Reconstructive strategies in soft tissue reconstruction after resection of spinal neoplasms.

STUDY DESIGN: A retrospective study of 134 consecutive cases in 92 patients who underwent soft tissue reconstruction of the spinal region following tumor removal. OBJECTIVE: To better understand how to optimize outcomes in soft tissue reconstruction of the spine region. SUMMARY OF BACKGROUND DATA: With the increasing use of instrumentation and the fact that many patients with spinal neoplasms have debilitated wound-healing capacity, most of these patients are at high risk for postsurgical wound complications. Unfortunately, the optimal strategy to prevent and to manage complex wound complications involving the spinal region remains unclear. METHODS: Factors potentially associated with the outcome of the reconstruction, including previous radiation therapy, chemotherapy, or surgery; medical comorbidities; timing of the reconstructive surgery; location of the defect; reconstructive approach; and presence of instrumentation, were evaluated and compared. RESULTS: Of 92 patients, 29 patients (32%) developed postoperative wound complications. Among 32 patients with instrumentation of the spine, the 10 patients who had prophylactic soft tissue reconstruction had a significantly lower incidence of complications than did the 22 patients who had not (20% vs. 45%, P = 0.018). Furthermore, those who had previous surgery to the spine had a significantly higher risk of developing exposed instrumentation than did those who did not (21% vs. 0%, P = 0.002). Of 9 patients with exposed instrumentation, all but 1 patient had successful coverage of the instrumentation. Ninety (98%) of 92 patients had successful closure of the wound at the time of their last follow-up. CONCLUSIONS: In the presence of instrumentation, providing preemptive soft tissue reconstruction at the time of the initial spinal surgery can help minimize potentially serious wound complications. For management of wound complications that have developed, an aggressive debridement and coverage with well-vascularized tissue can allow for expedient wound healing while maintaining stabilized instrumentation.

Quality of diabetes care in primary care setting in egypt: an example of health sector reform in developing countries.

The aim of this study was to evaluate the extent of provider adherence to evidence-based guidelines for diabetes care and the extent of glycemic, blood pressure, and lipid control in patients with diabetes in a developing country. A retrospective cohort study was carried out to evaluate diabetes care provided under Health Sector Reform Program (HSRP) in a major medical center in Alexandria, Egypt. Data on care provided for 137 patients were abstracted from medical records. Several process measures were studied including annual proportion of patients with measurements of blood glucose, blood pressure, and lipid levels. Patient outcomes on these measures were also examined. Logistic and poisson regressions were used to study factors related to having measurements done and number of measurements respectively. Multilevel analysis was then used to examine rate of change in patient outcomes and factors associated with this rate over one year of follow-up. For 137 patients with diabetes, annual testing was adequate for fasting blood glucose (FBG) (94.1%), blood pressure (100%), foot (92.7%), and fundus examination (86.6%) was adequate. On the other hand less attention was given to total cholesterol (60.6%), triglycerides (52.6%) and albuminuria (10.3%). At the end of 1 year follow-up, 89.2% did not meet the target level of fasting blood glucose of < 130 mg/dl. A total of 40.2% and 46.7% did not meet the goal of 130 mmHg for systolic and 80 mmHg for diastolic blood pressure. Fifty nine percent, and 76.4% did not meet the goal of total cholesterol level of <200 mg/dl, or triglycerides level of <150 mg /dl respectively. There was evidence of suboptimal treatment with insulin, antihypertensive drugs, and lipid- lowering drugs. This study demonstrates that diabetes care provided under HSRP is unsatisfactory. As a result more effort to increase compliance with evidence based guidelines in diabetes care is needed.

Patient preference for providers' gender at a primary health care setting in Alexandria, Egypt.

OBJECTIVE: The aim of this study is to determine patient's gender preferences in choosing general practitioners and specialists for both general and specific health issues at primary health care centers in Alexandria, Egypt. METHODS: A descriptive cross-sectional study was conducted at Smouha Health Center, Alexandria Governorate, Alexandria, Egypt. The study was conducted between the period January -- March 2004. A pre-designed questionnaire was used. The format included 3 main sections, namely, socio-demographic, beliefs towards provider's gender, and providers' preferences of patients. RESULTS: Both male and female patients preferred a male physician for consultation and clinical management of cases. The highest percentage of male patients (81.4%) and female patients (41.0%) preferred physician of the same gender, and such preference was of personal reasons for males (97.9%) and females (96.6%), while basing on traditions and norms for male (62.9%) and female (63.4%). Significant results of the stepwise logistic regression analysis in relation to socio-demographic factors on provider preference revealed that job and income were the significant determinants of gender preference for the sample under study. CONCLUSION: Patients prefer physicians of the same gender, but in actual practice a male physician is believed to be more competent.

