Impact of Continuous Two-Team Approach in Autologous Breast Reconstruction.

Background Autologous breast reconstruction has been noted in the literature to provide superior aesthetic outcomes and patient satisfaction. Additionally, free perforator flap tissue transfer has the potential for lower abdominal donor site morbidity. However, it has been noted that the percentage of women who are undergoing autologous breast reconstruction in the United States is decreasing. Factors related to the technical difficulty, prolonged operative times, and decreasing reimbursement have been implicated as the causes. Methods A retrospective review of electronic medical records over a 5-year period was performed with evaluation of 77 autologous breast reconstructions at a single institution. Patient demographics, comorbidities, number of surgeons involved, operative times, length of stay, and postoperative complications were measured. Wilcoxon rank-sum, Pearson's chi-squared, and proportional odds likelihood ratio tests were performed to compare continuous, categorical, and ordinal outcomes, respectively. Propensity score weighting was used to adjust for presurgical covariates and laterality. Results Operative time and length of stay were both significantly lower in the two- versus the single-microsurgeon groups in the unadjusted setting. When covariates and laterality were adjusted for, operative times still remained significantly shorter in the two-microsurgeon group; there were no differences in complications. Conclusion Based on our findings, we propose that the two-microsurgeon approach can be utilized in more time-consuming microsurgical cases, such as autologous breast reconstruction, to safely decrease operative times and potentially alleviate surgeon fatigue, reduce operative costs, and thus increase overall surgeon productivity.

Free flap reconstruction of the knee: an outcome study of 34 cases.

BACKGROUND: Open wounds around the knee joint can often be managed with local flaps; however, free tissue transfer may be required when local tissue options are unavailable or inadequate. Free tissue transfer around the knee can be challenging due to unique anatomic features of the joint. The outcomes of such procedures remain largely unreported. METHODS: We retrospectively analyzed 33 patients who underwent 34 free tissue transfer reconstructions to the knee from 1993 to 2010. Twenty-four flaps were composed of soft tissue only and 10 flaps included a bony component. Patient demographics, details of the defect, operative characteristics, and clinical outcomes were reviewed. Outcomes included rates of flap failure, flap reexploration, and limb salvage. RESULTS: Thirty-three (97%) of 34 flaps survived. One flap failed secondary to arterial thrombosis. In total, 6/34 flaps (18%) required reexploration (2 arterial thromboses and 4 venous thromboses). A wide variety of donor and recipient vessels were used. Vessel selection did not affect vascular reexploration. Overall, 88% of lower extremities were salvaged. Four of 10 (40%) patients receiving bone free flap reconstruction experienced delayed union and 2 (20%) of these required amputation for eventual nonunion. CONCLUSIONS: Free flap reconstruction of the knee has a high flap survival and limb preservation rate in threatened extremities. Flap survival rates in the knee are similar to reported rates elsewhere in the lower extremity. Despite flap survival, infected nonunions that occur after bone free flap reconstruction result in a high limb amputation rate.

Piper capitarianum essential oil: a promising insecticidal agent for the management of Aedes aegypti and Aedes albopictus.

