Two successful cases of DIEP flaps for breast reconstruction in patients with Factor V Leiden.

Factor V Leiden (FVL) is the most common inherited hypercoagulable condition. It is a genetic disorder caused by a missense mutation that prevents inactivation of Factor V in the clotting cascade, leading to overproduction of thrombin and excess clotting. This pathophysiological process is especially unfavorable in patients undergoing free tissue transfer. Many authors have noted a propensity for both venous and arterial thrombosis leading to partial or complete flap loss. To date, there have been no published reports of patients with FVL undergoing deep inferior epigastric perforator flap reconstruction without flap complications. Here, the authors present two cases of successful free tissue transfer for breast reconstruction in patients with diagnosed FVL. The perioperative thromboelastography lab values are evaluated to help guide anticoagulation regimen for these high-risk procedures.

Oculocardiac Reflex as a Late Presentation of Orbital Floor Fracture.

Delayed repair of orbital trapdoor fractures can jeopardize the viability of entrapped contents and prolong recovery. Variation in presentations, both clinically and radiographically, complicate prompt diagnosis. The oculocardiac reflex may be the only indication of fracture with entrapped orbital contents, but, unfortunately, the reflex has variable onset patterns and can mimic common diagnoses. Therefore, the authors present the case of a 14-year-old male with a right orbital floor fracture, who presented with delayed symptoms secondary to an oculocardiac reflex. The vagal sequelae of the reflex, including gastric hyperactivity and headache, were experienced approximately 1 week after the injury and caused the patient to be misdiagnosed with gastroenteritis and status migrainosus, on 2 separate hospital visits. After admission to the hospital due to progressive symptoms, a CT scan showed concerns for a subacute orbital blowout fracture. The patient underwent orbital floor exploration with findings of scarred orbital fat herniating into a healing fracture site. Repositioning of the fat into the orbit resulted in immediate resolution of the patient's symptoms. Awareness of the presenting characteristics of the oculocardiac reflex can lead to prompt diagnosis and maximize clinical outcomes.

Racial disparities in survival and age-related outcome in postsurgery breast cancer patients in a new york city community hospital.

Breast cancer survival has significantly improved over the past two decades. However, the diagnosis of breast cancer is lower and the mortality rate remains higher, in African American women (AA) compared to Caucasian-American women. The purpose of this investigation is to analyze postoperative events that may affect breast cancer survival. This is a retrospective analysis of prospectively collected data from The Brooklyn Hospital Center cancer registry from 1997 to 2010. Of the 1538 patients in the registry, 1226 are AA and 269 are Caucasian. The study was divided into two time periods, 1997-2004 (period A) and 2005-2010 (period B), in order to assess the effect of treatment outcomes on survival. During period A, 5-year survival probabilities of 75.37%, 74.53%, and 78.70% were seen among all patients, AA women and Caucasian women, respectively. These probabilities increased to 87.62%, 87.15% and 89.99% in period B. Improved survival in AA women may be attributed to the use of adjuvant chemotherapy, radiation, and hormonal therapy. Improved survival in Caucasian patients was attributed to the use of radiation therapy, as well as earlier detection resulting in more favorable tumor grades and pathological stages.

Wormian bones: a review.

Wormian bones are abnormal ossicles that develop from extra ossification centers within the cranium. They are most frequently located in the lambdoid suture or the coronal suture, and have been seen in the fontanelles, particularly the posterior fontanelle. It is unclear at this time exactly how or why they are formed, although genetic as well as environmental factors have been proposed. Their initial formation is thought to be caused by a degree of dural strain and increased sutural width. These conditions can result from mechanically induced stress due to intentional deformation like that practiced in ancient cultures, premature sutural closure, or from reduced skull ossification as seen in metabolic bone diseases. The cause of the malformation can have an influence on the number and location of Wormian bones. Clinically, Wormian bones are used as markers in the diagnoses of many autosomal dominant genetic disorders, namely, craniosynostosis and osteogenesis imperfecta.

Thinking beyond the obvious: hepatotoxicity secondary to idiosyncratic depakote toxicity.

Depakote-induced hepatotoxicity has been well established as an adverse effect, and periodic monitoring of drug level is often required. Depakote-induced hepatotoxicity mostly occurs at supratherapeutic drug level. Rarely, an idiosyncratic response is triggered, and hepatotoxicity can occur at the therapeutic drug level mostly in chronic users. Here, we describe a rare case of idiosyncratic depakote-induced hepatotoxicity. A 25-year-old female with non-insulin-dependent diabetes mellitus, hypothyroidism, seizure disorder, and Dandy Walker Syndrome presented with an unwitnessed seizure and altered mental status. The patient's medication list included zonisamide, depakote, and synthroid. She was noted to be lethargic, disoriented, nonverbal, but awake. An arterial blood gas examination showed severe anion gap metabolic acidosis. Blood work was consistent with hepatitis, hyperammonemia, thrombocytopenia, and coagulopathy. The Depakote level was therapeutic. Head computed tomography and liver ultrasound results were not significant. After ruling out all other causes and seeing improvement of parameters after the drug was discontinued, idiosyncratic depakote toxicity was diagnosed. Based on the patient's rapid improvement; idiosyncratic valproate toxicity was confirmed. This case signifies the importance of recognizing, diagnosing, and treating depakote toxicity in chronic users who have no other explanation for their symptomatology.

The history of mastectomy.

The mastectomy that is performed today is a procedure born from hundreds of years of discoveries, inventions, and amendments to existing surgical techniques. The reasons for performing this extreme surgery have changed as well, ranging from unilateral breast removal to allow greater upper limb functionality to bilateral removal of the breasts or breast tissue in individuals predisposed to breast cancer or in individuals who have already been diagnosed. The additions of surgical tools and anesthetics to the field of medicine further transformed the surgical field in general and had a large impact on the mastectomy. William Halsted's radical mastectomy served as the basis of most future breast removal techniques, and it the method recognized today as the "radical mastectomy." Most radical surgeries are currently used for prophylaxis, whereas less invasive lumpectomies have eclipsed breast removal surgeries as of the latter half of the 20th century.