of Bacillus amyloliquefaciens DSBA-11 through Physical and Chemical Mutagens to Control Bacterial Wilt Disease of Tomato Caused by Ralstonia solanacearum.

Bacterial wilt disease of tomato (Solanum lycopersicum L.), incited by Ralstonia solanacearum (Smith), is a serious agricultural problem in India. In this investigation, chemical mutagenic agents (NTG and HNO2 treatment) and ultraviolet (UV) irradiation have been used to enhance the antagonistic property of Bacillus amyloliquefaciens DSBA-11 against R. solanacearum UTT-25 towards an effective management of tomato wilt disease. The investigation established the fact that maximum inhibition to R. solanacearum UTT-25 was exerted by the derivative strain MHNO2-20 treated with nitrous acid (HNO2) and then by the derivative strain MNTG-21 treated with NTG. The exertion was significantly higher than that of the parent B. amyloliquefaciens DSBA-11. These two potential derivatives viz. MNTG-21, MHNO2-20 along with MUV-19, and a wild derivative strain of B. amyloliquefaciens i.e.,DSBA-11 were selected for GC/MS analysis. Through this analysis 18 major compounds were detected. Among the compounds thus detected, the compound 3-isobutyl hexahydropyrrolo (1,2), pyrazine-1,4-dione (4.67%) was at maximum proportion in the variant MHNO2-20 at higher retention time (RT) of 43.19 s. Bio-efficacy assessment observed a record of minimum intensity (9.28%) in wilt disease and the highest bio-control (88.75%) in derivative strain MHNO2-20-treated plants after 30 days of inoculation. The derivative strain MHNO2-20, developed by treating B. amyloliquefaciens with nitrous acid (HNO2), was therefore found to have a higher bio-efficacy to control bacterial wilt disease of tomato under glasshouse conditions than a wild-type strain.

Aminopyridine analogs selectively target metastatic pancreatic cancer.

Metastatic outgrowth is supported by metabolic adaptations that may differ from the primary tumor of origin. However, it is unknown if such adaptations are therapeutically actionable. Here we report a novel aminopyridine compound that targets a unique Phosphogluconate Dehydrogenase (PGD)-dependent metabolic adaptation in distant metastases from pancreatic cancer patients. Compared to structurally similar analogs, 6-aminopicolamine (6AP) potently and selectively reversed PGD-dependent metastatic properties, including intrinsic tumorigenic capacity, excess glucose consumption, and global histone hyperacetylation. 6AP acted as a water-soluble prodrug that was converted into intracellular bioactive metabolites that inhibited PGD in vitro, and 6AP monotherapy demonstrated anti-metastatic efficacy with minimal toxicity in vivo. Collectively, these studies identify 6AP and possibly other 6-aminopyridines as well-tolerated prodrugs with selectivity for metastatic pancreatic cancers. If unique metabolic adaptations are a common feature of metastatic or otherwise aggressive human malignancies, then such dependencies could provide a largely untapped pool of druggable targets for patients with advanced cancers.

The role of SHP/REV-ERBα/CYP4A axis in the pathogenesis of alcohol-associated liver disease.