Mosquitoes are responsible for serious public health problems worldwide, and as such, Aedes aegypti and Aedes albopictus are important vectors in the transmission of dengue, chikungunya, and Zika in Brazil and other countries of the world. Due to growing resistance to chemical insecticides among populations of vectors, environmentally friendly strategies for vector management are receiving ever more attention. Essential oils (EOs) extracted from plants have activities against insects with multiple mechanisms of action. These mechanisms hinder the development of resistance, and have the advantages of being less toxicity and biodegradable. Thus, the present study aimed to evaluate the chemical composition of the EOs obtained from Piper capitarianum Yunck, as well as evaluating their insecticidal potential against Aedes aegypti and A. albopictus, and their toxicity in relation to Artemia salina. The yields of the EOs extracted from the leaves, stems, and inflorescences of P. capitarianum were 1.2%, 0.9%, and 0.6%, respectively, and their main constituents were trans-caryophyllene (20.0%), α-humulene (10.2%), ß-myrcene (10.5%), α-selinene (7.2%), and linalool (6.0%). The EO from the inflorescences was the most active against A. aegypti and A. albopictus, and exhibited the respective larvicidal (LC50 = 87.6 µg/mL and 76.1 µg/mL) and adulticide activities (LC50 = 126.2 µg/mL and 124.5 µg/mL). This EO was also the most active in the inhibition of AChE, since it presented an IC50 value of 14.2 µg/mL. Its larvicidal effect was observed under optical and scanning electron microscopy. Additionally, non-toxic effects against A. salina were observed. Docking modeling of trans-caryophyllene and α-humulene on sterol carrier protein-2 (SCP-2) suggests that both molecules have affinity with the active site of the enzyme, which indicates a possible mechanism of action. Therefore, the essential oil of P. capitarianum may be used in the development of new insecticide targets for the control of A. aegypti and A. albopictus in the Amazonian environment.

Aspirated Almond Masquerading as an Obstructing Endobronchial Mass Suspicious for Lung Cancer.

Foreign body aspiration is relatively rare in adults compared to children. In adults with delayed presentation, a history of choking is often absent, resulting in delayed diagnosis and significant morbidity. Common presenting features in adults include nonresolving cough with or without fever, hemoptysis, or wheezing and may mimic infectious, inflammatory, or neoplastic disorders. We present a case of a 64-year-old man with 80-pack-year smoking history who had a nonresolving left lower lobe infiltrate on chest radiograph after treatment for community-acquired pneumonia. His insidious-onset symptoms included cough, decreased exercise tolerance, and localized wheezing. Computed tomography of the chest showed a left lower lobe consolidation, with narrowing of the bronchus. Flexible bronchoscopy revealed a fleshy endobronchial mass, prompting endobronchial needle aspiration and biopsies, all of which revealed acute inflammation on rapid onsite evaluation. After multiple biopsies, a white pearly object with a detached brown cover was revealed; the object was found to be an aspirated almond. The almond and its peel were retrieved. The patient acknowledged that he had frequently eaten almonds in the supine position while recovering from a previous injury. His symptoms completely resolved at 3-month follow up, and he has ceased smoking and no longer consumes food while supine.

Pulmonary Mycobacterial Spindle Cell Pseudotumor: A Report of 3 Cases Including a Practical Approach to Histopathologic Recognition of This Unusual Entity.

Mycobacterial spindle cell pseudotumor (MSP) is a rare benign spindle cell lesion containing acid-fact mycobacteria. These lesions are most commonly identified in the lymph nodes, skin, spleen, or bone marrow of immunocompromised patients and only rarely involve the lungs. We report 3 cases of pulmonary MSP, which include 2 patients who are known to be HIV-positive. The histopathological diagnosis of MSP in the lung lends itself to many challenges due to its rare incidence and its spindled tumor-like appearance. The differential diagnosis is broad and includes both benign and malignant entities. We highlight the importance of the clinical context in which these lesions typically present and the morphologic spectrum of features seen, and we offer a practical approach to the workup of pulmonary mycobacterial pseudotumor. Appropriate recognition of this entity should lead to an accurate diagnosis of a treatable benign condition despite the clinical presentation often favoring malignancy.

Dynamics of tissue ubiquitin pools and ubiquitin-proteasome pathway component activities during the systemic response to traumatic shock.

