Heads up reconstructive microsurgery: Utilisation of the three-dimensional microscope in microvascular procedures.

BACKGROUND: Since the earliest use of microscopes in surgery, several modifications have been made to improve the ergonomics of movement and posture, increase the resolution, and expand the visual field. The three-dimensional microscopes are latest innovation in this field. Despite the wider use of 3D microscopes in other specialities, their use in the reconstructive microsurgery in the United Kingdom is still limited. Reconstructive microsurgeons are highly skilled surgeons that are trained to operate utilising the microscope for long hours. This poses an occupational risk with a specific pattern of work-related conditions. AIMS AND METHODS: We aim in this report to demonstrate our experience utilising 3D microscopes in small cohort of patients matched to a control of patients operated utilising the traditional microscopes. Patients were matched by age, comorbidities, oncologic procedures. This was complemented by a survey completed by the operating surgeons. RESULTS: Nine patients were included in each group. There was no significant difference in operative or ischemia time and no significant post-operative complications in both groups. The surgeons reported better ergonomics, improved staff engagement, and a better teaching experience when utilising the 3D microscopes compared to traditional microscopes. CONCLUSION: The utilisation of the 3D microscopes in reconstructive microsurgery has shown to provide comfort, improve ergonomics of movement and posture without significant clinical implications in this series.

'Fat chance': a review of adipose tissue engineering and its role in plastic and reconstructive surgery.

Soft tissue reconstruction remains a continuing challenge for plastic and reconstructive surgeons. Standard methods of reconstruction such as local tissue transfer and free autologous tissue transfer are successful in addressing soft tissue cover, yet they do not come without the additional morbidity of donor sites. Autologous fat transfer has been used in reconstruction of soft tissue defects in different branches of plastic surgery, specifically breast and facial defect reconstruction, while further maintaining a role in body contouring procedures. Current autologous fat transfer techniques come with the drawbacks of donor-site morbidity and, more significantly, resorption of large amounts of fat. Advancement in tissue engineering has led to the use of engineered adipose tissue structures based on adipose-derived stem cells. This enables a mechanically similar reconstruct that is abundantly available. Cosmetic and mechanical similarity with native tissue is the main clinical goal for engineered adipose tissue. Development of novel techniques in the availability of natural tissue is an exciting prospect; however, it is important to investigate the potential of cell sources and culture strategies for clinical applications. We review these techniques and their applications in plastic surgery.

Publication rates from BAPRAS meetings: where are we now?

In the UK the BAPRAS (British Association of Plastic, Reconstructive and Aesthetic Surgeons) meetings have always represented the ideal platform for disseminating new information in the field of plastic surgery. Previous studies have suggested the publication rate for these meetings has been falling. Our aim was to re-assess the conversion rates of presented abstracts to publications. All abstracts from BAPRAS meetings between Winter 2014 and Summer 2016 were included. PubMed and Google Scholar databases were used to search for full publications. A database was collated, this included; time to publication, journal of publication and impact factor of journal. A total of 500 abstracts were presented during the study period for which the publication rate was 28.4%. The average time to publication was 16.8 months. The most common publication journal was the Journal of Plastic, Reconstructive and Aesthetic Surgery (JPRAS) (34%). Free papers were published in journals with significantly greater impact factors (p = 0.046). Publication rates were similar to previous literature for BAPRAS meetings and have increased since 2007. A continued downward trend of publication rates for BAPRAS meetings is not seen in our data. A reduction in the number of publications in JPRAS may be explained by a rise in the impact factor of the journal or increasing competitiveness for publications. When variations in methodology are accounted for publication rates are similar to other specialties. In order to continually assess the quality of papers presented at BAPRAS meetings, the conversion to publication should be regularly re-audited.

SOLEIL shining on the solution-state structure of biomacromolecules by synchrotron X-ray footprinting at the Metrology beamline.

