Mitochondrial DNA: An Endogenous Trigger for Immune Paralysis.

BACKGROUND: Critically ill patients are at high risk to suffer from sepsis, even in the absence of an initial infectious source, but the molecular mechanisms for their increased sepsis susceptibility, including a suppressed immune system, remain unclear. Although microbes and pathogen-associated molecular pattern are accepted inducers of sepsis and septic immunosuppression, the role of endogenous Toll-like receptor (TLR) ligands, such as mitochondrial DNA (mtDNA), in altering the immune response is unknown. METHODS: Mitochondrial DNA serum concentrations of the mitochondrial genes D-Loop and adenosine triphosphatase 6 were determined (quantitative polymerase chain reaction) in 165 septic patients and 50 healthy volunteers. Furthermore, cytotoxic T-cell activity was analyzed in wild-type and TLR9 knockout mice, with/without previous mtDNA administration, followed by injection of an ovalbumin-expressing adenoviral vector. RESULTS: Mitochondrial DNA serum concentrations were increased in septic patients (adenosine triphosphatase 6, 123-fold; D-Loop, 76-fold, P < 0.0001) compared with volunteers. Furthermore, a single mtDNA injection caused profound, TLR9-dependent immunosuppression of adaptive T-cell cytotoxicity in wild-type but not in TLR9 knockout mice and evoked various immunosuppressive mechanisms including the destruction of the splenic microstructure, deletion of cross-presenting dendritic cells, and up-regulation of programmed cell death ligand 1 and indoleamine 2,3-dioxygenase. Several of these findings in mice were mirrored in septic patients, and mtDNA concentrations were associated with an increased 30-day mortality. CONCLUSIONS: The findings of this study imply that mtDNA, an endogenous danger associated molecular pattern, is a hitherto unknown inducer of septic immunoparalysis and one possible link between initial inflammation and subsequent immunosuppression in critically ill patients.

Contemporary decision making and perception in patients undergoing cosmetic breast augmentation.

BACKGROUND: Today's breast augmentation (BA) patient obtains information from a variety of sources that may positively or negatively influence her decision. OBJECTIVES: The authors evaluate the decision-making process of patients undergoing BA, including how they seek information regarding the procedure, potential complications, the medical device itself, referral sources, and surgeon(s). METHODS: A written 36-item, blinded survey developed for this study was administered to all patients who underwent aesthetic primary BA by the senior author (JW) over a 12-month period in her metropolitan private practice. Patients were included only if they had undergone surgery after Food and Drug Administration approval of silicone implants and had at least four months of follow-up. Patients were excluded if they underwent reconstruction, revision, augmentation/mastopexy, or implant exchange. Data were analyzed utilizing descriptive statistics; frequencies of responses were calculated with SPSS (version 16). RESULTS: Of 153 mailed surveys, 100 respondents returned completed questionnaires (65%). Mean age was 30 years (range, 20-50 years). Eighty-eight patients were in the workforce, eight were students, and three were homemakers. Thirty-three percent had completed some graduate work or had a graduate degree, and 41% had a college degree. In terms of how patients began their informational searches, 41% began with Google, 18% began with a BA portal Web site, and 1% went through referral from a primary care provider (PCP)/OB-GYN. The primary influence in a patient's decision to have BA was her own desire to change her appearance (36%), and second was her plastic surgeon's Web site (16%). On a graded scale of 10 factors ranking importance (1 = not at all and 5 = extremely), 52% said that their plastic surgeon's Web site very much or extremely influenced their decision. Of respondents, 82% had silicone implants (18% saline). The most influential factor in choosing implant filler was the feel of the silicone versus saline implants (for 41%), followed by the plastic surgeon's explanation of the difference (29%) and recent FDA approval (13%). Primary sources of information for possible complications were the plastic surgeon and BA portal sites. When asked what the worst complication could be, patients reported capsular contracture (37%), implant rupture or leak (22%), and infection (20%). The most powerful influence on choice of surgeon for BA was the plastic surgeon's Web site (49%); meeting the doctor in consultation was next (14%), followed by BA portal sites (9%). Thirty-six percent of respondents consulted with a psychiatrist or psychologist at some point in their lives, with depression, anxiety, and stress management as top-ranked reasons (in that order). CONCLUSIONS: The Internet (specifically Google, the plastic surgeon's Web site, and portal Web sites) is very important to patients ages 20 to 50 in their search for information on BA. Educational and reality TV may have less influence on this particular group than was previously thought. Patients are well educated, are part of the workforce, and seem to be independent and private thinkers when it comes to their decision making. Referral sources such as the PCP assume a much smaller role in the search for information than in days past.

