Reconstructive microsurgery —a review

We present some important current applications of reconstructive microsurgery. This field is expanding rapidly and the techniques are finding application in many branches of surgery. There is a pressing need for educational programs and training in microsurgery, as well as for continued research.

Many of the procedures reviewed here have already been shown to substantially reduce costs, shorten hospitalization, and lessen patient disability; and as a result, several conventional procedures have been out-dated. We have stressed the concept that this is team surgery. To cover the needs of replantation and emergency free flaps around the clock, several micro-surgeons must work together in established centers, and the team must possess expertise from all the involved surgical specialities. This may imply revision of many organizational aspects of patient care. Replantation centers would provide the necessary educational bases and give an impetus to the development of microsurgery.     

Increased glucose excursion in cystic fibrosis and its association with a worse clinical status

BACKGROUND: Abnormal glucose tolerance is a frequent co-morbidity in cystic fibrosis patients (CF), and is associated with a worse prognosis. The objectives are to investigate (a) the relative contribution of insulinopenia and insulin resistance (IR) for glucose tolerance and (b) the association between various glucose parameters and CF clinical status. METHODS: Oral glucose tolerance tests were performed in 114 consecutive CF patients not known to be diabetic as well as 14 controls similar for age and BMI. RESULTS: Abnormal glucose tolerance was found in 40% of patients with CF: 28% had impaired glucose tolerance (IGT) and 12% had new cystic fibrosis related diabetes (CFRD). Compared to control subjects, all CF patients were characterized by an increased glucose excursion (AUC). While reduced early insulin release characterised CF, IGT and CFRD patients also present IR thus both mechanisms significantly contribute to glucose tolerance abnormalities. Increased glucose AUC and reduced early insulin release but not glucose tolerance categories were associated with a reduced pulmonary function (FEV(1)). CONCLUSION: In CF, early insulin secretion defect but also IR contribute to glucose intolerance. Early in the course of the disease, increased glucose AUC and reduced early insulin secretion are more closely associated with a worse clinical status than conventional glucose tolerance categories.     

31P MRS of heart grafts provides metabolic markers of early dysfunction.

OBJECTIVE: Early graft failure (EGF) is a life-threatening event still accounting for a significant percentage of early deaths after heart transplantation. We tested whether selected metabolic markers, including high-energy phosphate concentrations measured ex vivo in pre-transplant heart grafts by (31)P magnetic resonance spectroscopy (MRS) are related with early post-transplant outcome. METHODS: During a 3-year period, 26 heart grafts harvested in the vicinity of the transplantation centre were studied. Evaluation of transplantability was done conventionally. (31)P MRS was performed ex vivo approximately 60min after aortic cross-clamp to quantify ATP, P(i) and PCr concentration ratios. A MRS-score was defined as a combination of intracellular pH (pHi) and the PCr/P(i) ratio. EGF was defined as the need to abnormally extend circulatory support or to use more than two inotropes before weaning the patient from CPB after transplantation. The grafts were attributed to three groups as follows: A1, transplanted with uneventful outcome (n=14); A2, transplanted with subsequent EGF (n=3) and B, not suitable for transplantation (n=9). RESULTS: Significant differences between groups existed for the following metabolic markers: PCr/ATP (P=0.013), PCr/P(i) (P=0.0004), pHi (P=0.0016) and MRS-score (P=0.0001). The sensitivity, specificity and positive likelihood ratio for EGF with a MRS-score相似文献   

Diagrammatic recording of head and neck tumours1

The increasing demands of clinical audit have resulted in the need for accurate data collection. The use of tumour maps allows standardization of the records of patients with head and neck cancer, which facilitates collation of data in multicentre studies and makes interdepartmental comparisons more meaningful. The aim of this study was to develop an improved standard set of tumour maps for recording the stage of head and neck tumours. A review of the existing tumour diagrams was performed to identify those anatomical areas that are not adequately represented or where ambiguity exists. The areas where improvements could be made were identified as: (1) the anterior commissure of the larynx; (2) axial and sagittal views of the larynx; (3) the pyriform fossa and cervical oesophagus; (4) the oropharynx and vallecula; (5) the nasal cavity and paranasal sinuses; and (6) cervical nodal involvement. A new set of tumour maps is presented in an attempt to correct some of the limitations of the existing diagrams.     

Tacrolimus Pharmacokinetics and Dose Monitoring After Lung Transplantation for Cystic Fibrosis and Other Conditions

In cystic fibrosis (CF), absorption of tacrolimus through the gastrointestinal tract may be impaired due to fat malabsorption. The aim of this pilot study was to compare tacrolimus pharmacokinetics and inter- and intrasubject variability of exposure in stable lung transplant recipients with and without CF, and to determine the best single-time predictors of exposure. The study included 11 lung transplant recipients with CF and 11 without CF who received tacrolimus twice daily. Blood samples were obtained predose and at 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 8 and 12 h postdose on 3 separate days within 1 week. Tacrolimus pharmacokinetics and inter- and intrasubject variability of exposure were similar in the two groups, though exposure-per-milligram-dose was approximately 50% lower in CF patients. Tacrolimus trough concentration did not accurately predict the area under the concentration curve (AUC(0-12)), but the concentration measured 3 h postdose (C(3)) was tightly correlated with the AUC(0-12) in both CF (r(2)= 0.86) and non-CF (r(2)= 0.92) patients. In summary, patients with CF have a higher tacrolimus oral clearance, but nonsignificant differences in short-term inter- and intrasubject variability of exposure compared to patients without CF. C(3) is tightly correlated with AUC(0-12) in lung transplant recipients with and without CF.     