Synchrotron X-ray footprinting complements the techniques commonly used to define the structure of molecules such as crystallography, small-angle X-ray scattering and nuclear magnetic resonance. It is remarkably useful in probing the structure and interactions of proteins with lipids, nucleic acids or with other proteins in solution, often better reflecting the in vivo state dynamics. To date, most X-ray footprinting studies have been carried out at the National Synchrotron Light Source, USA, and at the European Synchrotron Radiation Facility in Grenoble, France. This work presents X-ray footprinting of biomolecules performed for the first time at the X-ray Metrology beamline at the SOLEIL synchrotron radiation source. The installation at this beamline of a stopped-flow apparatus for sample delivery, an irradiation capillary and an automatic sample collector enabled the X-ray footprinting study of the structure of the soluble protein factor H (FH) from the human complement system as well as of the lipid-associated hydrophobic protein S3 oleosin from plant seed. Mass spectrometry analysis showed that the structural integrity of both proteins was not affected by the short exposition to the oxygen radicals produced during the irradiation. Irradiated molecules were subsequently analysed using high-resolution mass spectrometry to identify and locate oxidized amino acids. Moreover, the analyses of FH in its free state and in complex with complement C3b protein have allowed us to create a map of reactive solvent-exposed residues on the surface of FH and to observe the changes in oxidation of FH residues upon C3b binding. Studies of the solvent accessibility of the S3 oleosin show that X-ray footprinting offers also a unique approach to studying the structure of proteins embedded within membranes or lipid bodies. All the biomolecular applications reported herein demonstrate that the Metrology beamline at SOLEIL can be successfully used for synchrotron X-ray footprinting of biomolecules.

Disaster Olympics: A Model for Resident Education.

OBJECTIVES: The aim of this study was to describe an educational method teaching Disaster Medicine to American Emergency Medicine (EM) physicians and to evaluate knowledge attainment using this method. METHODS: This was an observational study using a pre-test and a post-test. A full-scale disaster exercise (FSE) was conducted at a large academic center with two hospitals in Brooklyn, New York (USA). Eighty-two EM residents (physicians in training, post medical school) participated in the study. Inclusion criteria for study participation was all EM residents training at the State University of New York (SUNY) Downstate at the time of the study. There were no exclusion criteria. The exercise was a disaster drill designed as "Olympic Games." Participants in the exercise took a pre-test and a post-test. The primary outcome of the study was the mean difference between pre-test and post-test scores of the study participants using independent sample t-tests. Secondary outcomes of the study were percent of critical actions met by the residents and the hospitals as measured by direct observation of trained study personnel during the exercise. RESULTS: Mean resident post-test scores were higher than pre-test scores to a degree that was statistically significant (62% versus 53%; P =.002). The residents' performances ranged from 48% to 63% of objectives met. The hospitals' performances met 50% to 100% of their objectives. CONCLUSION: The use of an Olympic Games format was an effective model for disaster education for physicians. The model allowed for evaluation of performance and protocols of participants and hospital systems, respectively, and may be used objectively to evaluate for areas of improvement. The Disaster Olympics drill was found to improve emergency preparedness knowledge in the population studied and may constitute a novel and efficacious methodology in disaster training. Daniel P , Gist R , Grock A , Kohlhoff S , Roblin P , Arquilla B . Disaster Olympics: a model for resident education. Prehosp Disaster Med. 2016;31(3):237-241.

Does post-mastectomy radiotherapy affect the outcome and prevalence of complications in immediate DIEP breast reconstruction? A prospective cohort study.

