Microsurgical replantation after forehead avulsion - success or failure? A case report.

In this article we would like to present, to our best knowledge, the very first published replantation of a forehead/part of a forehead as a single unit. The patient is a 57-year-old male smoker who sustained an avulsion forehead injury after a dog bite. Replantation was performed using microanastomosis of the supratrochlear vessels with restoration of good blood circulation after the procedure. Unfortunately, 5 days after the surgery, ischemia of the flap occurred followed by successful acute revision surgery. Nevertheless, the day after the ischemia reoccurred due to the time that passed, circumstances and unfavorable conditions affecting the sutured vessels, no further revision surgery was indicated. Observation continued and eventual wound necrosis after demarcation was left to be treated with skin grafting or per secundam intentionem. Only partial necrosis of the flap occurred, approximately 50%, which was subsequently treated with a full-thickness skin graft with very good results leading to the satisfaction of the patient.

Head-to-head comparison of two continuous glucose monitoring systems on a cardio-surgical ICU.

In critical illness hypo-and hyperglycemia have a negative influence on patient outcome. Continuous glucose monitoring (CGM) could help in early detection of hypo-and hyperglycemia. A requirement for these new methods is an acceptable accuracy and precision in clinical practice. In this pilot study we prospectively evaluated the accuracy and precision of two CGM sensors (subcutaneous sensor: Sentrino®, Medtronic and intravasal sensor: Glucoclear®, Edwards) in 20 patients on a cardio-surgical ICU in a head to head comparison. CGM data were recorded for up to 48 h and values were compared with blood-gas-analysis (BGA) values, analysed with Bland-Altman-plots and color-coded surveillance error-grids. Shown are means ± standard deviations. In total 270/255 intravasal/subcutaneous pairs with BGA-values were analysed. The average runtime of the sensors was 28.4 ± 6.4 h. Correlation with BGA values yielded a correlation coefficient of 0.76 (subcutaneous sensor) and 0.92 (intravasal sensor). The Bland Altman Plots revealed an accuracy of 2.5 mg/dl, and a precision of + 43.0 mg/dl to - 38.0 mg/dl (subcutaneous sensor) and an accuracy of - 6.0 mg/dl, and a precision of + 12.4 mg/dl to - 24.4 mg/dl (intravasal sensor). No severe hypoglycemic event, defined as BG level below 40 mg/dl, occurred during treatment. Both sensors showed good accuracy in comparison to the BGA values, however they differ regarding precision, which in case of the subcutaneous sensor is considerable high.

Neurologic sequelae associated with delayed identification of iatrogenic skull base injury during endoscopic sinus surgery (ESS).

BACKGROUND: Skull base injury is an infrequent complication during endoscopic sinus surgery (ESS). We hypothesize that late recognition and repair of CSF leaks during ESS is associated with increased neurologic morbidity. METHODOLOGY: A retrospective review was performed of patients with skull base injury during ESS at a tertiary center from 1999-2015. The study population was separated into early (less than 72 hrs) and late (more than 72 hrs) intervention groups. Study parameters included time to diagnosis, imaging, site of injury, type of repair, neurologic complications, and clinical outcomes. RESULTS: Seventeen patients were studied. The primary surgical interventions included ESS and balloon sinuplasty. Mean latency from primary surgery to presentation to our facility was 11 days. The most common injury site was the cribriform plate and the mean defect size 4.5 mm. Late diagnosis was associated with increased total neurologic complications and increased rates of postoperative meningitis. No neurologic complications occurred in patients diagnosed intraoperatively. All patients underwent successful endoscopic repair. CONCLUSION: Skull base injury is a rare but major complication following both balloon sinuplasty and traditional primary ESS. Early diagnosis and endoscopic repair may prevent neurologic morbidity in these patients.

Carcinoma cuniculatum: not a verrucous carcinoma.