Alcohol-associated liver disease (ALD) represents a spectrum of histopathological changes, including alcoholic steatosis, steatohepatitis, and cirrhosis. One of the early responses to excessive alcohol consumption is lipid accumulation in the hepatocytes. Lipid ω-hydroxylation of medium- and long-chain fatty acid metabolized by the cytochrome P450 4A (CYP4A) family is an alternative pathway for fatty acid metabolism. The molecular mechanisms of CYP4A in ALD pathogenesis have not been elucidated. In this study, WT and Shp-/- mice were fed with a modified ethanol-binge, National Institute on Alcohol Abuse and Alcoholism model (10 days of ethanol feeding plus single binge). Liver tissues were collected every 6 hours for 24 hours and analyzed using RNA-Seq. The effects of REV-ERBα agonist (SR9009, 100 mg/kg/d) or CYP4A antagonist (HET0016, 5 mg/kg/d) in ethanol-fed mice were also evaluated. We found that hepatic Cyp4a10 and Cyp4a14 expression were significantly upregulated in WT mice, but not in Shp-/- mice, fed with ethanol. ChIP quantitative PCR and promoter assay revealed that REV-ERBα is the transcriptional repressor of Cyp4a10 and Cyp4a14. Rev-Erbα-/- hepatocytes had a marked induction of both Cyp4a genes and lipid accumulation. REV-ERBα agonist SR9009 or CYP4A antagonist HET0016 attenuated Cyp4a induction by ethanol and prevented alcohol-induced steatosis. Here, we have identified a role for the SHP/REV-ERBα/CYP4A axis in the pathogenesis of ALD. Our data also suggest REV-ERBα or CYP4A as the potential therapeutic targets for ALD.

Eyelid metastasis as presenting feature of disseminated leiomyosarcoma - A rare case report.

Soft tissue sarcomas with smooth muscle differentiation are termed leiomyosarcoma. Leiomyosarcoma is an aggressive tumor commonly originating from smooth muscle cells of uterus or retro peritoneal areas. Distant metastasis occurs by hematogenous route to liver and lung. Eyelid metastasis without involvement of other ocular structures is extremely rare. A case of eyelid metastasis which on extensive investigations was proved to be from upper gastrointestinal tract leiomyosarcoma is reported here.

Mixing with applications to inertial-confinement-fusion implosions.

Approximate one-dimensional (1D) as well as 2D and 3D simulations are playing an important supporting role in the design and analysis of future experiments at National Ignition Facility. This paper is mainly concerned with 1D simulations, used extensively in design and optimization. We couple a 1D buoyancy-drag mix model for the mixing zone edges with a 1D inertial confinement fusion simulation code. This analysis predicts that National Ignition Campaign (NIC) designs are located close to a performance cliff, so modeling errors, design features (fill tube and tent) and additional, unmodeled instabilities could lead to significant levels of mix. The performance cliff we identify is associated with multimode plastic ablator (CH) mix into the hot-spot deuterium and tritium (DT). The buoyancy-drag mix model is mode number independent and selects implicitly a range of maximum growth modes. Our main conclusion is that single effect instabilities are predicted not to lead to hot-spot mix, while combined mode mixing effects are predicted to affect hot-spot thermodynamics and possibly hot-spot mix. Combined with the stagnation Rayleigh-Taylor instability, we find the potential for mix effects in combination with the ice-to-gas DT boundary, numerical effects of Eulerian species CH concentration diffusion, and ablation-driven instabilities. With the help of a convenient package of plasma transport parameters developed here, we give an approximate determination of these quantities in the regime relevant to the NIC experiments, while ruling out a variety of mix possibilities. Plasma transport parameters affect the 1D buoyancy-drag mix model primarily through its phenomenological drag coefficient as well as the 1D hydro model to which the buoyancy-drag equation is coupled.

A tracking system to calculate patient skin dose in real-time during neurointerventional procedures using a biplane x-ray imaging system.

