Pudendal Thigh Fasciocutaneous Flaps for Vaginal Reconstruction in Gynecologic Oncology

The pudendal thigh is a sensate fasciocutaneous flap supplied by the posterior labial artery. We report on the results of pudendal thigh flaps used for vaginal reconstruction in eight patients at the time of pelvic exenteration (6) and radical vaginectomy (2). Patients were interviewed and results were assessed 5 to 19 months after surgery. The flaps were raised in the thigh creases just lateral to the hair bearing area of the labia majora and included skin, subcutaneous tissues, deep fascia of the thigh, and the epimysium of the adductor muscles. Flap sizes varied from 9 × 4 cm to 15 × 6 cm. Bilateral flaps were used in seven patients. The flaps were technically easy to perform. Partial (apical) flap necrosis occurred in four patients. One patient developed complete necrosis of bilateral flaps, followed by an enterovaginal fistula. One patient whose flaps did not necrose developed a rectovaginal fistula at the site of rectal reanastomosis. The functional results are disappointing. The only patient having successful vaginal intercourse had a unilateral flap reconstruction following lower vaginectomy in a nonirradiated pelvis. No patient with bilateral flaps or prior pelvic irradiation has had successful coitus. Other long-term sequelae include vulvar pain (2), chronic vaginal discharge (2), hair growth (4), and protrusion of the flaps (2). These vulvovaginal symptoms discourage patients and their partners from genital contact. Breaching the integrity of the vulva to construct a neovagina that is likely to be unsuitable for sexual intercourse may deprive women of their only potential for normal genital sexual responsiveness. Techniques of vaginoplasty require continued assessment.     

Common bile duct calculi: updated experience with dissolution with methyl tertiary butyl ether

The authors describe their experience with methyl tertiary butyl ether (MTBE) in a larger series of patients than previously reported in order to acquaint physicians with both its effectiveness for dissolution of common bile duct calculi and the limitations of its use. Ten patients with 13 biliary calculi underwent percutaneous stone dissolution treatment with the experimental cholesterol solvent, MTBE. Three stones completely dissolved within 30 minutes, seven were reduced in size, and three were visibly unaffected. All stones not completely dissolved were easily extracted by means of a stone basket except for one in a patient taken to surgery. Although MTBE perfusion is an effective technique for management of biliary calculi, practitioners should be aware that its use is quite time consuming and its odor difficult to control.     

Segmental intestinal muscular thinning: a possible cause of intestinal obstruction in the newborn

Intestinal obstruction proximal to a transition zone without an interposed physical barrier usually indicates Hirschsprung disease. The authors report one case of focal small bowel muscular thinning just distal to a transition zone that produced clinical and radiographic findings that simulated long-segment Hirschsprung disease in a 2-day-old infant.     

Image-directed percutaneous biopsies with a biopsy gun

Core tissue for histologic study is believed by many pathologists to be more diagnostic than material from needle aspiration. Recently, a biopsy "gun" has been introduced, which simplifies core biopsies. With this device, 182 biopsies of multiple anatomic sites were performed with ultrasonic, computed tomographic, and fluoroscopic guidance and 18-gauge needles. High-quality histopathologic specimens were obtained in 177 of the biopsies, and diagnostic target tissue was obtained in 167. Only three significant complications occurred: one bleeding complication that required transfusion and two cases of pneumothorax that necessitated placement of chest tubes. The biopsy gun eliminated the disjointed movements of conventional "skinny" needle biopsies, and none of the samples demonstrated significant "crush" artifact or obscuring blood, problems that are commonly associated with manual biopsy techniques. Patient discomfort was decreased with this system compared with that of manual biopsies, and the total procedure time was reduced. Because of these distinct advantages, the authors now use the biopsy gun exclusively for all percutaneous biopsies and recommend that other institutions consider the use of this biopsy method.     

Circadian rhythm of feeding induced changes in hypothalamic Met-enkephalin concentrations

Accumulating evidence suggests that opioid peptides play an important role in the hunger component of the control of food intake. The enkephalins, one of the opioid peptide families, stimulate feeding when injected into specific hypothalamic areas and endogenous concentrations change with the fed/fasted condition of rats and sheep and with phase of circadian cycle. To demonstrate a possible circadian rhythm in feeding-induced changes in Met-enkephalin (MEK), 54 male rats initially weighing 255 +/- 3 g were adapted to a 12-hr fast during the light (light-fasted) or dark (dark-fasted) phase of the circadian cycle, then sacrificed before (non-fed) or after (fed) being allowed to eat a meal. In non-fed compared with fed rats, MEK concentrations were higher in the paraventricular nucleus (PVN, 170 vs. 109 pg/mg tissue, p less than 0.05) and ventromedial hypothalamus (VMH, 209 vs. 161 pg/mg tissue, p less than 0.05) in the dark (light-fasted) but not light (dark-fasted), even though rats ate a larger meal in the light (8.6 vs. 5.0 g, p less than 0.01). In rats fed the same amount of food in the light (dark-fasted) as ad lib fed rats in the dark (light-fasted), MEK concentrations did not differ in the PVN or VMH, suggesting that circadian rhythm is more important than meal size. Rats gavaged with an amount of milk equal in calories to dark ad lib-fed rats (light-fasted) had MEK concentrations not different from light-fasted non-fed rats (216 vs. 209 pg/mg tissue, NS) suggesting that feeding behavior, pregastric stimuli and/or form of diet is important for influencing MEK concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Physiological and Psychological Effects of Delivering Medical News Using a Simulated Physician–Patient Scenario