INTRODUCTION: The decision to perform immediate deep inferior epigastric perforator (DIEP) flap reconstruction in patients requiring post-mastectomy radiation therapy (PMRT) is controversial, and often influenced by the increased potential of complications. We assessed the outcome and complications of irradiated immediate DIEP-reconstructed flaps in a two-surgeon series in our department. METHODS: Data collected prospectively from all patients undergoing immediate DIEP reconstruction under the two senior authors' care over 24 months were reviewed. Patients receiving previous radiation were excluded. Included patients were divided into two groups - requiring or not requiring PMRT. Primary outcome measures were fat necrosis, surgery for removal of fat necrosis, volume loss requiring surgery, wound complications and flap survival. All patients with a clinical diagnosis of post-radiation fat necrosis had an ultrasound scan. RESULTS: The series included 112 patients with a total of 156 flaps (44 bilateral, 68 unilateral). In 61/156 flaps the patients received PMRT (Group A) whilst 95/156 did not (Group B). Demographics in both groups were similar. Outcomes in PMRT vs. no PMRT, respectively were: fat necrosis 11.5% vs. 6.35% (p = 0.199); surgery for removal of fat necrosis 6.6% vs. 4.2% (p = 0.383); volume enhancement surgery 4.9% vs. 5.2% (p = 0.617); minor wound healing delay, 3.2% vs. 7% (p = 0.433); major wound healing delay 2.5% vs. 5.7% (p = 0.558). 0/61 flaps were lost in group A and 2/95 in group B. CONCLUSION: Although studies have shown the deleterious effects of post-operative radiotherapy on breast free flaps, our department offers immediate breast reconstruction with the acceptance of the risk/benefit profile. We found no increase in complication rates in patients undergoing immediate DIEP reconstruction receiving PMRT, and the outcome was not adversely affected. As part of an ongoing study, we do not feel that post-mastectomy radiotherapy precludes the decision for immediate free-flap breast reconstruction.

Structure of glycoproteins from Acacia gum: an assembly of ring-like glycoproteins modules.

The glycoprotein (GP) molecular fraction structure of the gum exudate of Acacia senegal (gum Arabic) isolated from hydrophobic interaction chromatography was investigated using high-performance size exclusion chromatography-multi angle laser light scattering (HPSEC-MALLS), small angle X-ray scattering (SAXS), synchrotron radiation circular dichroism (SRCD) and transmission electron microscopy (TEM) observations. In solution, GP would be a mixture of spheroidal monomers and more anisotropic oligomers as suggested by the two exponent values found in the Rg vs. Mw relationship and TEM observations. The GP conformation probed by SAXS was ascribed to a thin object with a triaxial ellipsoid morphology, certainly attributed to GP oligomers. A 9 nm diameter particle was also identified by SAXS in agreement with the dimensions identified by TEM on single isolated ring-like structures. The GP oligomerization process, as probed by TEM, would be the result of ring-like subunits self-association. This self-association would lead to more linear or, sometimes, cyclised assembly. At the molecular level, GP fraction was found to have secondary structures mainly made of ß-sheets and turns (64%) but also, to a lesser extent, made of polyproline II (PPII) and α-helices (19%). These features were characteristic of hydroxyprolin-rich glycoproteins with arabinosylated and arabinogalactan polysaccharide side chains grafted to the polypeptide backbone. The GP molecular fraction structure from Acacia gum would be an assembly of ring-like glycoproteins modules. These ring-like structures were certainly due to hydroxyproline (Hyp)-arabinogalactan (AG) subunits.

SAXS conformational tracking of amylose synthesized by amylosucrases.

Amylose, a linear polymer of α(1,4)-linked glucosyl units and a major constituent of starch granules, can also be enzymatically synthesized in vitro from sucrose by bacterial amylosucrases. Depending on the initial sucrose concentration and the enzyme used, amylose oligomers (or polymers) are formed and self-associate during synthesis into various semicrystalline morphologies. This work describes for the first time a synchrotron SAXS study of the structure in solution of two amylosucrases, namely, NpAS and the thermostable DgAS, under conditions of polymer synthesis and, simultaneously, the amylose conformation. The structure in solution of both amylosucrases during the reaction was shown to be similar to the known crystallographic structures. The conformation of amylose produced at an early stage consists of a mixture of wormlike chains and double helical cylindrical structures. In the case of NpAS, in a second stage, individual double helices pack into clusters before crystallizing and precipitating. Amylose produced by DgAS never self-associates in such clusters due to the higher temperature used for amylose synthesis. All the dimensions determined for wormlike chains and cylindrical conformations at different times of NpAS synthesis are in very good agreement with structural features usually observed on gels of amylose extracted from starch. This provides new insights in understanding the mechanisms of amylose gelation.

Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps.

BACKGROUND: Perineal wound complications following abdominoperineal excision (APE) for low rectal tumours remain an important cause of morbidity and prolonged hospital stay, particularly after chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator (IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors' previous experience and published literature on myocutaneous flaps. METHODS: A series of patients who underwent immediate IGAP flap reconstruction after APE between April 2008 and December 2010 were examined retrospectively to determine patient demographics, length of operation, complications (perineal wound and general) and length of hospital stay. RESULTS: Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal hernias requiring revisional surgery. CONCLUSION: Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series.

