The transversus and rectus abdominis musculoperitoneal (TRAMP) composite flap for vulvovaginal reconstruction

The transversus and rectus abdominis musculoperitoneal (TRAMP) flap, a novel composite flap supplied by the deep inferior epigastric vessels, was used successfully for partial vulvovaginal reconstruction following anterior and posterior exenteration. The full potential of the TRAMP flap in vulvovaginal reconstruction is being investigated further.     

Modifications of the paraspinous muscle flap: anatomy and clinical application

Soft-tissue defects of the back, particularly involving the paravertebral tissues, are generally covered with myocutaneous, muscle, or fasciocutaneous flaps. The case of a 64-year-old man with a paravertebral malignant fibrous histiocytoma is reported. To ensure adequately radical margins, the ipsilateral trapezius and latissimus dorsi muscles as well as the costal periosteum and the spinous processes were resected between T9 and T12. The resulting defect was covered with a pedicled latissimus dorsi flap and an island flap of the paravertebral muscles. Prompted by this case, we studied the blood supply of the paravertebral muscles in 10 cadavers. The vasculature was visualized after flushing with colored latex and microsurgical dissection. Another 4 specimens were subjected to angiography and tomography. In the majority of cases (8 of 10), three perforators emerging from the intercostal arteries were identified. These were found to communicate in a longitudinal and vertical direction. Before piercing the fascia, they ramified in three layers matching the layers of the paravertebral muscles. Since the intercostal arteries were shown to communicate through anastomoses of adequate caliber, the paravertebral muscles appear to be useful candidates for proximally or distally pedicled transposition or island flaps.     

A modification of the bladder flap of Boari for the management of defects of the distal ureter (author's transl)

The results of the management of defects of the distal ureter of various causes with a bladder flap of Boari including the anti-reflux implantation of the ureter in 65 patients are reported. 50 patients had prior gynaecological operations. The other 15 patients had prior urological operation, inflammations (tuberculosis), tumors or anomalies of the ureter. The follow-up time ranges from a few weeks to five years and 80-90% of the patients were cured. 24 of these patients had prior malignant tumors.     

Primary muscle lymphoma: clinical and imaging findings

PURPOSE: To assess the clinical and imaging findings in primary muscle lymphoma. MATERIALS AND METHODS: Seven patients with biopsy-proved primary muscle lymphoma without evidence of systemic disease underwent imaging with plain radiography or computed tomography (CT) and magnetic resonance (MR) imaging. Four underwent bone scintigraphy, and two underwent gallium scintigraphy and fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) before and after therapy. RESULTS: Plain radiographs at initial examination (n = 5) showed no bone abnormalities. Soft-tissue masses and bone marrow involvement showed isoattenuation at CT (n = 3), but at MR imaging (n = 7), all masses demonstrated increased signal intensity on T2-weighted images that involved multiple muscle compartments and typically spanned a long segment of the extremity. Adjacent bone disease was less extensive than muscle disease, and, in most cases, subcutaneous stranding or extension was observed adjacent to the masses. Good size correlation was observed between findings at MR imaging, gallium scintigraphy, and FDG PET. Two patients developed recurrent multifocal muscle lymphoma several years after initial examination. CONCLUSION: The presence of an extensive soft-tissue mass with infiltration of adjacent subcutaneous fat and minimal or no extension into the bone marrow cavity at MR imaging and normal plain radiographic findings may suggest primary muscle lymphoma.     

Müllerianosis of the urinary bladder: clinical and immunohistochemical findings

BACKGROUND: Intranasal desmopressin has been used extensively to treat primary nocturnal enuresis. While it has proven to be a safe, effective agent for many who are affected by this condition, the potential for complications exists. OBJECTIVES: To report a case of severe hyponatremia associated with a generalized tonic-clonic seizure in a 10-year-old boy who had been receiving intranasal desmopressin nightly for nocturnal enuresis and to briefly review therapeutic options for nocturnal enuresis; and to present the role of desmopressin. SETTING: Georgetown University Medical Center, Washington, DC. INTERVENTION: Fluid restriction and intravenous isotonic saline solution with 5% dextrose was administered to raise the serum sodium level. OUTCOME: Prevention of further seizures with normalization of serum sodium levels without any obvious neurological sequelae. CONCLUSIONS: This case illustrates the importance of weighing the benefits and risks of intranasal desmopressin therapy.     