BACKGROUND: Carcinoma cuniculatum and verrucous carcinoma are both very well differentiated forms of squamous carcinoma and thus difficult to separate histologically from pseudocarcinomatous hyperplasia. The diagnosis of each often requires clinical-pathologic correlation. METHODS: We reviewed the literature on cases reported as carcinoma cuniculatum and compared these to the cases originally reported by Aird et al. In addition, we report an additional case of this entity that we encountered in our practice. RESULTS: In reviewing the literature it is evident that most authors consider carcinoma cuniculatum and verrucous carcinoma to be synonymous even though Aird's original two cases had no verrucous features. The lack of a clear conceptual distinction between these two entities may cause diagnostic confusion. CONCLUSION: The purpose of this report is to record a case of carcinoma cuniculatum which the authors believe to be similar to those reported by Aird et al., to emphasize the differences between carcinoma cuniculatum and verrucous carcinoma, and to explain how the lack of a clear conceptual distinction between these two tumors can lead to further delay in an already difficult diagnosis.

Oligonucleotide inhibitors of human thrombin that bind distinct epitopes.

Thrombin, a multifunctional serine protease, recognizes multiple macromolecular substrates and plays a key role in both procoagulant and anticoagulant functions. The substrate specificity of thrombin involves two electropositive surfaces, the fibrinogen-recognition and heparin-binding exosites. The SELEX process is a powerful combinatorial methodology for identifying high-affinity oligonucleotide ligands to any desired target. The SELEX process has been used to isolate single-stranded DNA ligands to human thrombin. Here, a 29-nucleotide single-stranded DNA ligand to human thrombin, designated 60-18[29], with a Kd of approximately 0.5 nM is described. DNA 60-18[29] inhibits thrombin-catalyzed fibrin clot formation in vitro. Previously described DNA ligands bind the fibrinogen-recognition exosite, while competition and photocrosslinking experiments indicate that the DNA ligand 60-18[29] binds the heparin-binding exosite. DNA 60-18[29] is a quadruplex/duplex with a 15-nucleotide "core" sequence that has striking similarity to previously described DNA ligands to thrombin, but binds with 20 to 50-fold higher affinity. The 15-nucleotide core sequence has eight highly conserved guanine residues and forms a G-quadruplex structure. A single nucleotide within the G-quadruplex structure can direct the DNA to a distinct epitope. Additional sequence information in the duplex regions of ligand 60-18[29] contribute to greater stability and affinity of binding to thrombin. A low-resolution model for the interaction of DNA 60-18[29] to human thrombin has been proposed.

The potential of ki67 and p53 assessment in development of individualized targeted therapy in breast cancer patients.

INTRODUCTION: Despite the improvement of diagnostic methods and chemotherapeutic regimens in breast cancer, overall 5-year survival significantly depends on the stage of the disease. Over expression of tumor suppressor gene p53 and the marker for cellular proliferation Ki67 in breast cancer may have prognostic significance. METHODS: We evaluated 675 patients diagnosed with breast cancer at UF Health Jacksonville between January 2000 and June 2007 with up to 5-year follow up. The aim of the study was to determine whether immunohistochemical (IHC) assessment of Ki67 and p53 may predict outcome, the 'hazard' of dying. Cox's proportional hazards models were used to control for age (< 50 vs. ≥ 50), race (white vs. other), lymph node group (negative vs. positive), ER (estrogen receptor) group (negative vs. positive), PR (progesterone receptor) group (negative vs. positive), and tumor type. RESULTS: When only p53 was considered in the model, the hazard of dying was significantly higher for p53 positive compared to p53 negative (HR = 1.32, 95% CI 1.02, 1.70, p = 0.036). When only ki67 was considered in the model, the hazard of dying was significantly higher for ki67 positive compared to ki67 negative (Hazard ratio = 1.64, 95% CI 1.08, 2.49, p = 0.021). Neither of the two markers, nor their interaction was significant when all variables were considered in the model. DISCUSSION: This study confirms the expression of p53 and Ki67 as strong individual indicators of patient outcome. However, when controlling for the other variables, the two markers are not independent predictors. Future studies that will include these markers might help design targeted therapy.