Women health in poor urban settings in Alexandria.

The aim of this paper is to investigate women health and status as well as to study gender gap in three poor urban settings in Alexandria. Poor families were identified and invited to participate in the study through the help of local informants. The study included 172 families, 53 from Abu-Kir, 57 from El-Dahreya and 62 from Wadi El-Kamar area. An interviewing questionnaire was used to collect data form the wives as well as their husbands about household family members. Wives and husbands who participated in the study were clinically examined. Their weight and height were measured. For those who accepted to participate, stool, urine and blood analyses were performed. Female to male comparison as well as sex ratio of some parameters were used to investigate gender gap. Results showed that females were the head of the family in 19.8% of the families. In 18% of the families, wives participated in the family income. Illiteracy represented 94.2% among females aged 45+ years, and unemployment was 97.4%. The rate of ill health increased with age from 36% for girls to 90% among older women (45+) compared to 71% among older males. Cardiovascular and orthopedic disorders represented the most reported problems among older females and males. Diarrhea and ARI episodes were rather more frequent among females than among males. About 60% of examined women suffered from obesity, 45% had gynecological problems, 38% had parasitic infections in stool, and 45% had anemia. Female to male sex ratio was low for <6 and 60+ years old. In conclusion, poor women suffer from high burden of socio-economic disadvantage, gender inequality and ill-health.

Risk factors of puerperal sepsis in Alexandria.

Puerperal infections are an important cause of maternal morbidity and mortality in developing nations. Investigators have noted several risk factors for developing puerperal sepsis. However, the relative importance of these risk factors varies and has to be determined for each setting. Therefore the aim of the present work was to determine the risk factors for puerperal sepsis in Alexandria, Egypt. A case-control design was used to study the risk factors of puerperal sepsis in Alexandria. The study included 160 puerperal sepsis cases and 160 controls. Puerperal sepsis cases were recruited from the fever hospital as well as from 3 rural health units and three urban health offices in Alexandria. A pre-designed interviewing questionnaire was used to collect data about risk factors of puerperal sepsis. Logistic regression analysis indicated that very low socio-economic score (OR = 6.4), no ANC (OR = 4.5), delivery at a governmental maternity hospital (OR = 203.4), frequent vaginal examinations (OR = 5.1), anemia during puerperium (OR = 4.3), unsanitary vaginal douching during puerperium (OR = 19.9) and unhygienic preparation of diapers used immediately after delivery (OR = 12.1) were significantly related to the occurrence of puerperal sepsis. Improving infection control measures during delivery, limiting the frequency of vaginal examinations, and avoiding all unhygienic practices related to delivery are strongly recommended.

Breast reconstruction in older women: advantages of autogenous tissue.

As the population ages, the treatment of breast cancer among elderly women is becoming increasingly common. Decisions with regard to breast reconstruction require not only consideration of patient age and comorbidities but also a need to balance life expectancy with quality of life. Although it is often assumed that implant-based breast reconstruction is the least disruptive method, especially among patients who may be facing limited survival times, it was hypothesized that autogenous tissue breast reconstruction is a well-tolerated and perhaps preferable means of reconstruction for older women who choose to undergo reconstruction following mastectomy. No large series of autogenous tissue reconstructions in this age group has been presented. A retrospective study of 84 postmastectomy reconstructions (66 unilateral and 18 bilateral; 78.6 percent immediate) performed at the authors' institution for 81 women 65 years of age or older, between April of 1987 and December of 2000, was undertaken. Reconstructions were implant-based ( = 26), latissimus dorsi flap-based ( = 24), or transverse rectus abdominis myocutaneous (TRAM) flap-based ( = 34). Of the 34 TRAM flaps, 21 were free or supercharged. Breast complications were more frequent ( < 0.05) among recipients of implant-based reconstructions (76.9 percent) than among recipients of latissimus dorsi flap (41.7 percent) or TRAM flap (35.3 percent) reconstructions. In multivariate logistic regression analyses, comorbidities, smoking, radiotherapy, and body mass index had no effect. Medical complications without long-term sequelae were observed for two patients who underwent latissimus dorsi flap reconstructions and two patients who underwent free TRAM flap reconstructions; the difference in the rates of medical complications was not significant. At the mean follow-up time of 4.2 years, 92.8 percent of all study patients exhibited no evidence of disease. Notably, despite being free of disease, seven of the 26 patients (27 percent) who underwent implant-based reconstructions abandoned further reconstructive efforts after complications necessitated implant removal. It was concluded that age alone should not determine the type of breast reconstruction and that autogenous tissue breast reconstruction can be a safe successful alternative for women 65 years of age or older.

