The Bikini Inset: a reliable method for postradiation breast reconstruction with transverse rectus abdominis myocutaneous and free abdominal tissue transfer

The combination of radiation and mastectomy reduces the 3-dimensional topography of the breast into a relatively inelastic, 2-dimensional plane. This environment presents specific challenges to aesthetic breast reconstruction with autologous tissue transfer, and a relative sparsity of information exists in the surgical literature on how to address these challenges. Accordingly, this article details a formalized and reproducible approach for flap inset in postradiation breast reconstruction. We outline a novel technique for optimizing the recipient bed and present a sequential flow for contouring the autologous abdominal flap, so that it recreates the individual subunits of an aesthetic breast.     

Dipeptidyl Peptidase 4 Inhibition Increases Myocardial Glucose Uptake in Nonischemic Cardiomyopathy

BackgroundGlucose and fatty acids comprise the primary substrates for myocardial energy metabolism. The normal myocardium switches toward glucose metabolism in the setting of stress; the inability to affect such a switch is a fundamental mechanism behind “diabetic” or “insulin-resistant” cardiomyopathy. The purpose of this mechanistic study was to evaluate the effects of treatment with the dipeptidyl peptidase (DPP) 4 inhibitor sitagliptin on myocardial glucose uptake in patients with nonischemic cardiomyopathy.Methods and ResultsTwelve nondiabetic subjects with nonischemic cardiomyopathy underwent metabolic testing and assessment of myocardial glucose uptake by ¹⁸F-fluorodeoxyglucose positron-emission tomographic/computerized tomographic imaging at baseline and after 4 weeks of sitagliptin therapy. Sitagliptin therapy resulted in a significant increase in myocardial glucose uptake (19% increase; P = .04). Although most patients had at least a slight increase in glucose uptake, there was an overall bimodal response, with 6 patients (“responders”) demonstrating large increases (>20%) in glucose uptake and 6 patients (“nonresponders”) demonstrating <5% increases or slight decreases. Triglyceride–high-density lipoprotein ratios significantly dropped in the 6 responders compared with the 6 nonresponders (P < .02).ConclusionsTherapy with the DPP-4 inhibitor sitagliptin results in increased myocardial glucose uptake in nondiabetic patients with nonischemic cardiomyopathy.     

Phacoemulsification and goniosynechialysis for the management of refractory acute angle closure

Purpose. To evaluate the effectiveness of phacoemulsification with goniosynechialysis in the management of refractory acute angle closure (AAC). Methods. In this prospective, noncomparative interventional case series, patients with AAC who were unresponsive to medical and laser therapy were included. Success was defined as complete if intraocular pressure (IOP) had a drop of at least 30% and was between 6 and 21 mmHg without medication, and qualified if IOP was within that range with medication. Results. A total of 24 patients with a mean age of 56 years (range 39-77) were treated. Mean follow-up time was 15.7±4.2 months (range 6-24). Mean preoperative and last visit IOPs were 34.27±7.23 mmHg and 17.5±3.21 mmHg, respectively (p<0.001). Mean number of glaucoma medication dropped from 3.67±0.48 to 0.63±1.05 (p<0.001). There was a positive correlation between the attack-surgery interval and last visit IOP (p<0.001, r=0.697). There was a negative correlation between the preoperative anterior chamber depth and last visit IOP drop (p=0.03, r=-0.56). Also, a positive correlation was found between the preoperative IOP and last visit IOP drop (p<0.001, r=0.896). At final visit, complete and qualified success was achieved in 17/24 (71%) and 5/24 (21%) cases, respectively. The most common intraoperative and postoperative complications were hyphema and anterior chamber fibrinous reaction, respectively. Conclusions. Phacoemulsification with goniosynechialysis seems to be a safe and effective method for the management of patients with refractory AAC. This procedure can be considered for these patients before proceeding with filtering surgery.     

Liver transplantation for neuroendocrine tumors

Liver transplantation for the treatment of metastatic neuroendocrine tumors (NETs) is radical. Although cure is not impossible, it is improbable. The reported experience with transplantation for NETs is limited to less than 150 cases with widely varying results and few 5-year disease-free survivors. We reviewed our experience with transplantation for patients with NETs. Fourteen symptomatic patients with unresectable NET liver metastases who had failed medical management were listed for transplantation. Two patients listed for transplantation underwent prior right lobectomies. Three patients were listed but did not undergo transplantation: one was lost to follow-up, one died 14 months after listing, and one remains waiting over 4 years. Eleven patients underwent liver transplantation, three with living donor grafts. There were four men (36.4%) and seven women (63.6%) who had a mean age of 51.2 ± 6.3 years. Three patients had distal pancreatectomies and one patient had a Whipple procedure at the time of transplantation. There were six nonfunctioning tumors (54.6%), three carcinoid tumors (27.3%), and two (18.2%) Vipomas. In one patient, with fulminant hepatic failure, the NET was an incidental finding in the explant. The 1- and 5-year survival among transplanted patients is 73% and 36%, respectively, with a mean follow-up of 34 ± 40 months (range 0 to 119 months). Of the three patients surviving more than 5 years, only one was disease free. In carefully selected patients with metastatic NETs, liver transplantation may be an appropriate option. Presented in part at the Fourth Americas Congress of the American Hepato-Pancreatico-Biliary Association, Miami, Florida, February 28, 2003.     

The value of hysteroscopy in diagnosis of chronic endometritis in patients with unexplained recurrent spontaneous abortion

Objectives

We performed this study in order to investigate the role of chronic endometritis (CE) in unexplained recurrent spontaneous abortion (RSA) and to determine the correlation between hysteroscopic and histologic findings of CE in patients with unexplained RSA. We also tried to find out the relation between CE and primary vs. secondary RSA.

Study design

One hundred and forty-two consecutive patients with unexplained RSA and 154 fertile women were enrolled in this study. All the patients and controls underwent hysteroscopy and, at the same time, endometrial biopsy. CE was suspected when hysteroscopy revealed signs of focal or diffuse endometrial hyperemia or endometrial endopolyps (less than 1 mm in size). Histopathologic diagnosis of CE was based on superficial stromal edema, increased stromal density, and pleomorphic stromal inflammatory infiltrate dominated by lymphocytes and plasma cells. Results were compared between cases and controls as well as those with primary (n = 61) and secondary (n = 81) RSA.

Results

Patients with RSA had a significantly higher incidence of CE both hysteroscopically (67.6% vs. 27.3%; p < 0.0001) and pathologically (42.9% vs. 18.2%; p < 0.0001). The sensitivity, specificity, positive predictive value and negative predictive value of hysteroscopy in the diagnosis of CE were found to be 98.4%, 56.23%, 63.5% and 97.82% respectively. Patients with secondary RSA had a higher prevalence of CE both pathologically (83.9% vs. 45.9%; p < 0.0001) and hysteroscopically (58.1% vs. 24.6%; p < 0.0001).

Conclusion

CE is associated with unexplained RSA. Hysteroscopy, with high sensitivity and acceptable specificity, is suitable for the diagnosis of CE in those with unexplained RSA. CE should be taken into consideration in those with secondary unexplained RSA.