Long-term (4- to 6-year) outcome of Palmaz-Schatz stenting: paucity of late clinical stent-related problems

OBJECTIVES: The purpose of this prospective single-center study was to evaluate the longer-term outcome of Palmaz-Schatz stenting in the treatment of native coronary and saphenous vein bypass graft disease. BACKGROUND: The STRESS (Stent Restenosis Study) and BENESTENT (Belgian Netherlands Stent) trials have demonstrated a decrease in both angiographic restenosis and the need for repeat revascularization in the 1st year for vessels treated by stenting rather than balloon angioplasty. Longer-term (1 to 5 years) clinical results of Palmaz-Schatz stenting are not yet well established. Late migration of the stent, metal fatigue, endarteritis and late restenosis have all been proposed as potential late clinical complications of coronary stent implantation. METHODS: The study cohort consisted of 175 consecutive patients who underwent elective placement of 194 Palmaz-Schatz stents in 185 vessels. Clinical events (death, myocardial infarction, recurrent angina or any revascularization) were assessed at 6 weeks, 2, 4 and 6 months, 1 year and yearly thereafter. Clinical follow-up was available on all patients at a mean +/- SD of 54 +/- 17 months. RESULTS: Angiographic success was achieved in 173 patients (98.9%); angiographic restenosis was observed at 6 months in 26.1% of target sites. The survival rate was 86.7% at 5 years, with a 5-year event-free survival rate decreasing progressively to 50.7%, reflecting primarily repeat revascularization procedures (41.2% at 5 years). However, the rate of repeat revascularization of the treatment site (target site revascularization [TSR]) was 14.4%, 17.7% and 19.8% at 1, 3 and 5 years, respectively, with late (> 1 year) TSR driven by in-stent restenosis in only 3 patients (1.7%). Rates of both 5-year survival (70.5% vs. 93.4%) and event-free survival (21.1% vs. 63.3%) were lower for patients who underwent saphenous vein graft (SVG) stenting than for those with native coronary artery stenting. However, 5-year TSR rates were similar for SVGs (21.9%) and native vessels (19.2%), indicating that the higher incidence of repeat revascularization for SVGs was due to an increase in non-TSR, driven by progressive disease at other sites. CONCLUSIONS: The long-term outcome of stenting shows stability of the treated lesion, with only a slight increase in TSR between 2 and 5 years (17.1% to 19.8%). The progressive increase in repeat revascularization over that period (24% to 41%) and most ongoing late events can be attributed to the progression of coronary disease at other sites, rather than to late deterioration of the stent result itself. Such non-TSR events account for the majority of clinical events in the patients who underwent SVG stenting.     

Determining the pertinence of psychotherapy outcome research findings for clinical practice: Comment on Westen and Morrison (2001).

D. Westen and K. Morrison's (2001) article (see record 2001-05666-001) is a challenge to advocates of empirically supported therapies (ESTs) and to the research enterprise that has determined which therapies are given the EST designation. Their concern that the long-term effects of ESTs are understudied and, apparently, weak is valid. However, their pessimistic conclusions about the generalizability of the results from outcome studies of ESTs are based on a serious logical error. The authors of the present article described an alternative research method that can address important and appropriate questions about the generalizability of ESTs. Continued dialogue between proponents and opponents of contemporary trends in psychotherapy outcome research is encouraged. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Revisional lumbar microdiscectomy: an analysis of operative findings and clinical outcome