Cavernous nerve reconstruction to preserve erectile function following non-nerve-sparing radical retropubic prostatectomy: a prospective study.

Erectile dysfunction following radical prostatectomy for treatment of clinically localized prostate cancer remains a problem that deters many men from seeking surgical treatment. Sparing the cavernous nerves has been popularized as a method of preserving potency, but men with locally advanced disease may be at increased risk for positive margins with this technique. In this study, sural nerve grafting of the cavernous nerve bundles, to preserve postoperative potency while potentially maximizing cancer control, was examined. Thirty men were enrolled in this prospective phase I study and underwent non-nerve-sparing radical prostatectomy performed by one of two protocol surgeons. Preoperative erectile function was assessed both objectively, using a RigiScan (Timm Medical Technologies, Inc., Eden Prairie, Minn.), and subjectively. The cavernous nerves were identified and resected during the operation with the use of an intraoperative mapping device (CaverMap; Alliant Medical Technologies, Norwood, Mass.). Bilateral autologous sural nerve grafting to the cavernous nerve stumps was performed by one of two protocol plastic surgeons. Postoperative erectile dysfunction therapy, using intracorporeal injection, a vacuum pump, and/or oral sildenafil therapy, was instituted 6 weeks after the operation. Spontaneous erectile activity was subjectively and objectively measured every 3 months after the operation. Follow-up periods ranged from 13 to 33 months (mean, 23 months). Overall, 18 of 30 patients (60 percent) demonstrated both objective and subjective evidence of spontaneous erectile activity. Of those 18 men, 13 (72 percent) were able to have intercourse (seven unassisted and six with the aid of sildenafil). No disease or biochemical recurrences have been noted in this group of patients with locally advanced disease. In conclusion, autologous sural nerve grafting after non-nerve-sparing radical prostatectomy is an effective means of preserving spontaneous erectile activity after the operation while maximizing cancer control potential.

Time-course of adiposity and fasting insulin from childhood to young adulthood in offspring of parents with coronary artery disease: the Bogalusa Heart Study.

PURPOSE: Obesity and the attendant insulin resistance/hyperinsulinemia related to coronary artery disease (CAD) morbidity and mortality are well documented. However, information is lacking on the time-course relation of adiposity and fasting insulin from childhood to young adulthood in offspring of parents with CAD, a surrogate measure of future risk. METHODS: Longitudinal analysis was performed on data collected from the Bogalusa Heart Study cohort with (n = 271) and without (n = 805) a parental history of CAD followed since childhood by repeated surveys from 1973 to 1991. RESULTS: Lowess smoothing and multivariate analyses using Generalized Estimating Equations revealed that body mass index, triceps, and subscapular skinfolds were consistently higher from childhood to adulthood in offspring of parents with CAD history. Insulin levels during childhood and adolescence were lower in the offspring with affected parents. On the other hand, higher levels of fasting insulin from offspring were associated with positive parental history of CAD after age 20 and this association remained significant even after adjusting for body mass index. There was no significant interaction with race or sex in these relationships. CONCLUSION: These results indicate that the offspring at high risk for CAD develop excess body fatness beginning in childhood and then later manifest hyperinsulinemia in young adulthood. These observations have important implications for prevention.

Analysis of pharyngocutaneous fistula following free jejunal transfer for total laryngopharyngectomy.

