Diuretics vs. ACE inhibitors.
Explore the source record for details and available documents.
Benzothiadiazines↗
Biomedical subjects
S Slezak
Publications and source records attributed to S Slezak.
Surgeon perspectives on surgical options for early-stage breast cancer.
To evaluate the practice patterns of general and plastic surgeons regarding patients with early-stage breast cancer, all general and plastic surgeons in Quebec and Maryland were mailed self-administered questionnaires evaluating surgeon demographics, practice patterns, treatment preferences, and satisfaction with the results of lumpectomy and radiation therapy or breast reconstruction. Response rates of 38.3 percent and 26.7 percent were obtained for general surgeons in Quebec and Maryland, respectively. The ratio of reported mastectomies to lumpectomies was 1:2 in Maryland and 1:5 in Quebec. All general surgeons considered lumpectomy an important option. Ninety percent of Maryland surgeons versus 44 percent of Quebec surgeons considered mastectomy important. A total of 53.6 percent versus 24.9 percent of general surgeons in Maryland and Quebec, respectively, considered delayed reconstruction an important option. Additionally, 81.3 percent of Maryland surgeons considered immediate reconstruction important, and 79.6 percent discussed it with all stage I or II patients. More than 75 percent of Quebec general surgeons reported discussing immediate or delayed reconstruction with < or =50 percent of these women. Response rates of 53.6 percent and 48.8 percent were obtained for plastic surgeons in Quebec and Maryland, respectively. In one year Quebec plastic surgeons reported that they performed less than half the number of reconstructions performed by Maryland plastic surgeons (7.2 versus 17.3). In Quebec, 82.3 percent of surgeons reported that they frequently discuss delayed reconstruction, 25.1 percent immediate, 62.5 percent pedicled TRAM, and 51.7 percent nonautogenous options. In Maryland, 74.3 percent of plastic surgeons frequently discuss delayed reconstruction, 95.7 percent immediate, 89.9 percent pedicled TRAM, and 85.9 percent nonautogenous options. For women with early-stage breast cancer, regional variations exist in the surgical options discussed and provided.
Attitude of Health Personnel↗
Surgical options for the early-stage breast cancer: factors associated with patient choice and postoperative quality of life.
Patients with early-stage breast cancer have three surgical options: lumpectomy with radiotherapy, mastectomy alone, and mastectomy with breast reconstruction. Our objective was to compare women in these three groups with respect to demographics, preoperative counseling, postoperative body image, and quality of life. Women having undergone surgery for stage 1 or 2 breast cancer between 1990 and 1995 were selected by random sampling of hospital tumor registries and were mailed a self-administered questionnaire, which included the Medical Outcomes Survey Short Form 36. Patients were stratified into three mutually exclusive groups: lumpectomy with axillary node dissection and radiotherapy, modified radical mastectomy, and modified radical mastectomy with breast reconstruction. In total, 267 of 525 surveys were returned (50.9 percent). Compared with mastectomy patients, breast reconstruction patients were younger (p < 0.001), better educated (p = 0.001), and more likely Caucasian (p = 0.02). Among mastectomy patients, 54.9 percent recalled that lumpectomy had been discussed preoperatively and 39.7 percent recalled discussion of breast reconstruction. Post-operative comfort with appearance was significantly lower for mastectomy patients. The relationship between type of surgery and postoperative quality of life varied with age. Under 55, quality of life was lowest for mastectomy patients on all but two Medical Outcomes Survey Short Form 36 subscales. Over 55, quality of life was lowest for lumpectomy patients on all subscales (p < 0.05 for all subscales except social functioning and role-emotional). Treatment choice may be related to age, race, education, and preoperative counseling. Whereas the effect of breast cancer on a woman's life is complex and individual, the type of surgery performed is a significant variable, whose impact may be related to patient age.
Adult↗
Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures.
The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent). The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience.
Facial Asymmetry↗
A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients.
Research indicates that 8.5% of all patients undergoing surgical procedures for more than 3 hours develop pressure ulcers. In some types of surgery, incidence rates in excess of 25% have been reported. An 11-month study was conducted on the safety and efficacy of an experimental alternating air device in comparison with a tertiary care facility's conventional practice. A series of 217 patients undergoing surgical procedures scheduled for a minimum of 3 hours were enrolled. No ulcers developed in the experimental group and 11 ulcers developed in seven patients in the control group (8.75% incidence rate). Of the 11 ulcers, one was Stage I, four were Stage II, and six were unstageable secondary to eschar. The difference between the groups is significant at the P = 0.005 level. Individuals who developed ulcers had a length of stay approximately 7 days longer than the hospital average for comparable patients who did not develop ulcers.
Aged↗
Palatal fractures: classification, patterns, and treatment with rigid internal fixation.
A classification of palatal fracture types is developed from patterns observed on CT scans, and success with open reduction techniques is correlated with fracture pattern. The six palatal fracture types are as follows: I, anterior and posterolateral alveolar; II, sagittal; III, parasagittal; IV, para-alveolar; V, complex; and VI, transverse. Associated fractures were LeFort I (100 percent), LeFort II and III (55 percent), mandible (48 percent), and dental (55 percent). Large segment, sagittally oriented palatal fractures could be stabilized with rigid internal fixation. Complete rigid fixation of the palate consists of (1) roof of mouth, (2) pyriform or alveolar, and (3) four LeFort I buttress stabilization. Comminuted palatal fractures were managed by standard LeFort I and alveolar buttress fixation, palatal splinting, and intermaxillary, fixation. If complete rigid fixation was employed in the palate in type II, III, and IV fractures, a palatal splint was avoided in 60 percent of these cases. Rigid internal fixation is therefore concluded to facilitate the treatment of certain types of palatal fractures by reduced length of intermaxillary fixation and avoidance of palatal splinting.