Use of myocutaneous flaps for perineal closure following abdominoperineal excision of the rectum for adenocarcinoma.

INTRODUCTION: Abdominoperineal excision (APE) following radiotherapy is associated with a high rate of perineal wound complications. The use of myocutaneous flaps may improve wound healing. We present our experience using myocutaneous flaps for immediate reconstruction. METHOD: Prospective data were collected on patients undergoing APE from October 2003 to December 2008. Patient demographics, operating time, wound complications and length of stay were recorded. RESULTS: Fifty-one patients underwent APE for rectal adenocarcinoma, 21 had primary closure and 30 had myocutaneous flap closure (24 VRAM, 6 gracilis). The proportion of patients undergoing preoperative radiotherapy in each group were 62% and 93% respectively (P = 0.011). There were no major complications following primary closure of the unirradiated perineum. Major perineal wound complications requiring reoperation or debridement were seen in three (14%) patients following primary closure and five (17%) patients with flap closure. After radiotherapy, closure with a flap reduced the length of stay from 20 to 15 days, but this difference was not statistically significant (P = 0.36). CONCLUSION: The use of flap closure in irradiated patients is associated with fewer perineal complications and a shorter hospital stay.

Thermal injuries to autologous breast reconstructions and their donor sites--literature review and report of six cases.

Breast reconstruction using autologous techniques has now become the gold standard. In recent years the focus has been on maintaining excellent cosmesis whilst minimising the incidence of partial or complete flap loss and donor site morbidity. However, an area which is frequently overlooked is the sequelae resulting from denervation of these flaps and their donor sites which can potentially lead to thermal injury. We report on six patients who sustained burns following free autologous breast reconstruction using either a DIEP or a muscle sparing TRAM. Four of the burns were confined to the flap skin paddle and two to the abdominal donor site. To prevent such thermal injuries all patients undergoing flap reconstruction should be educated regarding the vulnerability of the flap and its donor site as well as means of protecting these susceptible areas during daily activities.

Successful stent-graft placement for the treatment of a superior gluteal artery pseudoaneurysm in a patient following complex pelvic surgery.

Aneurysms of the gluteal arteries are rare and were previously managed with open surgical procedures. Recently percutaneous embolisation techniques have helped reduce morbidity and mortality. A case is presented of a 63-year-old man who presented with haemorrhage and had developed a superior gluteal artery aneurysm following treatment for an invasive squamous cell carcinoma in the sacral area. There was concern that embolisation of the aneurysm might compromise the survival of the myocutaneous buttock rotation flaps that had been used for reconstruction. To overcome this, an endovascular stent was deployed to successfully close off the aneurysm whilst at the same time maintaining blood flow through the superior gluteal artery. Aneurysms in larger peripheral vessels have been managed with stents. However, this is the first reported case of this method of treatment being used in the management of gluteal artery aneurysms.

Use of the vertical rectus abdominis myocutaneous flap after abdominoplasty.

A vertical rectus abdominis myocutaneous flap was used to provide cover for a recurrent angiosarcoma in the abdominal skin. Of note, the patient had 9 years previously undergone formal abdominoplasty to allow closure following excision of the primary tumour. This flap is normally reliant on myocutaneous perforators originating from the deep epigastric system, which are divided during abdominoplasty. Despite this, the flap survived well, implying that a new blood supply had formed during the intervening years. This flap can, therefore, be considered a possible option in reconstructive cases where other options are limited, despite a preceding abdominoplasty. In the future because of the increasingly common occurrence of abdominoplasty in young females, this procedure may need to be considered.

In vitro activity of a novel diaminopyrimidine compound, iclaprim, against Chlamydia trachomatis and C. pneumoniae.

