The Prevalence of Respiratory Symptoms in Irish Dairy Farmers.

Work-related respiratory disease is a significant risk in the farming community. We assessed respiratory symptoms using a validated work-related respiratory questionnaire in 126 dairy farmers (19-75 years; 91.3% male). The prevalence of cough symptoms was 34.4%. Thirty-seven farmers (29.4%) complained of upper airway symptoms while forty (31.7%) complained of eye problems. Cumulated symptoms scores did not indicate higher than normal rates of chronic lung disease. Only 10 farmers (7.9%) were taking medication for lung conditions. Only 7 (5.6%) were current smokers. The rate of respiratory symptoms did not relate to the herd size or the method of animal feeding used by the farmers. The incidence of respiratory symptoms remains high among Irish dairy farmers. While the exact reason for this is unknown it may be related to continuing work- related dust exposure.

Geographic Variation in Access to Plastic Surgeons.

INTRODUCTION: While recent studies project a national shortage of plastic surgeons, there may currently exist areas within the United States with few plastic surgeons. We conducted this study to describe the current geographic distribution of the plastic surgery workforce across the United States. METHODS: Using the 2013 to 2014 Area Health Resource File, we estimated the number of plastic surgeons at the health service area (HSA) level in 2010 and 2012. The density of plastic surgeons was calculated as a ratio per 100,000 population. The HSAs were grouped by plastic surgeon density, and population characteristics were compared across subgroups. Characteristics of HSAs with increases and decreases in plastic surgeon density were also compared. RESULTS: The final sample included 949 HSAs with a total population of 313,989,954 people. As of 2012, there were an estimated 7600 plastic surgeons, resulting in a national ratio of 2.42 plastic surgeons/100,000 population. However, over 25 million people lived in 468 HSAs (49.3%) without a plastic surgeon, whereas 106 million people lived in 82 HSAs (8.6%) with 3.0 or more/100,000 population. Plastic surgeons were more likely to be distributed in HSAs where a higher percentage of the population was younger than 65 years, female, and residing in urban areas. Between 2010 and 2012, 11 HSAs without a plastic surgeon increased density, whereas 15 HSAs lost all plastic surgeons. CONCLUSIONS: Plastic surgeons are asymmetrically distributed across the United States leaving over 25 million people without geographic access to the specialty. This distribution tends to adversely impact older and rural populations.

Perineal reconstruction with bilateral bilobed flap for cloacal-like defect after childbirth.

Fourth degree lacerations of the vaginal wall and perineum following childbirth can cause cloacal-like defects of the perineum. The loss of the anterior anal sphincter and resultant thinning of the perineum and rectovaginal septum can lead to fecal incontinence and difficulties with sexual activity. This article introduces a technique to combine repair of the anterior anal sphincter with reconstruction of the perineal body with bilateral pedicled bilobed flaps.

Apolipoprotein E-epsilon 4 and recurrent genital herpes in individuals co-infected with herpes simplex virus type 2 and HIV.

Apolipoprotein E (APOE) alleles have been associated with the severity of, or susceptibility to, infection by various microbes. We investigated the potential association between the APOE-epsilon 4 allele and the rate of recurrence of genital herpes in patients who were HIV positive and herpes simplex virus type 2 (HSV-2) seropositive. The APOE-epsilon 4 allele was significantly associated with recurrent genital ulceration independent of ethnicity, antiretroviral therapy and CD4 count (OR 8.3; 95% CI 2.4 to 28.5). To our knowledge, this is the first published study to demonstrate this association and suggests that APOE-epsilon 4 may represent a future prognostic marker for symptomatic recurrence of genital herpes in individuals with HIV.

Pharmacokinetics of high-dose etoposide (VP-16-213) administered to cancer patients.

Plasma urine, and cerebrospinal fluid etoposide concentrations have been measured in 12 adult patients after administration of high-dose (400 to 800 mg/sq m) etoposide in order to determine the pharmacokinetics of this drug at these elevated dosages. Increasing the drug dosage produced proportionally higher peak plasma etoposide concentrations (27 to 114 micrograms/ml) and total areas under the concentration-time curve (9,200 to 48,000 micrograms/ml X min). The etoposide mean (+/- S.D.) terminal half-life of 8.05 +/- 4.3 hr and plasma clearance of 28.0 +/- 9.7 ml/min/sq m, however, were independent of the dosage given. The mean etoposide renal clearance in 5 patients was 10.0 +/- 4.3 ml/min/sq m, representing from 35 to 40% of the total clearance of this drug from plasma. Cerebrospinal fluid etoposide concentrations ranged from 0.1 to 1.4 micrograms/ml, as measured in 6 patients at 1 to 8 hr after high-dose etoposide therapy, and were 1.8 +/- 1.7% of the simultaneously measured plasma levels. Pleural fluid removed from one patient at 18 hr posttherapy contained etoposide at 1.8 micrograms/ml. Our data, combined with data published previously, indicate that the pharmacokinetics of high-dose etoposide is linear within the dosage range tested and similar to that seen with lower drug doses. They also suggest that etoposide penetrates poorly into the cerebrospinal fluid.