PURPOSE: Neurovascular interventional procedures using biplane fluoroscopic imaging systems can lead to increased risk of radiation-induced skin injuries. The authors developed a biplane dose tracking system (Biplane-DTS) to calculate the cumulative skin dose distribution from the frontal and lateral x-ray tubes and display it in real-time as a color-coded map on a 3D graphic of the patient for immediate feedback to the physician. The agreement of the calculated values with the dose measured on phantoms was evaluated. METHODS: The Biplane-DTS consists of multiple components including 3D graphic models of the imaging system and patient, an interactive graphical user interface, a data acquisition module to collect geometry and exposure parameters, the computer graphics processing unit, and functions for determining which parts of the patient graphic skin surface are within the beam and for calculating dose. The dose is calculated to individual points on the patient graphic using premeasured calibration files of entrance skin dose per mAs including backscatter; corrections are applied for field area, distance from the focal spot and patient table and pad attenuation when appropriate. The agreement of the calculated patient skin dose and its spatial distribution with measured values was evaluated in 2D and 3D for simulated procedure conditions using a PMMA block phantom and an SK-150 head phantom, respectively. Dose values calculated by the Biplane-DTS were compared to the measurements made on the phantom surface with radiochromic film and a calibrated ionization chamber, which was also used to calibrate the DTS. The agreement with measurements was specifically evaluated with variation in kVp, gantry angle, and field size. RESULTS: The dose tracking system that was developed is able to acquire data from the two x-ray gantries on a biplane imaging system and calculate the skin dose for each exposure pulse to those vertices of a patient graphic that are determined to be in the beam. The calculations are done in real-time with a typical graphic update time of 30 ms and an average vertex separation of 3 mm. With appropriate corrections applied, the Biplane-DTS was able to determine the entrance dose within 6% and the spatial distribution of the dose within 4% compared to the measurements with the ionization chamber and film for the SK150 head phantom. The cumulative dose for overlapping fields from both gantries showed similar agreement. CONCLUSIONS: The Biplane-DTS can provide a good estimate of the peak skin dose and cumulative skin dose distribution during biplane neurointerventional procedures. Real-time display of this information should help the physician manage patient dose to reduce the risk of radiation-induced skin injuries.

Supernovae. 44Ti gamma-ray emission lines from SN1987A reveal an asymmetric explosion.

In core-collapse supernovae, titanium-44 ((44)Ti) is produced in the innermost ejecta, in the layer of material directly on top of the newly formed compact object. As such, it provides a direct probe of the supernova engine. Observations of supernova 1987A (SN1987A) have resolved the 67.87- and 78.32-kilo-electron volt emission lines from decay of (44)Ti produced in the supernova explosion. These lines are narrow and redshifted with a Doppler velocity of ~700 kilometers per second, direct evidence of large-scale asymmetry in the explosion.

An ultraluminous X-ray source powered by an accreting neutron star.

The majority of ultraluminous X-ray sources are point sources that are spatially offset from the nuclei of nearby galaxies and whose X-ray luminosities exceed the theoretical maximum for spherical infall (the Eddington limit) onto stellar-mass black holes. Their X-ray luminosities in the 0.5-10 kiloelectronvolt energy band range from 10(39) to 10(41) ergs per second. Because higher masses imply less extreme ratios of the luminosity to the isotropic Eddington limit, theoretical models have focused on black hole rather than neutron star systems. The most challenging sources to explain are those at the luminous end of the range (more than 10(40) ergs per second), which require black hole masses of 50-100 times the solar value or significant departures from the standard thin disk accretion that powers bright Galactic X-ray binaries, or both. Here we report broadband X-ray observations of the nuclear region of the galaxy M82 that reveal pulsations with an average period of 1.37 seconds and a 2.5-day sinusoidal modulation. The pulsations result from the rotation of a magnetized neutron star, and the modulation arises from its binary orbit. The pulsed flux alone corresponds to an X-ray luminosity in the 3-30 kiloelectronvolt range of 4.9 × 10(39) ergs per second. The pulsating source is spatially coincident with a variable source that can reach an X-ray luminosity in the 0.3-10 kiloelectronvolt range of 1.8 × 10(40) ergs per second. This association implies a luminosity of about 100 times the Eddington limit for a 1.4-solar-mass object, or more than ten times brighter than any known accreting pulsar. This implies that neutron stars may not be rare in the ultraluminous X-ray population, and it challenges physical models for the accretion of matter onto magnetized compact objects.

Asymmetries in core-collapse supernovae from maps of radioactive 44Ti in Cassiopeia A.

