Insulin Secretion Predicts the Response to Antidiabetic Therapy in Patients With New-onset Diabetes.

CONTEXT: The results of the present study demonstrate that beta cell function in newly diagnosed T2DM patients is the key predictor of response to glucose lowering medications and provides a practical tool (C-Pep120 /C-Pep0) to guide the choice of glucose lowering agent. OBJECTIVE: This work aims to identify predictors for individualization of antidiabetic therapy in patients with new-onset type 2 diabetes mellitus (T2DM). METHODS: A total of 261 drug-naive participants in the Efficacy and Durability of Initial Combination Therapy for Type 2 Diabetes (EDICT) study, with new-onset diabetes, were randomly assigned in a single-center study to receive 1) metformin followed by glipizide and then insulin glargine on failure to achieve glycated hemoglobin A1c (HbA1c) less than 6.5%, or 2) initial triple therapy with metformin/pioglitazone/exenatide. Each patient received a 75-g oral glucose tolerance test (OGTT) prior to start of therapy. Factors that predicted response to therapy were identified using the area under the receiver operating characteristic curve method. RESULTS: Thirty-nine patients started and maintained the treatment goal (HbA1c < 6.5%) on metformin only, and did not require intensification of antihyperglycemic therapy; 54 patients required addition of glipizide to metformin; and 47 patients required insulin addition to metformin plus glipizide for glucose control. The plasma C-peptide concentration (C-Pep)120/C-Pep0 ratio during the OGTT was the strongest predictor of response to therapy. Patients with a ratio less than 1.78 were more likely to require insulin for glucose control, whereas patients with a ratio greater than 2.65 were more likely to achieve glucose control with metformin monotherapy. In patients started on initial triple therapy, the HbA1c decreased independently of the C-Pep120/C-Pep0 ratio. CONCLUSION: The increase in C-Pep above fasting following glucose load predicts the response to antihyperglycemic therapy in patients with new-onset diabetes. C-Pep120/C-Pep0 provides a useful tool for the individualization of antihyperglycemic therapy in patients with new-onset T2DM.

The Subtleties of Success in Simultaneous Augmentation-Mastopexy.

BACKGROUND: Many have challenged the safety of performing breast augmentation and mastopexy simultaneously. However, staging these procedures incurs the increased risk and inconvenience of two periods of anesthesia and recuperation. The authors set out to evaluate the occurrence of complications across the populations of patients undergoing (1) combined augmentation-mastopexy, (2) isolated augmentation, and (3) isolated mastopexy. METHODS: A retrospective analysis of one surgeon's consecutive series of each of these procedures from 2000 to 2009 was conducted. Preoperative risk factors were characterized. Sixteen different complications were examined, and those necessitating operative revision were tracked. Statistical analysis was performed looking for significant differences between the surgical groups. RESULTS: No instances of infection, tissue loss, or implant exposure occurred among the 297 patients over an average follow-up period of 15.5 months. The isolated mastopexy group did not provide sufficient data for statistical comparison. Tissue-related complications were most common in the combined procedure group. The operative revision rate for isolated augmentation was 7.97 percent compared with a combined procedure revision rate of 12.4 percent (p = 0.28). CONCLUSIONS: The majority of complications in this series comparing simultaneous augmentation-mastopexy to isolated augmentation were minor. Complications requiring operative revision were not found to be significantly different between the two groups. There was a much lower reoperation rate (12.4 percent) with the combined procedure compared with a 100 percent reoperation rate when the procedure is staged. Thus, the authors feel the combined procedure can safely be part of every plastic surgeon's practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Initial combination therapy with metformin, pioglitazone and exenatide is more effective than sequential add-on therapy in subjects with new-onset diabetes. Results from the Efficacy and Durability of Initial Combination Therapy for Type 2 Diabetes (EDICT): a randomized trial.

