Radiation effects on the cosmetic outcomes of immediate and delayed autologous breast reconstruction: an argument about timing.

OBJECTIVE: To conduct a systematic review to gather the available evidence on the optimum timing of the radiotherapy in relation to autologous breast reconstruction. MATERIAL AND METHODS: The data was extracted from scientific databases, and a manual follow-up of references. The studies were selected which included at least 20 patients with any method of autologous breast reconstruction who were treated with adjuvant radiotherapy either before or after their reconstruction, and had addressed the effects of radiotherapy on the cosmetic outcome in their results. The principal outcome was cosmetic appearance. Secondary outcomes were immediate and delayed complications. RESULTS: We could not find any randomised controlled trial on this topic. Ten studies were included, most were retrospective, heterogeneous in terms of control groups, radiation doses, follow-up duration, and outcome measurements. Two studies included no control groups, and four studies compared the outcomes of patients with radiotherapy either before (n=3) or after (n=1) autologous breast reconstruction. The overall incidence of complications was increased in patients with radiotherapy in three out of these four studies. Only four studies directly compared the outcomes of patients who received radiotherapy before with patients who received radiotherapy after autologous breast reconstruction and two out of these reported worse outcomes associated with post-reconstruction radiotherapy. CONCLUSIONS: Despite the paucity of the published data, the current evidence suggests that the radiation has a deleterious effect on autologous flap reconstruction. Until better methods of radiation delivery can be devised to minimise the long term radiation sequelae in the irradiated tissue, delayed reconstruction seems to be a safe option in most of the cases. However, the findings from these studies should be interpreted with great caution before generalising from their results.     

Endoscopic laser pancreatic cystogastrostomy

Traditionally the drainage of pancreatic pseudocysts has been carried out operatively, forming a cystenterostomy. A simple endoscopic method of forming a pancreatic cystogastrostomy with laser is presented. This procedure does not require a general anesthetic, is safe, and allows resolution of symptoms.     

Pyrimidine nucleobase ligands of orotate phosphoribosyltransferase from Toxoplasma gondii.

Sixty-seven pyrimidine nucleobase analogues were evaluated as ligands of Toxoplasma gondii orotate phosphoribosyltransferase (OPRTase, EC 2.4.2.10) by measuring their ability to inhibit this enzyme in vitro. Apparent Ki values were determined for compounds that inhibited T. gondii OPRTase by greater than 20% at a concentration of 400 microM. 1-Deazaorotic acid (0.47 microM) and 5-azaorotic acid (2.1 microM) were found to bind better (8.3- and 1.9-fold, respectively) to T. gondii OPRTase than orotic acid, the natural substrate of the enzyme. Based on these results, a structure-activity relationship of ligand binding to OPRTase was formulated using uracil, barbituric acid, and orotic acid as reference compounds. It was concluded that the following structural features of pyrimidine nucleobase analogues were required or strongly preferred for binding: (i) an endocyclic pyridine-type nitrogen or methine at the 1-position; (ii) exocyclic oxo groups at the 2- and 4-positions; (iii) a protonated endocyclic pyridine-type nitrogen at the 3-position; (iv) an endocyclic pyridine-type nitrogen or methine at the 5-position; (v) an exocyclic hydrogen or fluorine at the 5-position; (vi) an endocyclic pyridine-type nitrogen or methine at the 6-position; and (vii) an exocyclic negatively charged or electron-withdrawing group at the 6-position. A comparison of the results from the present study with those from a previous study on mammalian OPRTase [Niedzwicki et al., Biochem Pharmacol 33: 2383-2395, 1984] identified four compounds (6-chlorouracil, 5-azaorotic acid, 1-deazaorotic acid, and 6-iodouracil) that may bind selectively to T. gondii OPRTase.     

Impact of three dimensional printing in orthopedics

The primary objective of this article is to explore effects of latest development in the area of three dimensional(3D) printing & to assess its abilities,and fu...     

Accidental ingestion of magnetic foreign body in a pediatric patient: A potentially fatal attraction

Foreign body ingestion is one of the most common pediatric emergencies. As part of their cognitive development, infants and toddlers are extremely curious and constantly explore their surroundings through their senses, namely taste. The ubiquity of toys containing magnetic elements consecutively meant an increase in the cases of children ingesting said magnets. While most ingested foreign bodies, including a single magnet, will spontaneously traverse the gastrointestinal tract without problems, some may give rise to grave and potentially life-threatening complications; the latter is often seen in the presence of 2 or more magnets or paramagnetic material. The diagnosis of ingestion of magnetic foreign bodies remains a challenge, given its often ambiguous history and presentation; nonetheless, their abundance, gravity, and preventability of their complications alone should render physicians vigilant and keep a low threshold of suspicion.     

Long-term survivor of brain metastases from malignant melanoma

Malignant melanoma is notorious for distant metastases. Median survival for stage IV melanoma is 6-10 months and 5 year survival is less than 5%. Median survival for melanoma with brain metastases is even lower i.e. 2 to 9 months. Here a case is reported who was treated for melanoma of sole of left foot with ipsilateral inguinal adenopathy and brain metastases in 2001 and is still surviving disease-free after a lapse of 8 years.     