Asymmetry is required by most numerical simulations of stellar core-collapse explosions, but the form it takes differs significantly among models. The spatial distribution of radioactive (44)Ti, synthesized in an exploding star near the boundary between material falling back onto the collapsing core and that ejected into the surrounding medium, directly probes the explosion asymmetries. Cassiopeia A is a young, nearby, core-collapse remnant from which (44)Ti emission has previously been detected but not imaged. Asymmetries in the explosion have been indirectly inferred from a high ratio of observed (44)Ti emission to estimated (56)Ni emission, from optical light echoes, and from jet-like features seen in the X-ray and optical ejecta. Here we report spatial maps and spectral properties of the (44)Ti in Cassiopeia A. This may explain the unexpected lack of correlation between the (44)Ti and iron X-ray emission, the latter being visible only in shock-heated material. The observed spatial distribution rules out symmetric explosions even with a high level of convective mixing, as well as highly asymmetric bipolar explosions resulting from a fast-rotating progenitor. Instead, these observations provide strong evidence for the development of low-mode convective instabilities in core-collapse supernovae.

Genome-wide transcriptome analysis identifies novel gene signatures implicated in human chronic liver disease.

The molecular mechanisms behind human liver disease progression to cirrhosis remain elusive. Nuclear receptor small heterodimer partner (SHP/Nr0b2) is a hepatic tumor suppressor and a critical regulator of liver function. SHP expression is diminished in human cirrhotic livers, suggesting a regulatory role in human liver diseases. The goal of this study was to identify novel SHP-regulated genes that are involved in the development and progression of chronic liver disease. To achieve this, we conducted the first comprehensive RNA sequencing (RNA-seq) analysis of Shp(-/-) mice, compared the results with human hepatitis C cirrhosis RNA-seq and nonalcoholic steatohepatitis (NASH) microarray datasets, and verified novel results in human liver biospecimens. This approach revealed new gene signatures associated with chronic liver disease and regulated by SHP. Several genes were selected for validation of physiological relevance based on their marked upregulation, novelty with regard to liver function, and involvement in gene pathways related to liver disease. These genes include peptidoglycan recognition protein 2, dual specific phosphatase-4, tetraspanin 4, thrombospondin 1, and SPARC-related modular calcium binding protein-2, which were validated by qPCR analysis of 126 human liver specimens, including steatosis, fibrosis, and NASH, alcohol and hepatitis C cirrhosis, and in mouse models of liver inflammation and injury. This RNA-seq analysis identifies new genes that are regulated by the nuclear receptor SHP and implicated in the molecular pathogenesis of human chronic liver diseases. The results provide valuable transcriptome information for characterizing mechanisms of these diseases.

Tooth fragment embedded in the upper lip after dental trauma: a case report presenting an immediate diagnostic approach and complete rehabilitation.

Dental traumas are reasonably common, especially in children and adolescents. They are caused by many factors with fall accounting for the most frequent one. Dental trauma requires a special consideration when dental fractures accompany soft tissue lacerations. Dental fragments occasionally penetrate into soft tissue and may cause severe complications. Early diagnosis and surgical removal of these fragments could prevent undesirable foreign body reaction and scarring. This report presents immediate diagnosis and management of a case in which dental fragment was embedded in the lip soft tissue.

Long-term outcome with lenalidomide and dexamethasone therapy for newly diagnosed multiple myeloma.

The combination of lenalidomide and dexamethasone (Len-Dex) is a commonly used initial therapy for newly diagnosed multiple myeloma (MM). Although the initial response rates and toxicity are well known, long-term outcome is not well described. We studied 286 consecutive patients with newly diagnosed MM initially treated with Len-Dex. The median (range) age at diagnosis was 63 (28-92) years, 166 (58%) patients ≤ 65 years and 175 (61%) male. The median estimated duration on Len-Dex was 5.3 months with overall response (≥ partial response) of 72%, including 26% with very good partial response or better. The median overall survival (OS) from the diagnosis was not reached (NR) and the estimated 5-year survival was 71%. The median time to first disease progression, irrespective of transplant status, was 30.2 months. Overall, 143 (50%) patients underwent stem cell transplant. The median OS was NR for patients ≤ 70 years and 5.8 years for the older patients (P=0.01). The 5-year OS estimate for patients in International Staging System stage 1, 2 and 3 were 82, 65, and 44% respectively. There were 21 new second malignancies after MM diagnosis (6.6%). The median survival exceeding 7 years reflects the efficacy of novel agents. The risk of second malignancies doesn't appear to be excessive in this population.