AIM: To test our hypothesis that initiating therapy with a combination of agents known to improve insulin secretion and insulin sensitivity in subjects with new-onset diabetes would produce greater, more durable reduction in glycated haemoglobin (HbA1c) levels, while avoiding hypoglycaemia and weight gain, compared with sequential addition of agents that lower plasma glucose but do not correct established pathophysiological abnormalities. METHODS: Drug-naïve, recently diagnosed subjects with type 2 diabetes mellitus (T2DM) were randomized in an open-fashion design in a single-centre study to metformin/pioglitazone/exenatide (triple therapy; n = 106) or an escalating dose of metformin followed by sequential addition of sulfonylurea and glargine insulin (conventional therapy; n = 115) to maintain HbA1c levels at <6.5% for 2 years. RESULTS: Participants receiving triple therapy experienced a significantly greater reduction in HbA1c level than those receiving conventional therapy (5.95 vs. 6.50%; p < 0.001). Despite lower HbA1c values, participants receiving triple therapy experienced a 7.5-fold lower rate of hypoglycaemia compared with participants receiving conventional therapy. Participants receiving triple therapy experienced a mean weight loss of 1.2 kg versus a mean weight gain of 4.1 kg (p < 0.01) in those receiving conventional therapy. CONCLUSION: The results of this exploratory study show that combination therapy with metformin/pioglitazone/exenatide in patients with newly diagnosed T2DM is more effective and results in fewer hypoglycaemic events than sequential add-on therapy with metformin, sulfonylurea and then basal insulin.

The incidence of recurrence after endoscopic carpal tunnel release.

Endoscopic carpal tunnel release has been used to decompress the median nerve in carpal tunnel syndrome for over the past decade, with an advantage (over the traditional "open" release) being decreased pain in the postoperative period. The goals of this study were to attempt to define the recurrence rate after endoscopic carpal tunnel release and to determine if it differs from that of open technique. The charts of 191 consecutive carpal tunnel syndrome patients treated operatively at the University of Missouri were reviewed. For this study, recurrent carpal tunnel syndrome was defined as documented cases in which the symptoms had resolved following surgical release but subsequently recurred, requiring surgical rerelease of the carpal tunnel. All endoscopic releases were performed using the Chow two-portal technique. Statistical analysis was performed using Fisher's exact test. A total of 103 patient hands had open carpal tunnel releases; 88 were endoscopically released. Total follow-up time (from the initial release) averaged 29 months for the open group and 22 months for the endoscopic group. There were no recurrences in the open group and six recurrences in the endoscopic group (7 percent, p = 0.008). All six recurrences were in worker's compensation patients. The median time between endoscopic release and rerelease was 8.5 months. There seems to be a statistically higher incidence of recurrence of carpal tunnel syndrome after endoscopic release compared with the traditional "open" release in our cases. Although the pathogenesis of this increased rate of recurrence is not clear, this should be considered when planning surgical release of the volar carpal ligament for carpal tunnel syndrome.

In search of the ideal female umbilicus.

The umbilicus is essential to the aesthetic appearance of the abdomen. However, little research exists on what characterizes an aesthetically pleasing umbilicus. Often, the plastic surgeon is called on to reconstruct the umbilicus. Although a variety of reconstructive methods are available, no real standards define the appearance of an aesthetically pleasing umbilicus. To ascertain the characteristics of an aesthetically pleasing umbilicus, a photographic analysis was undertaken using 147 female participants between the ages of 18 and 62 years. Each subject's age, height, and weight were recorded. Photographs of each participant's umbilicus were then taken from 30 cm and 50 cm away. The photographs were reviewed by the authors, and each umbilicus was categorized on the basis of size, shape, hooding, or protrusion. The photographs were then reviewed by a panel and given a score between 1 and 10 to rate attractiveness. Using linear regression analysis, the effects of body mass index, shape, hooding, and umbilical protrusion on attractiveness were assessed. The T- or vertically shaped umbilicus with superior hooding consistently scored the highest in aesthetic appeal, whereas the presence of any degree of protrusion and a horizontal orientation or distorted shape detracted from the score. Those with a large umbilicus tended to score consistently lower than those with a smaller configuration. A desirable goal in umbilical reconstruction is, thus, to create a small T or vertically oriented umbilicus with the addition of a superior hood or shelf.

Digital images in the diagnosis of wound healing problems.