ATP release from human airway epithelial cells studied using a capillary cell culture system

Epithelial release of adenosine triphosphate (ATP), an important autocrine and paracrine signalling molecule, is acutely mechanosensitive and therefore difficult to study. We describe here a novel preparation that minimizes mechanical and metabolic perturbations, and use it to examine ATP secretion by epithelial cells. The Calu-3 cell line derived from human airway sub-mucosal glands was cultured in a hollow fibre bioreactor on porous capillaries that were perfused by a re-circulating medium pump. Cells became polarized and cultures were stable for > 5 months, as evidenced by microscopy and lactate production (≈250 μg (10⁸ cells)⁻¹ day⁻¹). Elevating apical flow rate 5-fold increased ATP secretion from ≈200 to 6618 fmol min⁻¹. Reducing apical osmolarity by 25–43 % also increased ATP secretion, which then declined spontaneously to a plateau rate that persisted as long as hypotonic perfusion was maintained. Release deactivated rapidly after shear and osmotic stresses were terminated, and was not associated with detectable cell lysis. Lowering apical [Ca²⁺] to increase connexin hemichannel permeability also stimulated ATP release and increased secretion during both hyposmotic and shear stress; however, the connexin 43 blocker flufenamic acid inhibited shear-induced ATP release only in low-Ca²⁺ solution, and therefore another secretory pathway may operate with physiological (i.e. m m ) calcium. Regardless of the mechanism, the present results quantify ATP responses to mechanical and osmotic stimuli and demonstrate the usefulness of capillary cultures for studying epithelial secretion.     

Reasons for consultation and explanations of illness among Finnish primary-care patients

The aim of this study is to describe triggers to consultation, and to further understanding of how patients construct explanations for what is wrong with them. Patients consulting a general practitioner were interviewed about the process that had led to their consultation and explanations for the causes of their illness. The results show that the factors which trigger professional consultation are related to the everyday demands of work, home and other people on the one hand, and to the interpretation of bodily symptoms on the other. Characteristically, symptom interpretation often involves a veiled dialogue with the tax-funded municipal health care system about a justification for the lay diagnosis. The results further show a domination of biomedical illness explanations among the patients studied. A third of the explanations concerned infectious, toxic and noxious agents, and a quarter constitutional defects in the body. Ten per cent were philosophical and metaphysical, and 16 per cent psychosocial in nature. The remainder were based on life style and risk behaviour, and on problems of medical care. The results are discussed from the standpoint of lay and professional models of explanation for illness.     

Present technique and long-term results of toe-to-antebrachial stump transplantation.

Complete hand amputation has been considered conventionally as an indication for the use of mechanical prosthetic devices in order to regain some hand like function. A microsurgical option to create a new pinching ability after wrist amputation has been used in a series of 13 patients. The actual operation technique is presented in detail. It was designed by the senior author in 1981 and applied into clinical use in 1983. In order to evaluate the functional results and patient satisfaction in long-term, a questionnaire was sent to 12 patients and 11 patients were interviewed, examined clinically and studied with a hand function scoring test according Sollerman. The operated series consist of 12 adults with posttraumatic distal antebrachial or wrist amputations and 1 adolescent boy with a congenital wrist level amputation. There were 3 females and 10 males in the series. The satisfaction to achieved result was generally good. The ADL section of Tamai score and the one we used correlated well with each other and patient satisfaction. Sollerman hand function test gave worse results in two blind patients and same occurred in two short antebrachial stump patients. However the satisfaction was much better in Tamai score among blind patients, with wrist amputation level amputations. In our opinion this single toe transfer method gives an acceptable pinch reconstruction for hand amputation patients. We measured pinch strength and total active motion. They averaged about half of the normal values. The reconstruction is suitable to the patients, who are not willing to donate multiple toes or who are aware and concerned about the risks of human hand transplantation, which necessarily will need a life-long immunosuppressive medication to prevent from rejection.     

Genetic analysis of seven Mediterranean families with multiple endocrine neoplasia type 2A

OBJECTIVE   Genetic analysis is now essential for the accurate screening of families with multiple endocrine neoplasia type 2 (MEN2). We present the genetic analyses by both haplotype and direct RET proto-oncogene mutation analysis in seven Mediterranean MEN 2A families and have compared these results with biochemical screening tests and pathological examinations.
DESIGN  Total DNA was extracted from leucocytes. Linkage analysis was performed using five RFLP systems from three loci that flank the MEN2A locus (FNRB, RBP3, D10S15). RET proto-oncogene analysis was carried out by automatic DNA sequencing and adequate digestion of PCR amplified products for exons 10 and 11. Screening for medullary thyroid carcinoma or C-cell hyperplasia was performed by the pentagastrin provocation test. Adrenal medullary function was assessed by measurements of 24-hour urinary excretion of catecholamines and their metabolites. Serum calcium and phosphate measurements were the initial screen for hyperparathyroidism. Serum PTH was determined only if hyperparathyroidism was suggested by the former determinations.
PATIENT   Genetic study was performed in 59 individuals (39 at risk) from seven kindreds of Mediterranean origin with MEN 2A.
RESULTS   Diagnosis by linkage analysis was not possible in 30% of individuals at risk, but RET proto-oncogene analysis identified all these individuals. Mutations of the RET proto-oncogene were detected in exon 10 (codon 618) in one MEN 2A kindred and in exon 11 (codon 634) in the others. The results of direct analysis were concordant with linkage studies in each case. Three individuals from different MEN 2A kindreds, who were subsequently shown not to be gene carriers, had false positive pentagastrin stimulation tests.
CONCLUSION   Biochemical tests can be replaced by direct DNA mutation analysis as the first line screening test in order to identify gene carriers of MEN 2A.