Magnetic resonance angiography in preoperative planning of deep inferior epigastric artery perforator flaps.

Accurate preoperative localisation of deep inferior epigastric artery perforator (DIEaP) provides optimal surgical planning for DIEaP flaps. Cross-sectional imaging by contrast-enhanced magnetic resonance angiography (CE-MRA) has advantages over previously described techniques for perforator imaging including reduced radiation exposure and better muscle to vessel contrast. A retrospective series of 10 unilateral free breast reconstructions following preoperative CE-MRA of the anterior abdominal wall is presented. Mean age of the patients at the time of surgery was 50.3 years (range 44-63 years). An average of 2.8 perforators per study (range 1-5) was identified. Mean perforator luminal diameter was 2.6mm (1.4-4.0mm) with a mean intramuscular course length of 22.3mm (6.4-51.9 mm). Perforator course length was classified as 17% long intramuscular course (>4 cm), 80% short intramuscular course (<4 cm) and 3% paramedian. In all 10 patients, DIEaP flaps were successfully elevated. In all cases the flaps were elevated on vessels identified in preoperative review of the CE-MRA. There was a significant difference in the rates of conversion from DIEaP to transverse rectus abdominis myocutaneous (TRAM) flaps in the group who underwent CE-MRA in comparison to historical controls from the previous year (P=0.025). CE-MRA is an effective tool for DIEaP flap planning.

Are routine preoperative CT scans necessary in the management of single suture craniosynostosis?

CT scanning is accepted as a regular component of the investigation of patients with simple craniosynostosis. In a series of 109 cases with simple craniosynostoses treated at Great Ormond Street Hospital for Children, a correct diagnosis on the basis of clinical findings was made in 100% of cases by an experienced clinician. CT scans with 3D reconstructions provided diagnostic confirmation in 100% of the patients when performed, but 91% of patients had already had sufficient confirmation of diagnosis by radiography. The clinical use of the scans for purposes other than diagnosis was examined. CT scanning in simple craniosynostosis in this series did not provide any additional clinical benefit as a screening method for the detection of intracranial abnormalities or for surgical planning. We propose that it may be appropriate to limit CT scanning, both axial images and three dimensional reconstructions, to selected cases where diagnostic uncertainty exists or where, it is used in surgical planning.

Tumescent steroid infiltration to reduce postoperative swelling after craniofacial surgery.

Steroids are often administered to paediatric craniomaxillofacial patients perioperatively to reduce postoperative facial swelling, although there is little evidence of their efficacy. Preoperative tumescent infiltration using 7 ml x kg(-1) of a solution consisting of 0.1 mg x ml(-1) triamcinolone acetate, 0.0125% bupivacaine, 0.025% lignocaine, 3 units x ml(-1) hyaluronidase and 1:1000000 adrenaline in Hartmann's solution was evaluated from a retrospective case controlled study of patients undergoing standard fronto-orbital remodelling for simple craniosynostosis (n = 20). Eye closure (i.e. inability to open the eyes) was used as a marker for severe facial swelling. Patients receiving the tumescent infiltration demonstrated significantly less eye closure (P < 0.005), implying that the tumescent infiltration had a significant effect on facial swelling. The avoidance of eye closure allowed more effective monitoring for neurological and ophthalmological complications, which is a significant clinical benefit. The infiltration solution has the advantage of a lower corticosteroid dose than previously reported dexamethasone-based perioperative regimens, thereby minimising any unwanted metabolic effects. The technique is advocated for the reduction of postoperative facial swelling in craniomaxillofacial surgical patients.

Setting standards for parenting--by what right?

Mental health professionals, like other professionals involved in family matters, feel constrained when advocating for the interests of children by the belief that parents are entitled to custody and control of their children's lives, regardless of what others may think of their parenting behavior, absent severe harm to the children. This belief is morally untenable, and the legal doctrine of parental rights that is its concrete embodiment is consistent with other well-established legal principles and should be abandoned. Children alone should have legal rights in connection with their upbringing, and those rights should include an entitlement to much higher standards of parenting than the law presently imposes.

The use of tissue-type plasminogen activator for acute myocardial infarction in the elderly: results from thrombolysis in myocardial infarction Phase I, open label studies and the Thrombolysis in Myocardial Infarction Phase II pilot study. The TIMI Investigators.

The impact of age on hospital mortality, incidence of major hemorrhagic events and transfusion requirements was examined in 756 patients with acute myocardial infarction enrolled in the Thrombolysis in Myocardial Infarction (TIMI) Phase I, open label studies and the TIMI Phase II pilot study. The mortality rate significantly increased with age and was 3.5%, 11.5% and 12% in patients less than 65, 65 to 69 and 70 to 76 years of age, respectively (p less than 0.001). Logistic regression analyses selected female gender, diabetes mellitus, extensive coronary artery disease, history of congestive heart failure, continuing chest pain immediately after recombinant tissue-type plasminogen activator (rt-PA) administration, low systolic blood pressure at the time of admission and advanced age as variables predictive of in-hospital death. The incidence of major hemorrhagic events among patients not undergoing cardiac surgery during hospitalization was 8.7%, 14.5% and 24.7% in patients aged less than 65, 65 to 69 and greater than or equal to 70 years, respectively (p less than 0.001). The majority of hemorrhages were secondary to cardiac catheterization or puncture wounds. Variables related to a major hemorrhagic event included protocol, age, rt-PA dose/kg body weight and elevated diastolic blood pressure on admission. Of five intracranial bleeding events, three occurred in patients greater than 65 years. Transfusion requirements significantly increased with age (p less than 0.001). Reperfusion status at 90 min in the TIMI Phase I and open label studies A to C was similar in the three age groups studied and ranged from 60% to 71%.(ABSTRACT TRUNCATED AT 250 WORDS)

Subcellular localization of a cytochrome P-450-dependent monogenase in vesicles of the higher plant Catharanthus roseus.

The intracellular location of a cytochrome P-450-dependent monoterpene hydroxylase from the higher plant, Catharanthus roseus, has been investigated. By differential and sucrose density gradient centrifugation, utilizing marker enzymes and electron microscopy, the monooxygenase was demonstrated to be associated with vesicles having a membrane thickness of 40-60 nm. The vesicles could be distinguished from endoplasmic reticulum, Golgi apparatus, mitochondria, and plasma membrane and were found in light membrane fractions containing provacuoles. Most definitive results were obtained when seedlings were ground in the presence of sand and in a medium containing sorbitol. Upon subjection of the 20,000-g pellet preparation to linear sucrose density gradient centrifugation, a threefold enrichment in hydroxylase activity was afforded in a yellow band having vesicles varying in size from 0.1 to 0.8 mum in diam and having a density of 1.09 to 1.10 g/cm3. Since the monooxygenase has been implicated in indole alkaloid biosynthesis in this plant, the data suggest the compartmentalization of at least a part of this pathway.