Based on the biological significance of the ubiquitin-proteasome pathway (UPP) and its potential role during sepsis, burns and ischemia-reperfusion injury, we hypothesized that the systemic response to traumatic shock (TS) is accompanied by tissue-specific UPP alterations. Therefore, we studied tissue ubiquitin pools, chymotryptic- and tryptic-like proteasome peptidase activities and ubiquitin-protein ligation (UbPL) rates in skeletal muscle, heart, lung, liver, spleen and kidney using a clinically relevant porcine model (bilateral femur fracture/hemorrhage followed by fluid resuscitation). TS induced a systemic reduction of tissue-specific high molecular mass ubiquitin-protein conjugates (>50 kDa). Free ubiquitin was unaffected. The dynamic organ patterns of ubiquitin pools paralleled the typical physiological response to TS and resuscitation. Reduction of ubiquitin-protein conjugates was most pronounced in heart and lung (p<0.05 vs. control) and accompanied by significant increases in proteasome peptidase and UbPL activities in these organs. Unlike all other tissues, spleen proteasome peptidase and UbPL activities were significantly reduced 10 h after TS. These findings support the concept that the UPP could play an important role in regulation of cell functions during the early whole-body response to TS. The UPP might be a therapeutic target to improve the metabolic care after TS, particularly in the heart, lung, and spleen.

The effect of metal ions on mitochondrial pyridine dinucleotide transhydrogenase.

Bovine heart submitochondrial particle transhydrogenase is inhibited by cations in a concentration and pH-dependent manner, and non-energy-linked transhydrogenation is inhibited to a greater extent by metals than the energy-linked reaction. The inhibition of the enzyme by Mg2+ is competitive with the NADP substrate and non-competitive with the NAD substrate. Mg2+ stimulates inactivation of the enzyme by 5,5'-dithiobis(2-nitrobenzoic acid), and protects against thermal and proteolytic inactivation. This suggests that Mg2+ binding in the NADP site alters transhydrogenase to a more thermostable conformation, which is less susceptible to attack by trypsin and more reactive with 5,5'-dithiobis(2-nitrobenzoic acid). Other cation inhibitors mimic Mg2+ in these properties. The order of effectiveness of the inhibitors tested is La3+ greater than Mn2+ greater than Ca2+ congruent to Mg2+ greater than Sr2+ greater than Na+ congruent to K+. This order is described by the Irving-Williams order for the stability of metal-ligand complexes, suggesting that carboxylates or amines may comprise the inhibitory cation binding site.

Can virtual reality trainers improve the compliance discrimination abilities of trainee surgeons?

The assessment of tissue compliance using a handheld tool is an important skill in medical areas such as laparoscopic and dental surgery. The increasing prevalence of virtual reality devices raises the question of whether we can exploit these systems to accelerate the training of compliance discrimination in trainee surgeons. We used a haptic feedback device and stylus to assess the abilities of naïve participants to detect compliance differences with and without knowledge of results (KR) (groups 1 and 2), as well as the abilities of participants who had undergone repetitive training over several days (group 3). Kinematic analyses were carried out to objectively measure the probing action. Untrained participants had poor detection thresholds (mean just noticeable difference, JND = 33%), and we found no effect of KR (provided after each trial) on performance (mean JND = 35%). Intensive training dramatically improved group performance (mean JND = 12%). Probing action (in particular, slower movement execution) was associated with better detection thresholds, but training did not lead to systematic changes in probing behaviour. These findings set a benchmark for training systems that act to increase perceptual sensitivity and guide the learner toward optimal movement strategies to improve discrimination.

Why some women do not breast feed: bottle feeding and fathers' role.

OBJECTIVE: To explore women's experiences and perceptions of baby feeding and to explore the explanations offered by women who choose to either breast or bottle feed. DESIGN: A qualitative study, which was prospective in design. Participants were interviewed three times: the first stage was between six and 14 weeks of pregnancy; the second stage was between 34 and 39 weeks; and the third stage was between six and 14 weeks after childbirth. PARTICIPANTS: 19 participants were recruited to the study group via 12 antenatal clinics in Coventry, UK. FINDINGS AND DISCUSSION: The data indicate that participants make baby-feeding decisions either prior to conception or early in the pregnancy. Findings also indicate that both breast and bottle feeders possessed knowledge of the benefits of breast feeding, but this did not seem to influence decision making. One of the most significant factors influencing the decision to bottle feed appears to be a desire for paternal involvement. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To increase the incidence of breast feeding, health-care professionals should consider the need for preconceptual health promotion. The role of paternal involvement in baby-feeding decisions also needs to be acknowledged and men need to be included in breast-feeding promotion campaigns.