Metoprolol with and without chlorthalidone in hypertension.

After a control period on a placebo, 45 patients with mild to moderate hypertension were treated with metoprolol, 100 mg twice daily alone and in free combination with chlorthalidone 50 mg daily using a double-blind crossover technique. The beta-blocker alone induced a significant fall in blood pressure; the diastolic pressure was reduced to 100 mg Hg or less in 37 of the 45 patients and to 95 mm Hg or less in 19 patients. The addition of chlorthalidone enhanced the antihypertensive effect so that in 33 patients diastolic pressure fell to 95 mm Hg or less. The drugs were well tolerated even by a small number of patients with chronic bronchitis and diabetes mellitus. None of the patients developed cardiac failure. Adding a diuretic caused a small reduction in serum potassium concentrations, and the relevance of this observation is discussed.

A hospital out-patient study of timolol/bendrofluazide combination ('Prestim') in essential hypertension.

A study was carried out in 44 patients with mild to moderate essential hypertension attending a hypertension clinic in a general hospital. Treatment was administered using fixed-dose combination tablets of timolol maleate (10 mg) and bendrofluazide (2.5 mg) taken twice daily for 16 weeks, in order to assess the efficacy and side-effects of this combination and to monitor changes in serum electrolytes and other biochemical indices. Blood pressure control (supine diastolic blood pressure less than or equal to 95 mmHg) was achieved in 38 (86%) patients on a mean dose of 2.6 tablets daily (range 1 to 4 tablets). Adverse effects were uncommon, 3 (6%) patients being withdrawn at an early stage. In a complementary investigation, 14 patients who completed the 16-weeks' treatment were changed onto a regimen in which the drug dosage remained unchanged but was taken on a once-daily basis for a further 16 weeks to assess the efficacy of once-daily dosing and to monitor any further long-term changes in biochemistry. The trend of changes in biochemical indices which were observed in the 16-week study tended to reverse during the second 16 weeks so that, overall, changes in biochemistry were minimal. The combination of timolol maleate and bendrofluazide was effective in controlling blood pressure in most mild to moderate hypertensives and the dose range allowed accurate titration of dosing for each patient. The effect was equal on a once-daily or a twice-daily dosage.

Propranolol in cardiac arrhythmias: a comparative study of the conventional and long-acting formulations.

The comparative anti-arrhythmic effect of equivalent daily doses of conventional propranolol ('Inderal') and long-acting propranolol ('Inderal' LA) was assessed in a double-blind, crossover study lasting 6 weeks in 13 patients with cardiac arrhythmias. Patients were investigated using 24-hour ambulatory monitoring. Both formulations of propranolol significantly reduced the heart rate, together with the number of ventricular premature beats and ventricular couplets, with no significant difference between treatments. The two formulations also produced similar plasma concentrations of propranolol. The long-acting formulation of propranolol proved an effective anti-arrhythmic treatment which, with once-daily dosage, may improve patient compliance with treatment.

Nifedipine and nisoldipine in hypertensive diabetics.

The effects of nisoldipine and slow release nifedipine on mild to moderate hypertension and glycaemic control were studied in 28 diabetic hypertensives, all except one of whom were non-insulin dependent. After two weeks placebo treatment patients were randomised to receive either nisoldipine 5 mg twice daily or nifedipine 10 mg twice daily. If, after four weeks of treatment, diastolic blood pressures (DBP) were 95 mmHg or more, the doses were doubled. On the 'optimum' dose patients were reviewed at weeks 4, 8, 12 and 24. At each visit blood was taken for haematology, biochemistry, glucose and glycosylated haemoglobin (GHb). Twenty-four hour home blood glucose (HBG) profiles were done at the end of the placebo period, and at weeks 8, 12, and 24, when on 'optimum' treatment. Mean sitting blood pressure fell from 173/99 to 161/92 (nisoldipine) and 158/86 mmHg (nifedipine) on the lower doses. Responses to higher doses were less marked. Changes in post breakfast blood glucose and GHb were not statistically significant. There were no significant changes in 24 hr HBG profiles on nisoldipine 5 mg and only minor decreases on 10 mg. On nifedipine 10 mg there was a similar change but on 20 mg an increase in HBG was seen at all points.