Molecular analysis of colorectal tumors within a diverse patient cohort at a single institution.

PURPOSE: African American colorectal cancer patients have worse survival outcomes than Caucasian patients. To determine whether differences exist in the molecular mechanisms driving colorectal cancer between African Americans and Caucasians, we characterized patient tumors from a single institution by assessing genetic alterations involved in colorectal cancer progression and response to treatment. EXPERIMENTAL DESIGN: We retrospectively examined 448 African Americans and Caucasians diagnosed with colorectal cancer at The University of Chicago Medical Center between 1992 and 2002. Microsatellite instability (MSI) status was determined by genotyping the BAT25, BAT26, BAT40, D5S346, and BAX loci. Mutations in KRAS codons 12 and 13 and BRAF codon 600 were identified by direct sequencing. MSI and detected mutations were correlated with clinicopathologic features. RESULTS: Overall, no difference existed in MSI or BRAF mutation frequencies between African Americans and Caucasians. However, African Americans with microsatellite stable (MSS)/MSI-low (MSI-L) tumors had a higher proportion of KRAS mutations than Caucasians (34% vs. 23%, P = 0.048) that was isolated to proximal colon cancers and primarily driven by mutations in codon 13. There was no racial difference in receipt of chemotherapy, but African Americans with MSS/MSI-L tumors had a 73% increased risk of death over Caucasians that could not be explained by known prognostic factors. CONCLUSIONS: The significantly higher risk of death among African Americans with MSS/MSI-L tumors may be related to differences in the distribution of factors influencing response to standard therapies. These data underscore the need for further research into the molecular mechanisms driving colorectal cancer progression in underserved and understudied populations.

SU-E-I-28: Development of Graphic Patient Models for a Real-Time Skin Dose Tracking System (DTS) for Fluoroscopic Interventional Procedures.

PURPOSE: To develop a library of graphic human models that closely match patients undergoing interventional fluoroscopic procedures in order to obtain an accurate estimate of their skin dose. METHODS: A dose tracking system (DTS) has been developed that calculates the dose to the patient's skin in real time during fluoroscopic procedures based on a graphical simulation of the x-ray system and the patient. The calculation is performed using a lookup table containing values of mGy per mAs at a reference point and inverse-square correction using the distance from the source to individual points on the skin. For proper inverse-square correction, the external shape of the graphic should closely match that of the patient. We are in the process of developing a library of 3D human graphic models categorized as a function of basic body type, sex, height and weight. Two different open- source software applications are being used to develop graphic models with varying weights and heights, to 'morph' the shapes for body type and to 'pose' them for proper positioning on the table. The DTS software is being designed such that the most appropriate body graphic can be automatically selected based on input of several basic patient dimensional metrics. RESULTS: A series of male and female body graphic models have been developed which vary in weight and height. Matching pairs have been constructed with arms at the side and over the head to simulate the usual placement in cardiac procedures. The error in skin dose calculation due to inverse-square correction is expected to be below 5% if the graphic can match the position of the patient's skin surface within 1 cm. CONCLUSIONS: A library of categorized body shapes should allow close matching of the graphic to the patient shape allowing more accurate determination of skin dose with the DTS. Support for this work was provided in part by NIH grants R43FD0158401, R44FD0158402, R01EB002873 and R01EB008425, and by Toshiba Medical Systems Corporation.

Development and evaluation of mathematical model to predict disintegration time of fast disintegrating tablets using powder characteristics.