We examined the acute stress response associated with having to deliver either bad or good medical news using a simulated physician–patient scenario. Twenty-five healthy medical students were randomly assigned to a bad medical news (BN), a good medical news (GN), or a control group that read magazines during the session. Self-report measures were obtained before and after the task. Blood pressure and heart rate were measured throughout the task period. Four blood samples were obtained across the task period. The BN and GN tasks produced significant increases in self-reported distress and cardiovascular responses compared with the control group. There was also a significant increase in natural killer cell function 10 min into the task in the BN group compared with the control group. The BN task was also somewhat more stressful than the GN task, as shown by the self-report and cardiovascular data. These findings suggest that a simulated physician–patient scenario produces an acute stress response in the physician, with the delivery of bad medical news more stressful than the delivery of good medical news.     

Decreased pancreatic exocrine response to cholecystokinin in Zucker obese rats

Cholecystokinin (CCK), one of the peptides secreted by the gastrointestinal tract during a meal, stimulates release of enzymes into pancreatic juice and is a trophic hormone for the pancreas. Administration of CCK also decreases food intake, and obese rats have been shown to have a higher threshold than lean rats for this apparent effect on satiety. In this study experiments were designed to compare the sensitivity of obese and lean rats to the effects of CCK octapeptide (CCK-8) on pancreatic structure and exocrine function. In both growing and adult Zucker rats DNA content of the pancreas from obese rats was decreased compared with that from lean rats [2.42 +/- 0.21 vs. 3.07 +/- 0.18 mg (P less than 0.01) and 2.46 +/- 0.25 vs. 3.01 +/- 0.19 mg (P less than 0.05), respectively], and in adult obese rats this was accompanied by decreased pancreas size on both absolute weight and percent of body weight bases. In adult obese Bar Harbor mice, although DNA content of the pancreas was also decreased [1.70 +/- 0.10 vs. 2.41 +/- 0.11 mg (P less than 0.01)], pancreas weight was not different (0.30 +/- 0.01 vs. 0.32 +/- 0.01 g). In young rats growth of the pancreas was stimulated by 2 micrograms/kg CCK-8 administered subcutaneously or 100 mg/kg of a trypsin inhibitor administered orally twice daily for 2 wk. Although both treatments increased weight and DNA and protein content of the pancreas, the increases in DNA and protein content were smaller in obese than lean rats, indicating a decreased responsiveness to both trophic agents. Administration of CCK-8 stimulated smaller increases in pancreatic juice volume and amylase release in obese compared with lean rats, indicating decreased pancreatic exocrine function in response to CCK. In adults the CCK-8 dose-response curve for amylase release from dispersed pancreatic acini of obese rats was similar to that of lean rats, indicating normal sensitivity in vitro. Thus, in obese rats and mice DNA content of the pancreas is decreased when compared with that of lean rats and mice, and this is accompanied by decreased in vivo responses to CCK in obese rats.     

A behavioral analysis of chest pain in patients suspected of having coronary artery disease

A group of 83 men and women who had been referred to Johns Hopkins Hospital for cardiac catheterization for evaluation of chest pain and possible coronary artery bypass surgery were assessed behaviorally for their chest pains. During the approximately 2-week period between clinical evaluation and catheterization, the patients completed self-report forms about their chest pains. Patients completed one form for each episode of chest pain. Referring physicians also completed a form about the patients "typical" chest pain. The data were analyzed in terms of the antecedents, concomitants, and consequences of the chest pain, and patients' reports were compared to physicians' judgments. Major findings were as follows: 1) Antecedents--most episodes occurred while the patient was at home at times when his mood was one of contentment. 2) Concomitants--the average patient reported fewer than one episode per day which persisted for about 4 min and was rated as 36 on a scale of 0 to 100. The most common physical symptoms accompanying the episode were breathlessness and weakness, and the most common pain sensations were reported to be pressing or aching. There was no consistency among patients either in primary location or path of radiation of the pain. Duration of pain did not correlate significantly either with sensation or symptoms; however, severity rating did correlate with symptoms and sensations. 3) Consequences--most episodes were self-treated with nitroglycerin or rest. Patients typically returned to their ongoing activities; however, there were a number of interactions between the likelihood of returning to ones ongoing activity and the antecedents of the episodes. 4) The referring physicians significantly overestimated the frequency and severity of their patients' episodes; furthermore, they were selective in their abilities to identify correctly the antecedents or concomitants associated with their patients' pain--e.g., they were reliable in their judgments about subjects who had sleep-related episodes; however, they were inaccurate in characterizing the typical sensations or symptoms reported by their patients. It is suggested that a behavioral analysis may enable a physician to characterize his patient's chest complaints better, and perhaps also may facilitate the differentiation between chest complaints indicative of coronary artery disease and chest complaints of a noncoronary origin.