Teaching sociology within the speech and language therapy curriculum.

In the United Kingdom, the Royal College of Speech and Language Therapists suggests that sociology should be included within the speech and language therapy curriculum. However, in spite of this, sociology is seldom given priority. Although the role of sociology with the curricula of other professions has been discussed, the role of sociology within speech and language therapy has not. Given the contemporary climate of competence-based training, the position of subjects such as sociology is being compromised. This paper sets out three reasons in support of including sociology within speech and language therapy by drawing on the distinction between a "personal education" and a "semantic conjunction" model of the relationship between theory and professional practice. First, it is argued that sociology makes a valid contribution to an holistic approach to care--which is rapidly becoming the cornerstone of speech and language therapy practice. Second, this paper suggests that the inherent reflexivity within the discipline provides health professionals with an invaluable tool with which to engage in reflexive practice. Finally, it is argued that given the global emphasis on evidence-based practice, the study of sociology and sociological research methods equips therapists to interpret and conduct empirical research. This paper concludes by arguing that sociology should be viewed as an essential component of the speech and language therapy curriculum.

Disability, facilitated sex and the role of the nurse.

AIM: The aim of this paper is to explore the role that nurses can play in acknowledging and facilitating the sexual needs of disabled patients within an holistic framework of nursing care. BACKGROUND: Contemporary nursing claims to offer patient care within an holistic framework; this framework should encompass the biopsychosocial needs of patients, as defined by patients themselves. In spite of the importance of sexuality and sexual expression to the psychosocial welfare of patients, sexuality is often excluded from nursing practice. METHOD: Literature is reviewed from nursing, disability studies, and a variety of social science disciplines. FINDINGS: The paper begins with a discussion of the concept of 'holistic care' and the ways in which this has been interpreted in the nursing literature. The biopsychosocial approach and the notion of 'whole person' holism seem particularly significant, although the lack of attention to patient sexuality is identified. Literature from the social sciences is used to explore the significance of sexuality to individual self-identity and psychosocial welfare. This literature also highlights the way in which the denial of sexual identity is a significant feature of power relations. The disability studies literature catalogues the way in which disabled people are generally infantilized by society and perceived as asexual. This literature also highlights the professional neglect of disabled sexual identities. Using a variety of literature, the concept of facilitated sex is explored as a continuum of activities and the role of nursing, within a holistic framework, is examined. CONCLUSION: The paper concludes by arguing that an holistic approach to nursing care should include an appreciation of patient sexuality. In particular, it suggests that nurses can play an important role along the continuum of facilitated sex.

A direct demonstration of proton translocation coupled to transhydrogenation in reconstituted vesicles.

Homogeneous bovine heart mitochondrial transhydrogenase was reconstituted into K+-loaded phosphatidylcholine liposomes. Transhydrogenase-catalyzed reduction of 3-acetylpyridine adenine dinucleotide by NADPH was stimulated severalfold when valinomycin was added to collapse the developing membrane potential. A rapid and extensive quenching of the fluorescence of the pH probe, 9-aminoacridine, under these conditions indicates that transhydrogenation is coupled to the acidification of the vesicle interior. A corresponding uptake of protons from the medium is demonstrated by electrode measurements that indicate 1 or less proton is translocated for each hydride ion equivalent transferred between the substrates.

Bovine heart mitochondrial transhydrogenase catalyzes an exchange reaction between NADH and NAD+.