A practical, theory-based approach to establishing school nutrition advisory councils.

This article describes a process for establishing school nutrition advisory councils (SNACs) as an integral part of a school environment approach to promoting the nutritional health of students. The application of social cognitive theory as the conceptual framework for SNACs is discussed and the steps for establishing councils, including describing the school food environment, recruiting council members and convening the council, are reviewed. Actions taken by SNACs to positively affect the school nutrition environment are also described. SNACs are 1 component of the Teens Eating for Energy and Nutrition at School (TEENS) study, a group randomized, school-based intervention trial conducted in 16 middle schools in the Minneapolis-St Paul, Minn, metropolitan area. TEENS seeks to promote healthful dietary behaviors among young adolescents to reduce future cancer risk. Primary outcome measures include increasing fruit and vegetable intake and decreasing fat consumption. SNACs were established in the intervention schools to assess the overall school food environment and to advance school-level policy that promotes a healthful food environment.

Technology-enhanced distance education: from experimentation to concerted action.

Despite the rush to embrace technology-enhanced learning (TEL), descriptions of how schools of nursing move toward systemwide implementation of this type of teaching are scarce. There is a wide gap between sporadic dabbling by individual instructors in specific courses and adoption and implementation of TEL throughout a program. This article describes the experiences of a group of nursing faculty who helped move one school of nursing from experimentation with TEL in distance education to concerted action toward a strategic schoolwide plan. J Prof Nurs 17:135-140, 2001.

[Maternal hyperphenylalaninemia in a population of healty Czech women. 18 years' experience with mass screening, diet therapy and metabolic monitoring]. / Materské hyperfenylalaninémie v ceské populaci zdravých tehotných zen. 18leté zkusenosti s fakultativním screeningem, dietní lécbou a metabolickým sledováním.

BACKGROUND: Elevated phenylalanine levels in maternal blood (hyperphenylalaninaemia) during pregnancy damages the developing foetal tissues. Early detection of pregnant women with hyperphenylalaninaemia and adherence to a low phenylalanine diet already before conception and throughout pregnancy can prevent this damage. The objective of the investigation are results achieved screening and strict monitoring of low phenylalanine dietetic treatment in detected pregnant women of the Prague population. METHODS AND RESULTS: 186 350 healthy women of the Prague population were examined by the chromatographic screening test in a venous blood sample during their first visit in a maternity welfare centre and 22 positive cases were detected (incidence 1:8470). In 86% mild, persistent or benign forms of phenylketonuria were involved. Nineteen patients were treated by a low phenylalanine diet and the phenylalanine tolerance was monitored as well as the nitrogen balance, amino acids in serum and urine, protein markers, trace elements, vitamins, lipids, the body mass index-BMI, changes of body weight after introduction of the dietetic treatment and treatment during pregnancy. A significant increase of the phenylalanine tolerance by 20 to 200% was found, mostly in the second half of pregnancy and reduced values of serum and urinary selenium. The decrease of body weight when the diet was introduced and the increment during pregnancy correlated with the BMI value. In the other investigated parameters no significant deviations were found. CONCLUSION: Fifteen healthy children with normal psychomotor development delivered by 12 mothers with hyperphenylalaninaemia provide evidence of the effectiveness of prenatal screening for hyperphenylalaninaemia during pregnancy.