Forty-one consecutive patients who underwent a revision microlumbar exploration for recurrent or persistent sciatica were reviewed retrospectively to analyse the operative findings and assess the clinical outcome following surgery. Thirty-three (80%) patients were found to have a recurrent intervertebral disc protrusion at the previous site, two patients had a disc herniation at a new site, one had severe perineural scarring, two had lateral recess stenosis, one patient had undergone previous exploration at an incorrect site and in two patients no cause for ongoing symptoms was found. Nineteen of the 33 patients with a re-prolapse presented with persistent or recurrent sciatica within 1 year of their first operation. The other 14 patients presented with a late re-prolapse (after 1 year) and their clinical outcome was better than for those patients with an early re-prolapse (12/14 vs 11/19 satisfactory result, respectively). The result of operating on patients with a late re-prolapse was comparable to the 80-95% satisfactory outcomes following primary lumbar microdiscectomy reported by other authors.     

Tumor-related arthrodesis. Reconstruction of the shoulder contour using a free TRAM (Transverse Rectus Abdominis Musculocutaneous) flap]

We evaluated growth hormone binding protein (GHBP) activity in a group of obese children (12 boys and 12 girls, age 3.1-14.7 years, BMI 21.1-33.3, 11 prepubertal and 13 early pubertal) and in 26 age-matched normal weight children (14 boys and 12 girls, age 2.1-16.0 years, BMI 14.2-21.4, 18 prepubertal and 8 early pubertal). All children were of normal stature. GHBP activity was significantly higher in the obese (39.1 +/- 1.1%) than in the control children (28.3 +/- 1.0%, p < 0.0001). Mean serum GHBP was not different between boys and girls or between prepubertal and pubertal subjects. A positive correlation was found between BMI and GHBP levels only in the normal weight children (r = 0.425, p < 0.05). Baseline insulin concentrations in the obese children were 97.6 +/- 7.9 pmol/l (normal values, 45.0 +/- 18.6 pmol/l), and the mean insulin AUC following OGTT in the obese was 811.3 +/- 160.7 pmol/l (normal values, 373.1 +/- 150.1 pmol/l). Serum GHBP activity in the obese was not correlated with baseline serum insulin concentrations or with the insulin AUC following OGTT. In conclusion, we found that obese children have elevated GHBP activity, and speculate that this phenomenon may serve to compensate for their reduced GH secretion and accelerated GH clearance.     

Three-dimensional reconstruction of types IV and V midfacial defects by free rectus abdominis myocutaneous (RAM) flap

A 25-year old woman with rapid HIV disease progression had been receiving zidovudine (ZDV) for two years, when she became pregnant. She had a high viral load and carried out zidovudine-resistant viral strains. For these reasons, and with the main objective to maximally reduce viremia, the association of DDI to ZDV was introduced a few weeks before delivery. The virological follow-up for one year has confirmed the lack of HIV infection in the child. Combined antiretroviral therapy during the last weeks of pregnancy might be considered for the prevention of vertical transmission of HIV in cases of high risk of newborn infection, without adding relevant toxicity.     

Overview of the rectus abdominis myocutaneous flap in head and neck reconstruction

OBJECTIVES: To examine the current in-patient respite service in terms of the type of patient served, whether their care could be provided satisfactorily outwith hospital and whether hospital resources could be used more efficiently. DESIGN: Multi-disciplinary assessment of subjects and completion of recording form. SETTING: Inverclyde and Renfrew, Scotland (population 288,000). SUBJECTS: All elective respite admissions to Merchiston Hospital during the period 1.1.93 to 31.12.93. RESULTS: Twenty-six patients received respite care in the period studied. Seventy-three per cent had severe/profound handicap, and all had at least one additional problem to their learning disability. We found the majority (73%) would require extra nursing care in hospital. Current social work respite placements do not cater for this level of disability. Respite bed occupancy rates are lower during the week than at the weekend. CONCLUSIONS: Most patients receiving respite care in our hospital are a highly dependent group whose needs cannot be met by local social work services. There is a need for more accurate planning of respite provision to maximise the efficient use of beds.     