The use of digital wound images could allow remote consultation among patients, physicians, or other care-givers located at quite distant sites by means of the Internet. To evaluate the efficacy and validity of digital images for the evaluation of wounds, the ability and reliability of surgeons to diagnose and make treatment suggestions using digital images of several types of wounds were compared. Twenty-four wound images on 35-mm slides were selected for use in this study. Each slide image was digitized at 24-bit color with a resolution of 640 pixels horizontal by 425 pixels vertical and stored as a JPEG file. These images were then presented as a slide show on a video monitor, with resolution set at 640 x 480. Six physicians examined the images, first in digital format and later in the original slide form. Each observer assessed each wound and possible treatment options by filling out a questionnaire using a series of yes/no questions. For all observers, there was an 87 percent agreement between digital and slide images (p = 0.004). The agreement between the digital and slide images was measured for each individual observer using a kappa coefficient. The agreement level corresponded to the experience of the observer, with the kappa values ranging from greater than 0.8 (almost perfect agreement) for the attending plastic surgeon to just greater than 0.5 (moderate agreement) for the intern. With this study, the feasibility of distance wound consultation using digital images of a quality consistent with consumer-grade digital photography was demonstrated.

The antibacterial effects of tumescent liposuction fluid.

Tumescent liposuction is currently one of the most commonly performed aesthetic procedures. Despite the variable use of preoperative antibiotics, infection is uncommon. Prior works suggest that the low incidence of infection may be due to lidocaine's antibacterial properties. However, these properties have only been demonstrated using concentrations of lidocaine above 0.8%, significantly higher than those used in tumescent liposuction. The purpose of this study was to determine if the commonly used tumescent fluid containing 0.1% lidocaine, 1:1000,000 epinephrine, and 0.012 mEq sodium bicarbonate possesses antibacterial activity. Using the broth microdilution method, the minimum inhibitory concentrations of Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, and Group A beta-hemolytic Streptococcus were determined after exposure to either lidocaine, epinephrine, bicarbonate, or the combination of all three agents. To determine if there were significant growth differences not detectable by the broth microdilution method, bacterial concentrations were obtained through the use of a spectrophotometer, and significant differences from the controls were calculated by one-way analysis of variance. To determine if prolonged exposure to the tumescent mix would alter bacterial growth, a Killing Time study was also undertaken. The results indicated that the minimum inhibitory concentration of lidocaine was not less than 0.5% for any of the bacteria, whereas the lowest minimum inhibitory concentration of the combined solution was 0.25%. The lowest inhibitory concentration as determined by spectrophotometric analysis for the combined solution was 0.13% (p < 0.01). Analysis of the Killing Time data revealed no inhibition of bacterial growth over time. In conclusion, lidocaine, epinephrine, and bicarbonate do exhibit antibacterial properties at high concentrations. However, the commonly used tumescent mixture containing dilute concentrations of these agents does not significantly inhibit the growth of commonly encountered bacteria.

Microsurgical replantation of an ear in a child without venous repair.

Ear amputation can leave a devastating deformity; the application of microsurgical replantation techniques has allowed very favorable aesthetic outcomes when successful. We report a case of ear replantation in a child in whom a venous repair was not performed; instead medicinal leeches were used to decompress the ear in the immediate postoperative setting. This represents the third reported case of successful ear replantation without microsurgical venous anastomosis. A review of the literature reveals the high incidence of venous congestion requiring external decompression (57 percent) and the very high rate of salvage (80 percent) after replantation. Surgeons attempting ear replantation should be aware of the high rate of ear survival in the situation of no venous outflow (with appropriate decompression techniques) and should not abandon attempts at replantation because of the inability to establish venous outflow microsurgically.

Wound coverage using modified tissue expansion.

We describe the use of a "lacing apparatus" across large and complex wounds to accomplish wound closure. This technique utilizes the principles of tissue expansion (exploiting inherent extensibility of the skin, mechanical creep, and biologic creep) but is able to employ them in situations in which traditional tissue expansion (utilizing implantable expanders) is not practical. After preparation, the wounds are laced with large nylon suture, which is tightened on a daily basis, typically allowing closure of even massive wounds within 8 to 10 days. In this report, we describe the technical details of wound preparation, application of the lacing apparatus, and postoperative execution of the expansion leading to final wound closure. This technique is particularly valuable in the upper arm, trunk, and lower extremity but has limited application in the distal forearm and the distal third of the lower extremity.

Tumescent infusion for liposuction: a practical method and pressure delivery system.

To facilitate tumescent liposuction, a pressure infusion technique is necessary. We have devised a new technique for anesthetic solution infusion-a pressure infusion bag along with an automatic low-pressure tourniquet pump-that can generate sustained and significant volume infusion. This system is readily available, requires a minimal capital outlay, and is economically advantageous to our patients.