The ABMS MOC Part III Examination: Value, Concerns, and Alternative Formats.

This article describes the presentations and discussions at a conference co-convened by the Council on Medical Education of the American Medical Association (AMA) and by the American Board of Medical Specialties (ABMS). The conference focused on the ABMS Maintenance of Certification (MOC) Part III Examination. This article, reflecting the conference agenda, covers the value of and evidence supporting the examination, as well as concerns about the cost of the examination, and-given the current format-its relevance. In addition, the article outlines alternative formats for the examination that four ABMS member boards are currently developing or implementing. Lastly, the article presents contrasting views on the approach to professional self-regulation. One view operationalizes MOC as a high-stakes, pass-fail process while the other perspective holds MOC as an organized approach to support continuing professional development and improvement. The authors hope to begin a conversation among the AMA, the ABMS, and other professional stakeholders about how knowledge assessment in MOC might align with the MOC program's educational and quality improvement elements and best meet the future needs of both the public and the physician community.

A tribute to the founding figures of the American Board of Plastic Surgery.

The American Board of Plastic Surgery recently celebrated its 75th anniversary as an established specialty board. This historical article provides an outline of the events that led to the formation of the American Board of Plastic Surgery and gives insight into the personalities and achievements of the key individuals whose unique talents coalesced into a common vision of making plastic surgery the diverse and well-respected specialty that it is today. This is a historical literature review outlining the circumstances leading to the formation of American Board of Plastic Surgery. The emphasis on the role of its founding fathers is reviewed and detailed in the article. The founding figures continue to inspire us through their unrelenting dedication to the field of plastic surgery. Over the past 75 years, the field of plastic surgery has been very well served by their successors, and these founding figures have fostered a surgical specialty of great repute.

Severe allopurinol toxicity. Description and guidelines for prevention in patients with renal insufficiency.

A life-threatening toxicity syndrome consisting of an erythematous, desquamative skin rash, fever, hepatitis, eosinophilia, and worsening renal function in 78 patients receiving allopurinol is described. In a majority of cases, the development of this syndrome was associated with the use of standard (200 to 400 mg per day) doses of allopurinol in patients with renal insufficiency. In pharmacologic studies, it was demonstrated that the renal clearance of the major metabolite of allopurinol, oxipurinol, is directly proportional to the renal clearance of creatinine (oxipurinol clearance = 0.22 X creatinine clearance -2.87). An inverse linear relation was noted between the serum oxipurinol half-life and the renal creatinine clearance [( serum oxipurinol half-life in hours]-1 = 0.00034 X creatinine clearance in milliliters per minute + 0.0045). Long-term use of 300 mg per day of allopurinol was found to result in elevated steady-state serum oxipurinol concentrations in patients with renal insufficiency (serum oxipurinol concentration in micromoles per liter = -2.5 X creatinine clearance in milliliters per minute + 326). Avoidance of allopurinol or use of reduced doses in patients with renal insufficiency according to proposed guidelines should be adequate to inhibit uric acid production in most patients and may reduce the incidence of life-threatening allopurinol toxicity.

Improved high-performance liquid chromatography assay of doxorubicin: detection of circulating aglycones in human plasma and comparison with thin-layer chromatography.