Development of idiopathic dacryostenosis (clinical and pathologico-anatomical findings)

The authors describe microsurgical appearances of tear-sac and nasal mucous membranes from 45 patients suffering from dacryostenosis without clinically manifest nose or sinus conditions. In addition the observations of Henle (1865), that described the continuation of expandible conchal mucous membrane up to the lower part of the tear duct were controlled. The observations gave the following results: 1. In all cases of dacryostenosis there was a past history of more or less severe acute or chronic inflammation of the nasal and tear-duct mucous membrane. 2. The submucose of the ductus naso-lacrimalis surrounded by bone contains arterioles with sphincters and cavernous vessel complexes which can cause swelling up to displacement of the canal lumen, according to the blood flow. The results support the hypothesis of the authors that "idiopathic" dacryostenosis is caused by ascending inflammations from the region of the nose and sinus cavities, which can be clinically quite inconspicuous.     

Superiority of the microvascularly augmented flap: analysis of 50 transverse rectus abdominis myocutaneous flaps for breast reconstruction

Our experience with 50 transverse rectus abdominis myocutaneous (TRAM) flap transfers was evaluated as to the types of TRAM flaps, indications for breast reconstruction with a TRAM flap, and complications. The TRAM flap was transferred as a free flap in 7 patients, a unipedicled flap in 14 patients, and a microvascularly augmented flap in 29 patients. Microvascular augmentation was performed through the contralateral inferior epigastric vascular system to the superiorly pedicled muscle in 10 patients who had undergone radical mastectomy and the ipsilateral inferior epigastric vascular system in 19 patients who had undergone modified radical mastectomy. In this series, the incidence of flap-site complications, including total flap loss, partial flap loss, and fat necrosis, was lowest in the microvascularly augmented flap group. Particularly, incidence of partial flap loss in the microvascularly augmented flap group was significantly lower than in the unipedicled flap group (p < 0.01). These outcomes demonstrated the superiority of the microvascularly augmented TRAM flap for breast reconstruction.     

A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy

PURPOSE: The optimal technique of excising the juxtavesical ureter and bladder cuff during laparoscopic nephroureterectomy is still evolving. We report on a novel transvesical needlescopic (2 mm. instrumentation) assisted technique of en bloc retrieval of the juxtavesical ureter and bladder cuff during laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma. MATERIALS AND METHODS: Retroperitoneal laparoscopic nephroureterectomy was performed in 8 patients using this technique. Two needlescopic ports (2 mm.) inserted suprapubically into the bladder were used in combination with a cystoscopically positioned Collins knife. RESULTS: Satisfactory circumferential detachment of the bladder cuff and en bloc mobilization of 3 to 4 cm. of the intact pelvic extravesical ureter were achieved transvesically in each case in a manner comparable to open surgery. CONCLUSIONS: This technique simulates established open surgical principles of treating the distal ureter during laparoscopic nephroureterectomy.     

Therapeutic alliance and clinical outcome in the NIMH Treatment of Depression Collaborative Research Program: Preliminary findings.

Investigated the effect of the therapeutic alliance on clinical outcome in the 7 most improved and 7 least improved cases in the 4 treatments investigated in a study (I. Elkin et al; see PA, Vols 72:20648 and 77:10249) of treatment of depression. The treatments were interpersonal therapy (IPT), cognitive-behavior therapy, imipramine plus clinical management, and placebo plus clinical management. Clinical observer ratings of alliance, using Vanderbilt Therapeutic Alliance Total Scale scores, were compared across and within treatment groups and were related to clinical status at termination. Despite selective, significant relationships between alliance and outcome across treatments, the alliance–outcome relationship was significant only for IPT within treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diagnosis, management, and outcome of late duodenal complications in portal-enteric pancreas transplantation: case reports