Painless blood testing to prevent neonatal sepsis.

The current US guidelines advise that all women colonized with Group B streptococcus (GBS) at 35-37 weeks, as well as those laboring before this time and all women with GBS urinary tract infections, should be offered intrapartum antibiotic prophylaxis, usually in the form of high-dose intravenous penicillin or ampicillin, unless delivered by planned cesarean section before the onset of labor in a woman with intact membranes. In term and preterm babies who are born to treated women, in addition to babies who act ill, the recommendation is to treat the baby with antibiotics. In certain circumstances, such as when the mother receives an intrapartum antibiotic < 4 hours prior to delivery, the baby receives antibiotics even if the baby appears well. This paper proposes a new process for testing for GBS that involves using the umbilical cord. If this process were used, babies would not need to have blood drawn and would experience less pain.

Cross-chest lipoplasty and surgical excision for gynecomastia: a 10-year experience.

BACKGROUND: Gynocomastia is a relatively common condition in men, with a reported overall incidence of 32% to 36% and as high as 65% among adolescent males in some series. OBJECTIVE: We reviewed the senior surgeon's experience over the past decade in the surgical treatment of gynecomastia using suction-assisted lipoplasty (SAL) with a cross-chest tunneling technique, performed alone or in combination with direct excision. METHODS: Thirty-four patients with gynecomastia were evaluated and treated surgically at the University of Texas Medical Branch in the past 10 years. Twelve were treated with cross-chest SAL alone, 16 with cross-chest SAL and direct excision, and 6 with direct excision. Infusion of wetting solution was performed with the use of a 2.0-mm cannula, through an access site at the medial border of the contralateral nipple-areolar complex. Next, a 4.0-mm Mercedes-tip (Byron/Mentor Corp., Santa Barbara, CA) cannula was tunneled across the sternum to liposuction the contralateral prepectoral fatty breast. Patients with composite fatty and glandular tissue first underwent SAL, then direct excision through a periareolar incision; those with only retroareolar glandular tissue underwent direct excision alone. RESULTS: All patients who underwent SAL alone or SAL combined with excision had satisfactory aesthetic results and no reported postoperative complications. In one patient who underwent excision alone, a hematoma developed. CONCLUSIONS: Despite newer technologies, traditional SAL performed with a cross-chest technique and direct excision as indicated is a valuable approach that yields predictable success. This approach avoids scarring and offers a sculpted reduction of the retroareolar glandular and fatty elements, resulting in a natural, smooth breast contour.

Career development resource for plastic and reconstructive surgery.

Plastic surgery is a broad-based discipline with emphasis on areas such as breast, craniomaxillofacial, burn, aesthetic, and hand surgery as well as complex wounds and wound healing. Plastic surgery as a specialty captures a great deal of media attention over many other fields of medicine, so education, training, and credentialing have become an area of national interest. The purpose of this article was to provide information on the organization, basic requirements for training, fellowship, and volunteer opportunities within the specialty.

Current methods for brow fixation: are they safe?