The in vitro activities of iclaprim, a novel dihydrofolate reductase inhibitor, azithromycin, and levofloxacin were tested against 10 strains of Chlamydia trachomatis and 10 isolates of Chlamydia pneumoniae. For C. trachomatis and C. pneumoniae, the iclaprim MIC and minimal bactericidal concentration at which 90% of isolates were inhibited (MIC(90) and MBC(90)) were 0.5 micro g/ml, compared to an azithromycin MIC(90) and MBC(90) of 0.125 micro g/ml and levofloxacin MIC(90)s and MBC(90)s of 1 micro g/ml for C. trachomatis and 0.5 micro g/ml for C. pneumoniae.

Serum S100 concentrations are not useful in predicting micrometastatic disease in cutaneous malignant melanoma.

BACKGROUND: S100 protein is an acidic calcium binding protein that is expressed by melanoma cells. Elevated serum values of S100 have been described in metastatic disease and it has been suggested that it may be used as an adjunct to staging and monitoring of treatment. Micrometastatic disease in the sentinel lymph node can be demonstrated by sentinel node biopsy (SNB) and the sentinel node status is known to be the most important predictor of relapse. OBJECTIVES: To determine whether serum S100 concentrations could predict the presence of micrometastatic disease. METHODS: Thirty-one patients with primary cutaneous melanoma > 1 mm were recruited from referrals to the Melanoma clinic. All patients had serum S100 concentrations evaluated prior to undergoing SNB. Serum S100 concentrations were established using an immunoluminometric method. Sentinel nodes were identified using a dual technique with both radiolabelled colloid (residual from preoperative lymphoscintigraphy) and blue dye according to the MD Anderson Cancer Center protocol. Results Nine of these 31 patients had evidence of micrometastatic disease on SNB. The mean serum S100 concentration of those with positive SNBs was 0.027 microg L-1 compared with 0.045 microg x L(-1) in patients with negative SNBs (normal < 0.14 microg x L(-1)). No patient in the study demonstrated raised concentrations of serum S100. CONCLUSIONS: We conclude that serum S100 concentrations do not predict the presence of micrometastatic melanoma in sentinel nodes in primary cutaneous melanoma.

Anomalous anterior midline cervical tube.

Anterior midline cervical anomalies, excepting thyroglossal tract abnormalities, are rare. Two unusual and almost identical cases of an anomalous congenital tube connecting the chin to the upper sternum are described; only one previous similar report exists in the literature. In all three cases, the tubes occurred as isolated anomalies in otherwise healthy children.

Ultrastructural study of Chlamydia pneumoniae in a continuous-infection model.

We have established an in vitro model of long-term continuous Chlamydia pneumoniae infection in HEp-2 cells. Using transmission electron microscopy, we demonstrated the presence of spontaneous abnormal chlamydial inclusions similar in appearance to the persistent chlamydial forms induced in vitro by treatment with cytokines or antibiotics or by nutrient deprivation.

Activity of telithromycin, a new ketolide antibacterial, against atypical and intracellular respiratory tract pathogens.

Atypical respiratory pathogens such as Mycoplasma pneumoniae and intracellular pathogens such as Legionella spp. and Chlamydia spp. form a significant proportion of the aetiological agents underlying community-acquired pneumonia (CAP). The clinical signs or radiological features of atypical pneumonia are generally insufficient to predict accurately the pathogen involved; in addition, high costs and a considerable length of time are involved in the identification of atypical pathogens. Treatment is, therefore, most often empirical, and it is important that the activity of antibacterial agents available to treat CAP is sufficiently broad to eradicate infection with both common and atypical bacterial pathogens. Telithromycin (HMR 3647) is the first of a new family of antibacterials, the ketolides, and has been designed specifically for the treatment of community-acquired respiratory tract infections (RTIs). The excellent activity of telithromycin against the respiratory tract bacterial pathogens most commonly associated with community-acquired RTIs, including resistant strains, is well established. This review examines the considerable body of evidence showing that telithromycin also has a high level of activity against atypical and intracellular respiratory tract bacterial pathogens.

Fibromatoses and related tumors of the hand in children. A clinicopathologic review.

Benign and malignant tumors of the hand are rare in children. This article reviews some of the common tumors that affect the hand in children, with an emphasis on clinico-pathologic correlations. Illustrated case histories on some rare tumors are also included.