The predictive value of electrodiagnostic studies in carpal tunnel syndrome.

In recent years, electrodiagnostic studies have become an expected component in the work up and evaluation of carpal tunnel syndrome. We conducted a retrospective review of 460 carpal tunnel decompressions to determine whether the accuracy of diagnosis and the prediction of therapeutic outcome could be related to the positivity and severity of findings on preoperative electrical studies. The 349 patients (460 hands) were divided into two groups: group 1 consisted of hands with the clinical diagnosis of carpal tunnel syndrome but with normal electrodiagnostic studies (n = 62); in group 2 the hands had a clinical diagnosis of carpal tunnel syndrome with confirmatory electrodiagnostic studies (n = 398). The number and distribution of signs and symptoms of carpal tunnel syndrome were not statistically different between these two groups. There was not a statistically significant difference in the success rate of surgery or the incidence of complications. The similarities between these two groups suggests that the distinction between them (the positivity of electrodiagnostic studies) is an artificial one and that the clinical diagnosis of carpal tunnel syndrome is sufficient to predict the presence of the disease, as well as outcome of surgery. On the basis of these data, strict adherence to electrodiagnostic studies to confirm the diagnosis will exclude 13 percent of the patients with legitimate carpal tunnel syndrome from receiving appropriate therapy.

Bone induction using demineralized bone in the rabbit femur: a long-term study.

While traditional bone grafting is the standard for replacement of segmental bony defects, alternative options (avoiding morbidity of autologous grafts) are attractive and continue to be sought. This study attempted to determine whether demineralized bone powder could be used reliably to replace a significant bony deficit at a weight-bearing site. The long-term functional characteristics of this induced bone were analyzed to determine whether it maintained its strength and shape and reacted normally to physiologic stress over an extended period of time (12 months). In 55 New Zealand White rabbits, a 1-cm length of femur was removed (approximately 20 percent of the total length of the rabbit femur). The femur was then reconstructed with a titanium mandibular plate, leaving the gap intact. In 38 of the animals, this gap was filled with demineralized bone powder in an attempt to induce bone to form across the defect. In group 1 (n = 23), the mandibular plate remained in place for the duration of the study (12 months). In group 2 (n = 15), the plate was removed 8 weeks after placement of the demineralized bone powder, and the animals were followed for an additional 12 months. In group 3 (n = 10), nothing was placed within the bony gap. In group 4 (n = 7), the gap was repaired with autologous bone graft. All the animals that received demineralized bone powder completely filled the osteotomy gap with new bone within 6 to 8 weeks after implantation. None of control group 3 formed bone across the gap (p < 0.001). Eighty-six percent of control group 4 (autologous bone graft) successfully formed bone across the osteotomy gap. In addition, 90 percent of control group 3 had hardware failure within 8 weeks after surgery compared with 0 percent (0 of 38) of the group that received demineralized bone powder (p < 0.001). In group 1, analysis after 12 months revealed that the bone formed ultimately became thin and easily fractured, most likely because of shielding from stress loading by the mandibular plate. In contrast, in group 2 (in which the plate was removed after 8 weeks), the bone remodeled and hypertrophied in response to the physiologic stress of weight bearing and at the end of the 12-month period was essentially identical to normal femur. In certain circumstances, reconstruction of bony defects using bone-induction techniques may be as good as autologous bone grafting, with the advantage of limiting the donor-site morbidity for the patient.

Outcome analysis of reduction mammaplasty.

In an attempt to obtain objective analysis of outcome in reduction mammaplasty patients, a retrospective study was done for women having elective bilateral reduction mammaplasty. Participants were chosen from a pool of over 200 consecutive reduction mammaplasty patients at the University of Missouri-Columbia. Of those eligible for inclusion, 72 met the criteria and were available for long-term follow-up. These patients answered a panel of questions regarding weight change, brassiere size, exercise, activity level, symptoms, and a personal appraisal of appearance. Statistical analysis was done to evaluate the change in each variable in relationship to the time of surgery, i.e., before surgery, 6 months after surgery, and at the present time. The findings revealed a significant stable reduction of breast mass. The women reported a significant reduction of symptoms that had been associated with their macromastia. They also reported a significant increase in exercise and other physical and social activities.