We compared doxorubicin and metabolite pharmacokinetic data obtained from thin-layer chromatography (TLC) and high-performance liquid chromatography (HPLC) assay of plasma samples from six patients who had been treated with doxorubicin. Duplicate 1-ml samples were extracted with chloroform: isopropanol (1:1) and assayed using a sensitive HPLC system incorporating a dual pump gradient with tetrahydrofuran as the mobile phase and fluorescence detection. Duplicate 1-ml samples from the same specimens were assayed using a modification of a previously described TLC assay. Areas under the curve for doxorubicin by HPLC (3.36 +/- 2.30 microM X h) and TLC (4.16 +/- 2.50 microM X h) were not significantly different (P = 0.5). Terminal half-life of doxorubicin by HPLC (28.0 +/- 6.98 h) and TLC (23.2 +/- 7.8) (P = 0.29) and the calculated total-body clearances by HPLC (0.55 +/- 0.29 l/min) and TLC (0.45 +/- 0.23) (P = 0.55) were not significantly different. Areas under the curve for doxorubicinol by HPLC (2.75 +/- 1.4 microM X h) and TLC (2.53 +/- 7.1 microM X h) (P = 0.73) showed no significant differences. HPLC detected a mixed 7-deoxydoxorubicinol aglycone-doxorubicin aglycone peak, 7-deoxydoxorubicin aglycone, and two nonpolar, unidentified metabolites. TLC detected the following aglycone metabolites: doxorubicin aglycone, doxorubicinol aglycone, 7-deoxydoxorubicinol aglycone, an unidentified polar metabolite, and several unidentified nonpolar metabolites. From these data we conclude that HPLC and TLC detect concentrations of doxorubicin and doxorubicinol from human plasma equally well to concentrations of 7.0 nM (4 pmol injected doxorubicin). Aglycones do circulate in human plasma at concentrations above the detection limits of both assays. Doxorubicinol aglycone, which is detected by TLC but not by HPLC, may be formed from artifactual breakdown of doxorubicinol during TLC development. Unidentified nonpolar compounds seen on HPLC and TLC may represent further doxorubicin metabolism than previously described.

Pachyonychia congenita (Jadassohn-Lewandowski syndrome: case report.

We report an illustrative case of pachyonychia congenita, with a description of the presenting complaints, the associated physical findings, the rationale for surgical treatment, and the technical aspects of the surgical treatment.

Autotransfusion and reduction mammaplasty: a reappraisal in the 1990s.

Since the first report of autotransfusion and blood loss in major anesthetic procedures by Noone et al. in 1972, much has changed. The single most significant event is the development of the AIDS epidemic. With today's stringent and precisely defined transfusion criteria, the current practice of routinely using autologous units for reduction mammaplasties has caused considerable controversy. This study reviews the mean estimated blood loss during reduction mammaplasty and the use of autologous transfusion during a 46-month period at the Hospital of the University of Pennsylvania ending in November of 1991. The need for red blood cell transfusion is retrospectively analyzed. One-hundred female patients were entered into the study. The results demonstrate a decrease in blood loss from an average of 865 ml in the 1970s to 385 ml in the 1990s and suggest that routine employment of autologous transfusion is no longer necessary.

Primary Kaposi's sarcoma of an intraparotid lymph node with AIDS.

A case of Kaposi's sarcoma of an intraparotid lymph node in a patient with previously undiagnosed AIDS is presented. In patients at risk for AIDS who present with undiagnosed head and neck tumors, the diagnosis of epidemic Kaposi's sarcoma should be considered. Although transmission of AIDS to health care workers is exceedingly rare, proper precautions should be exercised when working with these patients.

The psychological contribution of nipple addition in breast reconstruction.

Two groups of consecutive patients from two different plastic surgical practice populations were evaluated to determine psychosocial differences between those who underwent nipple-areola reconstruction in addition to breast reconstruction (N = 33) versus those who did not undergo nipple-areola reconstruction in addition to breast reconstruction (N = 26). Psychological assessment consisted of a standardized symptom inventory (Brief Symptom Inventory) and a specially designed self-report questionnaire investigating reactions unique to surgeries for breast cancer and breast reconstruction. Both groups were equivalent sociodemographically, with the exception of age, where the nipple-added group was significantly younger (P = 0.035) than the nipple-not-added group. The nipple-added group reported significantly greater satisfaction with breast reconstruction with regard to overall satisfaction (P = 0.004), satisfaction with size (P = 0.02), satisfaction with softness (P = 0.0004), sexual sensitivity (P = 0.006), and satisfaction with nude appearance (P = 0.02). Of the nine scales of clinical symptomatology on the Brief Symptom Inventory, the nipple-added group showed more increased symptoms on seven of the nine. The nipple-added group was significantly higher on two of these scales, namely, paranoid ideation (P = 0.009) and anxiety (P = 0.03).

The mutagenicity of electrocautery smoke.

Careful analysis of electrocautery smoke produced during breast surgery has found organic compounds that are unidentifiable with current analytical techniques. The purpose of this study was to determine the potential mutagenicity of the smoke produced by the electrocautery knife during reduction mammaplasty. Multiple air samples were collected in the operating room during two reduction mammaplasty procedures. Airborne smoke particles were tested for mutagenic potential in both tester strains of Salmonella typhimurium (TA98 and TA100) using the standard Salmonella microsomal test (Ames test). All testing was performed by the Hazard Evaluations and Technical Assistance Branch of the National Institute of Occupational Safety and Health. The smoke produced with the electrocautery knife during reduction mammaplasty was found to be mutagenic to the TA98 strain. The Ames test, an established technique for evaluating the mutagenicity of a substance, was convincingly positive for the smoke collected during the breast surgery. Whether the smoke represents a serious health risk to operating room personnel is not known. Development of techniques to limit electrocautery smoke exposure in the operating room appears to be needed, and surgeons should attempt to minimize their exposure.