BACKGROUND: No single technique for fixation of the scalp after forehead-lift is universally accepted. Complications such as alopecia, loss of elevation, implant palpability, paresthesia, and dural injury are possible with the variety of techniques used currently. This anatomic study was designed to evaluate the thickness of the calvarium at selected points used in brow fixation. The depth of cranial penetration necessary for currently used techniques is measured and compared. METHODS: In a study of 14 fresh adult cadavers, calvarial thickness was measured at selected points (A-F) used in various brow-lifting procedures. This was accomplished by drilling holes in selected points and using a depth gauge to measure thickness. Immediately adjacent to selected points, the cranium is prepared for brow fixation using the following techniques: cortical tunnels, 2.0-mm screw fixation (10, 12, and 14 mm), the Mitek 2.0-mm Quickanchor screw, and the Endotine 3.5 Forehead Device. The depths required for adequate fixation and the potential for cranial penetration through the inner table with all the standard techniques are compared. RESULTS: Depth analysis by mean values showed that sites posterior to the coronal suture (points C-F) were thickest. Depth analysis of sites stratified by gender showed that mean values for the thickness of female skulls were greater than those for males. A review of fixation methods found that cortical tunnels at 45 degrees angles never penetrated the inner table in any of the 14 skulls. Mitek screws never penetrated the inner table, and one Endotine post penetrated the inner table on the left side of one cadaver skull. After placement of 10-, 12-, and 14-mm miniscrews at each of the sites, it was found that three penetrated the inner table. The penetrations all were at far lateral sites, posterior to the coronal suture. CONCLUSION: Variation in skull thickness exists among cadaver specimens at different sites on the skull. In this study, thickness increased medially and posteriorly. Women tended to have thicker skulls than men, and age was not a major variable. This is consistent with findings in previous work. Given the unpublished reports of inner table penetration, with cerebrospinal fluid leak after invasive brow fixation, it behooves the surgeon to keep in mind the anatomy of the calvarium and its nuances.

An anatomical comparison of transpalpebral, endoscopic, and coronal approaches to demonstrate exposure and extent of brow depressor muscle resection.

BACKGROUND: Approaches for exposure of the muscles of brow depression include transpalpebral, endoscopically assisted, and open coronal techniques. The purpose of this anatomical study was to compare the capacity for visualization and amount of brow depressor muscle resection with each technique. METHODS: The corrugator supercilii, depressor supercilii, medial orbicularis oculi, and procerus muscles were studied by gross anatomical dissection carried out on 24 sides of 12 cadaver heads. First, all visible corrugator and depressor supercilii muscles were resected by means of an upper blepharoplasty incision. Subsequently, a subgaleal endoscopic approach was used to evaluate the extent of resection performed and remove the remaining muscle after transpalpebral corrugator resection. This was followed by coronal exposure to assess the anatomical location and extent of muscle resection accomplished by the two previously mentioned techniques. RESULTS: In all dissections, endoscopy demonstrated that up to one-third of the lateral aspect of the transverse heads of the corrugator supercilii remained following transpalpebral resection. Oblique corrugator head resections were complete, without significant residual muscle following transpalpebral corrugator resection. The procerus muscle was able to be blindly transected by means of the transpalpebral incision but exposed and ablated in all 12 specimens using endoscopy. Coronal exposure demonstrated that no significant amount of corrugator, depressor supercilii, or procerus muscle remained in any of the 12 heads following endoscopically assisted exposure and resection. The medial head of the orbital portion of the orbicularis oculi was visualized and accessible regardless of the technique used. CONCLUSIONS: In 24 anatomical dissections, transpalpebral corrugator resection failed to remove up to one-third of the transverse head of the corrugator muscle. Removal of the brow depressor muscles was accomplished with the endoscopic approach, as confirmed by coronal exposure.

Wellness in Tillery: a community-built program.

Occupational therapy faculty and students from East Carolina University, in collaboration with the residents of Tillery, North Carolina, participated in a community-built wellness program. Outcomes of the program indicated that a program with participant input results in enhanced perceived wellness, maintenance of meaningful activities, and improved self-reported quality of life. Program elements necessary for duplication of the program are discussed. Recommendations for similar programs include developing mutual trust and respect, utilizing activities that are meaningful to participants, working within the culture, and considering the participants' lifestyles when planning.