BACKGROUND: Enteric drainage (ED) of pancreas allografts is an alternative to the bladder drainage (BD) technique and eliminates unique metabolic complications seen in the BD pancreas transplant recipients. Little longterm data has been reported in ED pancreas transplants. STUDY DESIGN: Of 53 patients who underwent pancreas transplantations performed with ED drainage of the exocrine secretion to a Roux-en-Y limb, who had more than 6 months graft function, four patients were identified with late duodenal segment complications (more than 6 months after transplantation) and are presented as case reports. RESULTS: The duodenal segment complications occurred between 8 and 48 months after simultaneous pancreas-kidney transplantation. Three patients were diagnosed with leakage from the duodenal segment. All were managed operatively. The fourth patient developed a distal stricture of the transplant duodenum occluding the anastomosis between the duodenum and the Roux-en-Y limb and also had a pancreatic pseudocyst. Drainage via a cyst-jejunostomy resulted in graft salvage. The mean followup after operative management of the duodenal-related complications was 15 months (range, 3-24 months). The patient, pancreas and kidney graft survival are 100%. CONCLUSIONS: Late duodenal complications occurred in 8% of pancreas transplant recipients with ED. Operative intervention in all four patients resulted in excellent graft and patient outcome and is recommended for these complications.     

The clinical picture and dynamics of long-term late remissions in the outcome of shift-like schizophrenia]

Varying doses of protoscolices of Echinococcus granulosus were injected intraperitoneally into Mongolian jirds, Swiss mice, and golden hamsters. After 4 months the animals were killed and the numbers of developing cysts counted. Jirds were by far the most susceptible hosts. Doses of 500 protoscolices produced 100% infection rates in both weanlings and adults. Comparable infection rates in weanling mice required inocula of 5,000 protoscolices, but even at this dose hamsters were refractory to infection. Three of 5 jirds developed pulmonary cysts after intravenous administration of 500 protoscolices. Serologic responses in infected jirds were followed using the indirect hemagglutination tests and a purified fraction of hydatid cyst fluid (HCF) as antigen. Titers reached a plateau after 15 weeks and were maintained for several months. Much brisker serologic responses occurred in animals sensitized with the antigenic fraction in various adjuvant vehicles. At no time during infection did jirds show any evidence of immediate hypersensitivity to HCF in direct skin tests, passive cutaneous anaphylactic tests, or after intravenous challenge with antigen. After artificial immunization with hapten-conjugated antigens or HCF, jirds underwent a fatal shock following intravenous challenge with antigen. HCF provoked the appearance of circulating antibodies which were capable of sensitizing normal recipients for passive systemic anaphylaxis after a latent period of 72 hr. It is concluded that the failure of the infected jird to develop immediate hypersensitivity responses to E. granulosus represents a marked deviation from the parrern of the immune response in echinococcosis in man and domestic animals and must be considered in the future use of this animal in experimental studies on the host-parasite relationship.     

MR imaging of perinatal brain damage: comparison of clinical outcome with initial and follow-up MR findings

BACKGROUND AND PURPOSE: The purpose of our study was to determine whether MR studies in the neonatal period are predictive of the neuroradiologic sequelae and clinical outcome in premature and term infants with perinatal brain injury. METHODS: Thirty subjects (15 premature and 15 term infants) with abnormalities revealed by initial MR studies were reexamined approximately 1 year after birth with both MR imaging and a neurologic assessment. All initial MR studies were performed between 35 and 45 weeks corrected age in premature infants and within 28 days of life in term infants. The initial MR studies were evaluated for deep gray matter involvement, hemispheric parenchymal change, intracranial hemorrhage, and periventricular signal and/or morphologic changes. These MR findings were compared with the follow-up MR findings and with the neurologic outcome. RESULTS: The development of cerebral palsy in premature infants was related to the following initial MR findings: subependymal hemorrhage associated with parenchymal destruction, periventricular signal alteration with irregularity of the ventricular wall, and widespread cerebral infarction. These MR findings were predictive of the subtypes of cerebral palsy. In term asphyxiated infants, T2 signal alterations of the deep gray matter rather than T1 shortening and diffuse involvement of the hemispheres were predictive of an unfavorable outcome. Both in term and premature infants, focal hemispheric parenchymal lesions alone (including infarction and intracerebral, subdural, intraventricular, and subarachnoid hemorrhage) did not produce poor outcomes. CONCLUSION: MR studies performed at or near term in either premature or term infants with perinatal brain damage are effective in predicting both late neuroradiologic and clinical outcome.