Salvage of jeopardized total-knee prosthesis: the role of the gastrocnemius muscle flap.

Total-knee arthroplasty has provided many patients with excellent long-term functional results. However, exposure of a total-knee replacement usually eventuates in failure. The relatively superficial location of the prosthesis, the need for early active motion, previous surgical incisions, and a variety of systemic factors may militate against early wound healing. Restoration of well-vascularized soft-tissue cover can salvage an otherwise disastrous situation. The authors recommend early operative intervention upon observation of wound breakdown, devitalized skin edges, or significant subcutaneous infection leading to necrotic overlying skin. The operative procedure found to salvage the majority of prostheses consists of adequate debridement, antibiotic irrigation (of the joint, if exposed), and coverage with a well-vascularized muscle flap, preferably the medial gastrocnemius muscle. The operative technique and ultimate long-term outcome are reviewed based on experience with 10 consecutive patients presenting with a jeopardized knee prosthesis. Follow-up ranged from 1 to 6 years. Representative case histories are presented.

A 6-year experience with immediate reconstruction after mastectomy for cancer.

A 6-year retrospective review is presented of 185 patients who underwent immediate reconstruction of the breast at the same operation as mastectomy for carcinoma. The patients were treated at two institutions under similar protocols of patient selection, surgical technique, and postoperative care. A detailed evaluation is presented from both the oncologic and surgical points of view. The data support the conclusion that immediate reconstruction of the breast does not alter survival or cancer recurrence rates and does not interfere with the treatment of primary or secondary disease. A low incidence of significant surgical complications is also detailed. Combined with previous reports answering psychological concerns about this mode and timing of reconstruction, this review offers significant reassurance about the overall safety of immediate reconstruction. The authors therefore recommend immediate reconstruction of the breast as a safe treatment option for the woman facing mastectomy.

Psychosocial correlates of immediate versus delayed reconstruction of the breast.

Two groups of consecutive patients from two different plastic surgical practice populations were evaluated to determine psychosocial differences between those who underwent immediate (n = 25) versus delayed (n = 38) breast reconstruction. Psychological assessment consisted of a standardized symptom inventory (BSI) and a specially designed self-report questionnaire investigating reactions unique to mastectomy and reconstruction. Both groups were extremely equivalent with regard to sociodemographic data, with the typical subject being a well-educated and employed Caucasian wife. Verbal reports of physical complaints revealed no significant differences between the two groups except for difficulty with arm movement, which was statistically higher for the immediate group (p = 0.006.). This difference most likely was due to the axillary dissection being performed simultaneously at the time of reconstruction. The relationship between timing of reconstruction and self-reported distress over the mastectomy experience revealed that only 25 percent of the women who underwent immediate repair reported "high distress" in recalling their mastectomy surgery compared with 60 percent of the delayed reconstruction group (p = 0.02). In reference to the two scales measuring psychological symptoms, a general trend was present, with the delayed group scoring higher (although not statistically significantly) on 9 of our 12 scales. Ninety-six percent of the immediate group and 89 percent of the delayed group reported satisfaction with results.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrence of breast carcinoma following immediate reconstruction: a 13-year review.

To evaluate the effect of immediate reconstruction on the incidence, location, detection, and treatment of recurrent breast cancer, a review of 306 patients operated on according to a standard protocol during the 10-year period 1979 through 1988 was performed. Reconstruction techniques included submuscular implants (207), tissue expanders (84), and musculocutaneous flaps (15). During a minimum follow-up period of 3 years with a mean of 6.4 years, 60 patients (19.6 percent) developed recurrent disease, at a mean interval to recurrence of 31 months. The first locations of recurrences were local (16), regional (11), and systemic (33). Recurrence rates by stage included stage I, 7 patients (5.2 percent); stage II, 45 patients (32.1 percent); and stage III, 8 patients (40 percent). It was not possible to include comparisons with internal control groups of patients in our institution who were not reconstructed or who had delayed reconstructions, thereby preventing conclusions based on such comparisons. Our recurrence data are similar to literature reports of recurrence rates in patients who were not reconstructed after mastectomy. Detection and treatment of recurrences were not inhibited by the reconstructions. When radiation therapy was used in the treatment of local recurrences, the development of symptomatic capsular contracture was recorded in 58 percent of the patients.