Vomiting-Induced Pneumomediastinum and Subcutaneous Emphysema Does Not Always Indicate Boerhaave's Syndrome: Report of Six Cases

Spontaneous pneumomediastinum is an uncommon, self-limiting condition resulting from alveolar rupture in young adults. Because of the ambiguous presentation and the general lack of awareness of this condition, its diagnosis is often delayed, missed, or confused with spontaneous esophageal perforation. We report our experience of treating six patients who were referred to our unit with vomiting-induced pneumomediastinum, subcutaneous emphysema, and an initial diagnosis of spontaneous esophageal perforation. Ultimately, we diagnosed spontaneous pneumomediastinum in all six patients, who recovered uneventfully without any surgical intervention. We review the literature with particular emphasis on differentiating spontaneous pneumomediastinum from spontaneous esophageal perforation.     

Posterior ankle arthroscopy portal safety regarding proximity to the tibial and sural nerves

The aim of this cadaveric study was to assess the relative safety of posterior ankle arthroscopy portal sites regarding their distance from the tibial and sural nerves. We dissected 20 embalmed cadaveric lower limbs, carefully exposed the nerves, preserving their original position, and established the entry points of five posterior ankle portals using pins. We measured distances with a digital calliper and used Friedman test and Wilcoxon Signed Ranks tests for statistical analyses. There was unequal safety between the five portals (p = 0.00001). There was no statistically significant difference between the two posterolateral or two posteromedial portals. The trans-Achilles tendon portal as expected was significantly further away from either nerve (p = 0.00001). In conclusion, the trans-Achilles portal is the safest portal in terms of its distance from the nerves but has the disadvantage of surgical injury to the Achilles tendon. The two medial and two lateral posterior portals are equivalent in terms of safety.     

Does radial use as a second arterial conduit for coronary artery bypass grafting improve long-term outcomes in diabetics?

Objectives: The evidence supporting the survival benefit of multiple arterial grafts in the general coronary bypass surgery (CABG) population is compelling. Alternatively, results of studies comparing 2 versus 1 internal thoracic artery (ITA) grafts in diabetics have reported conflicting survival data. The use of radial versus ITA as the second arterial conduit has not been studied. Methods: We obtained complete death follow-up in 1516 consecutive diabetic [64 ± 10 years (mean ± SD). Insulin/no insulin: There were 540 (36%)/976 (64%)] primary isolated CABG patients all with ≥1 ITA grafts. The series included 626 ITA/radial (41%) and 890 ITA/vein (59%) patients. Using separate radial-use propensity models, we matched one-to-one 475 (76%) ITA/radial to 475 (53%) unique ITA/vein patients; each including 166 insulin and 309 no insulin patients. Results: Unadjusted survival was markedly better for (1) ITA/radial (94.3%, 86.7% and 70.4% at 1, 5 and 10 years, respectively) versus ITA/vein (91.8%, 74.5% and 53.8%; p < 0.0001) and (2) for no insulin (94.2%, 82.8% and 65.5%) versus insulin (90.4%, 73.1% and 49.2%; p < 0.0001). In matched patients, 11-year Kaplan–Meier analysis showed essentially identical ITA/radial and ITA/vein survival for all diabetics combined (p = 0.53; log rank) and for the no insulin (p = 0.76) cohort. Lastly, a trend for better ITA/radial survival in insulin dependent diabetics after the second postoperative year did not reach significance (p = 0.13). Conclusions: Using radial as a second arterial conduit as opposed to vein grafting did not confer a survival benefit in diabetics. This unexpected result is perhaps related to relatively diminished radial graft patency and/or the augmented radial vasoreactivity characteristic of diabetics. These findings indicate that the radial survival advantage demonstrated in the general CABG population lies primarily in non-diabetics in whom this advantage may be underestimated.     

Comparison of Calcaneal Ultrasound and DXA to Assess the Risk of Corticosteroid-Induced Osteoporosis: A Cross-sectional Study

Patients on long-term oral corticosteroids have an increased risk of low bone mass and fragility fractures. Fracture risk rises soon after commencement of corticosteroid therapy and it is possible that these agents adversely influence bone architecture disproportionately to their effect on bone mass. The best means of assessing bone status in patients using corticosteroids remains uncertain, but quantitative ultrasound of the calcaneus may provide evidence of microarchitectural changes not detected by dual-energy X-ray absorptiometry (DXA). Patients with Crohn’s disease have an increased risk of low bone mineral density (BMD), the etiology of which is multifactorial but includes corticosteroid use. We studied 118 consecutive patients with Crohn’s disease, 21 of whom used continuous oral corticosteroids, 70 of whom were intermittent users, and 27 who had never used the drug. All patients received DXA of the lumbar spine, hip and calcaneus and quantitative ultrasound (QUS) of the calcaneus. The different techniques were compared using a femoral neck T-score ≤−1.5 as the threshold of corticosteroid-induced osteoporosis. When compared with the femoral neck T-score, there were no significant differences between the predictive values of lumbar spine DXA, calcaneal DXA or calcaneal QUS to identify low femoral neck BMD. However, the absolute T-score required to give similar discriminatory capacity to femoral neck T-score varied substantially (T=−0.81 to −1.5) between the different measurement techniques and sites. Received: 29 July 2000 / Accepted: 9 April 2001