The objective of the study was to develop a mathematical model for predicting the disintegration time of fast disintegrating tablets (FDTs) by estimating the powder characteristics of powder blend prior to compression. A combination of chitosan-alginate complex and glycine in the ratio of 50:50 was used for preparing FDTs. The developed mathematical model allowed water sorption time (WST), effective pore radius (R(eff.p)) and swelling Index (SI) of powder mixture as well as tablet crushing strength to be successfully correlated with disintegration time (DT) of FDTs. The predicted model showed that disintegration time of FDTs to be directly correlated with powder characteristics and inversely correlated with tablet crushing strength. Furthermore, a correlation of 0.97 was obtained when DT of FDTs was compared with SI/(WST * R(eff.p)). This correlation was not affected by inclusion of water soluble (ondansetron hydrochloride or metaclopramide hydrochloride) or water insoluble (domperidone) drugs in the powder blend or FDTs. These observations indicated the versatility of the mathematical model in predicting the disintegration time of FDTs by evaluating the selected characteristics of the powder blends without actually preparing the FDTs.

Peripheral giant cell granuloma.

Peripheral giant cell granuloma is a benign reactive lesion of gingiva. It manifests as a firm, soft, bright nodule or as a sessile or pedunculate mass. This article reports the management of peripheral giant cell granuloma in a 12-year-old boy by surgical excision.

Massive lower intestinal bleeding--a decade of experience.

BACKGROUND: Lower gastrointestinal bleeding is defined as hemorrhage orginating distal to the ligament of Treitz. Its diagnosis is difficult, often requiring endoscopy, angiography and isotope scans. METHODS: All patients with massive lower gastrointestinal bleeding seen in three gastroenterology centers of Armed Forces during an 11 year period between 1988 and 1999 were retrospectively analysed. RESULTS: A total of 91 patients with massive lower gastro intestinal bleeding were seen during 11 years. The mean age of the patients was 38.9 years and 64 were males. Aetiological diagnosis was: Non-specific ulcers--11, Ileal tuberculosis--8, NSAID enteropathy--8, Enteric fever--7, Meckel's diverticulum--7, Polyps--6, Ulcerative colitis--5, Carcinoma colon--5, Colonic diverticulosis--5, No cause found--5, Polyposis coli--5, Jejunal diverticulae--3, Angiodysplasia colon--3, Radiation colitis--3, Ischaemic colitis--3, Ileal tumor--2, Ileal angiodysplasia--2, Intestinal Lymphoma--2, Bechet's syndrome--1. Bleeding stopped on conservative therapy in 18 patients (including 5 where no diagnosis could be made). Diagnosis was made in 36 patients on fiber-optic colonoscopy done during active bleeding. Remaining patients were subjected to emergency laparotomy and diagnosis was obvious on inspection of abdominal contents in 25 cases. The diagnosis was finally made in remaining 12 cases by intraoperative endoscopic examination through an ileotomy. Four patients died, only one of them due to rebleed after surgery from an additional lesion. CONCLUSIONS: Compared with experience in Western countries, massive lower gastro-intestinal hemorrhage in India affects younger patients, has different causes and carries a lower mortality. Colonoscopy is useful in making diagnosis during active lower intestinal bleeding in about one-third cases. Exploratory laparotomy and Intra-operative endoscopy are complimentary to above examination and can make the diagnosis in most of the remaining cases.

Thiophosphorylation of histidine.

The preparation of a novel phosphorus species, thiophosphoramidate, has enabled the specific thiophosphorylation of histidine at its 3-position. The rates of phosphorylation and thiophosphorylation of histidine are reported, as well as the spectroscopic properties of both thiophosphoramidate and 3-thiophosphohistidine. Structural assignment of the latter was made by analogy to the NMR properties of the known 3-phosphohistidine. The alkylation of 3-thiophosphohistidine by phenacyl bromide serves as a model for the introduction of labeling or probe reagents into histidine phosphorothioate-containing proteins.