The development of a pharyngocutaneous fistula is the most common and troublesome complication in the early postoperative period following free jejunal transfer for total laryngopharyngectomy. However, many aspects of this complication remain unclear. In this study, the authors analyzed their experience with the pharyngocutaneous fistula formation following free jejunal transfers to evaluate its clinical behavior, determine the significance of the anastomotic technique used, and evaluate the role of preoperative radiation therapy on its formation and management. Of 168 patients who underwent free jejunal transfers following total laryngopharyngectomy at the authors' institution between July of 1988 and March of 2000, 23 patients (13.7 percent) with postoperative fistulas were identified. The mean onset of fistula formation was 16 days. Of the 23 fistulas, 13 (56.5 percent) occurred at the proximal and 10 (43.5 percent) at the distal anastomoses. Whereas the majority of the proximal fistulas (69.2 percent) developed near the mesenteric side of the jejunal flap, most of the distal fistulas (90 percent) were located anteriorly. The incidence of proximal fistula formation was higher in patients with a single-layer repair than in patients with a two-layer repair of a proximal anastomosis (80 percent versus 38.5 percent, p = 0.09). The incidence of fistula formation was greater in patients who received preoperative radiation therapy than in those who did not (16.3 percent versus 11.4 percent, p = 0.36). In addition, whereas a majority of fistulas (80 percent) occurred at the proximal anastomosis in patients who did not receive preoperative radiation therapy, most fistulas (61.5 percent) occurred at the distal anastomosis in patients who did receive radiation therapy (p = 0.09). The fistulas closed spontaneously in 15 patients (65 percent). On average, spontaneous closure occurred in 7.4 weeks. Proximal fistulas had a significantly higher rate of spontaneous closure compared with distal fistulas (85 percent versus 40 percent, p = 0.04). The rate of spontaneous fistula closure was higher in patients who had not received preoperative radiation therapy than in those who had (90 percent versus 46 percent, p = 0.07). Surgical closure of the fistula was required in five patients. The fistulas were not repaired in three patients because of recurrent tumor. Twenty patients (87 percent) resumed oral feeding after the closure of the fistula, with 17 (85 percent) of 20 patients tolerating a regular diet and three (15 percent) of 20 a liquid diet only.In conclusion, most fistulas occur at the proximal anastomosis and near the mesenteric side of the jejunal flap, and the use of a two-layer anastomotic technique seems to be associated with a lower incidence of fistula formation at the proximal suture line. Most fistulas close spontaneously, especially ones that occur proximally. Preoperative radiotherapy does seem to increase the risk of fistula formation, especially at the distal anastomotic site and make subsequent resolution of the fistulas more difficult. Most patients are able to resume oral feeding once the fistula is closed.

Quantification of vascular density using a semiautomated technique for immunostained specimens.

OBJECTIVE: To develop a semiautomated, quantitative techniquefor the assessment of vascular density in immunohistochemically stained tissue sections using diaminobenzidine tetrahydrochloride (DAB) and hematoxylin as chromagens. STUDY DESIGN: A semiautomated thresholding technique was developed to quantitate vascular density in tissue sections stained with anti-CD31 (1 degrees antibody). The immunohistochemically stained specimens were digitally imaged using a 24-bit color camera. The blue component of the RGB image was segmented using a variable high-pass filter. After thresholding, the segmented areas (CD31 positive) were quantified and vascular density determined. The validity of the method was verified by calculating the precision of the technique using the coefficient of repeatability and by quantifying its agreement with manual analysis according to the Bland-Altman approach. RESULTS: Vascular endothelial cells were specifically selected using anti-CD31 as the primary antibody and the appropriate horseradish peroxidase-conjugated secondary antibody. Utilizing the semiautomated thresholding technique, the separation of DAB-stained tissuefrom non-DAB-stained tissue was achieved. The method developed possesses a low coefficient of repeatability (0.49%), agrees well with manual assessment (mean difference = -0.29 +/- 0.92%), is highly automated and is user friendly. CONCLUSION: A novel semiautomated technique for the quantification of vascular density was developed. This technique provides a method for reproducible measurement of immunostaining procedures (immunohistochemistry, immunocytochemistry and in situ hybridization) utilizing immunoperoxidase techniques with DAB as a chromagen.