Reconstitution of homogeneous bovine heart mitochondrial transhydrogenase into phosphatidylcholine liposomes results in a greater than 80% inhibition of NADPH leads to 3-acetylpyridine adenine dinucleotide (AcPyAD+) transhydrogenation. This coupled rate is stimulated 5-fold by addition of protonophore to the rate observed with unreconstituted enzyme. In the absence of uncoupler, addition of low concentrations (10 microM) of NADH promotes by about 3-fold the rate of reduction of AcPyAD+ in the presence of NADPH. In the absence of NADPH, no reduction of AcPyAD+ by NADH occurs. Addition of valinomycin to K+-loaded proteoliposomes stimulated NADPH leads to AcPyAD+ transhydrogenation to the uncoupled rate and allowed the uptake of protons from the medium. In the absence of valinomycin, the rapid reduction of AcPyAD+ seen on addition of NADH was not coupled to proton translocation. In the presence of valinomycin, NADH addition neither equilibrated protons across the liposomal membrane nor affected the stoichiometry of proton uptake to hydride ion transfer (H+:H- ratio). Addition of NADH to proteoliposomes in the presence of AcPyAD+ and NADPH resulted in an initial rapid formation of reduced 3-acetylpyridine adenine dinucleotide comparable to the amount of NADH added. Thereafter, the rate of AcPyAD+ reduction returned to that seen in the absence of NADH. These results suggest that the NADH requirement for AcPyAD+ reduction is stoichiometric rather than catalytic. Stereospecificity studies demonstrate that reconstituted transhydrogenase catalyzes a direct transfer of a hydride ion equivalent from the 4A locus of NADH to the 4A locus of the NADH product in the presence, but not in the absence, of NADPH. It is proposed that NADH leads to NAD+ transhydrogenation represents a partial reaction of NADPH leads to NAD+ transhydrogenation which involves the participation of a reduced-enzyme intermediate.

Chemical modification of mitochondrial transhydrogenase: evidence for two classes of sulfhydryl groups.

Chemical-modification studies on submitochondrial particle pyridine dinucleotide transhydrogenase (EC 1.6.1.1) demonstrate the presence of one class of sulfhydryl group in the nicotinamide adenine dinucleotide phosphate (NADP) site and another peripheral to the active site. Reaction of the peripheral sulfhydryl group with N-ethylmaleimide, or both classes with 5,5'-dithiobis(2-nitrobenzoic acid), completely inactivated transhydrogenase. NADP+ or NADPH nearly completely protected against 5,5'-dithiobis(2-nitrobenzoic acid) inactivation and modification of both classes of sulfhydryl groups, while NADP+ only partially protected against and NADPH substantially stimulated N-ethylmaleimide inactivation. Methyl methanethiolsulfonate treatment resulted in methanethiolation at both classes of sulfhydryl groups, and either NADP+ or NADPH protected only the NADP site group. S-Methanethio and S-cyano transhydrogenases were active derivatives with pH optima shifted about 1 unit lower than that of the native enzyme. These experiments indicate that neither class of sulfhydryl group is essential for transhydrogenation. Lack of involvement of either sulfhydryl group in energy coupling to transhydrogenation is suggested by the observations that S-methanethio transhydrogenase is functional in (a) energy-linked transhydrogenation promoted by phenazine methosulfate mediated ascorbate oxidation and (b) the generation of a membrane potential during the reduction of NAD+ by reduced nicotinamide adenine dinucleotide phosphate (NADPH).

Percutaneous transhepatic cholangiography

The experience with percutaneous transhepatic cholangiography at the University Hospital of the West Indies has been reviewed. The success rate has increased with improved technique, and the results of this series compare favorably with other workers. The introduction of the flexible 23-gauge Chiba needle has further reduced our morbidity with the procedure and, although the interval between study and laparotomy within 24 hours of PTC is still recommended. The selection and preparation of patients remain of paramount importance especially to document and to correct coagulation defects and biliary infection prior to embarking on the investigation (AU)