Alveolar Process↗
Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts.
Necrotizing abdominal wall infections, enteric fistulae, or exposed prosthetic material after ventral hernia repair often results in a loss of abdominal wall integrity. Further surgical reconstruction with prosthetic material is usually contraindicated in the contaminated wound because of the high infection rate necessitating prosthetic removal and further abdominal wall debridement. Consequently, for the past 9 years, we have been using free grafts of autologous fascia lata to replace deficient abdominal wall fascia and muscle in situations where prosthetic material is contraindicated and local tissue rearrangement (i.e., component separation) would be inadequate. Thirty-two patients (mean age 59 years) underwent abdominal wall reconstruction with autologous fascia lata grafts. Indications included exposed mesh (31 percent), enteric fistulae (28 percent), enteric contamination (22 percent), wound infection (13 percent), and immunosuppression alone (6 percent); 31 percent of all patients were immunosuppressed secondary to either a solid organ transplant or a systemic inflammatory disorder. Fascia grafts (mean size 10 x 17 cm) were sutured to the surrounding abdominal wall and covered by local skin flap advancement and/or myocutaneous flap rotation. All abdominal reconstructions were initially successful. Subsequent local abdominal wall complications included cellulitis (n = 3), seroma (n = 2), and skin dehiscence with exposed fascia grafts (n = 7). Five of seven patients with skin dehiscence healed by secondary intention, whereas two had split-thickness skin grafts successfully applied to the granulating fascia. Thigh donor site complications included hematoma (n = 1), skin dehiscence (n = 1), and seroma (n = 2). There have been no cases of lateral knee instability. The average follow-up period is 27 months (range 3 to 106 months). Recurrent hernia has been seen in three patients (9 percent). Interestingly, laparotomy has been performed through an intact fascia lata patch in three patients for unrelated intra-abdominal conditions. In each case, the graft was intact and revascularized, confirming experimental animal data performed in our laboratory. Recurrent hernia has not been observed through the laparotomy site. Our 9-year experience has demonstrated that in the face of large, contaminated abdominal wounds where prosthetic material is contraindicated and local tissue rearrangement would be inadequate, fascia lata autografts are a reliable adjuvant to abdominal wall reconstruction.
Abdominal Muscles↗
The edentulous Le Fort fracture.
A retrospective review of 328 Le Fort fractures has identified 20 (6.1%) of these fractures as edentulous. A review of treatment of the patients was conducted. Conservative (nonsurgical treatment methods) and classic open reductions produce aesthetic and functional results that lead to posterior and oblique positioning of the maxillary occlusal segment in comminuted fractures. Attention to positioning the maxilla by relating it to the mandible through maxillomandibular fixation minimized these deformities. Establishing maxillary-mandibular relationships in edentulous fractures, therefore, seems to have the same importance as establishing occlusion in dentulous patients as an important initial step in the treatment of comminuted Le Fort fractures.
Adult↗
Cigarette smoking, plastic surgery, and microsurgery.
Although tobacco smoking is known to result in coronary heart disease, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, lung cancer, and other smoking cancers, many surgeons believe that smoking also results in impaired wound healing and poor surgical results. Large clinical experiences in several areas of plastic surgery reinforce this suspicion. Procedures that have been noted to be adversely affected by cigarette smoking include rhytidectomy, abdominoplasty, breast reconstruction, free-tissue transfer, and digital replantation. This article reviews the available data, introduces new clinical data, and hypothesizes about the ways in which some procedures are more affected than others.
Aging↗
High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction.
A 17-year experience from 1977 to 1993 with gunshot, shotgun, and high-energy avulsive facial injuries emphasizes the superiority and safety of "ballistic wound" surgical management: (1) immediate stabilization in anatomic position of existing bone, (2) primary closure of existing soft tissue, (3) periodic "second look" serial debridement procedures, and (4) definitive early reconstruction of soft-tissue and bony defects. The series contains 250 gunshot wounds, 53 close-range shotgun wounds, and 15 high-energy avulsive facial injuries. Four general patterns of involvement are noted for both gunshot and shotgun wounds and three for avulsive facial injuries. The treatment algorithm begins with identifying zones of injury and loss for both soft and hard tissue. Gunshot wounds are best classified by the location of the exit wound; shotgun and avulsive facial wounds are classified according to the zone of soft-tissue and bone loss. Treatment, prognosis, and complications vary according to four patterns of gunshot wounds and four patterns of shotgun wounds. Avulsive wounds have not been recommended previously for ballistic wound surgical management. The appropriate management of high-energy avulsive and ballistic facial injuries is best approached by an aggressive treatment program emphasizing initial primary repair of existing tissue, serial conservative debridement, and early definitive reconstruction.
Adult↗
Silicon tissue assays in nonaugmented cadaveric patients: is there a baseline level?
Microscopic silicone in various tissues in the bodies of females with breast implants has led to the possible incrimination of these implants with connective-tissue disorders. Current technology precludes accurate silicone measurements, but all compounds containing the element silicon (which would include silicone) may be measured accurately. Direct positive correlations of silicon assays with silicone measured levels were confirmed by adding known amounts of silicone oil as a control. With the ubiquitous nature of organosilicons (food containers, syringes, etc.), we hypothesized that baseline silicon levels could be detected in tissues of cadavers without silicone breast augmentation. Ten cadavers were examined. Tissue samples were derived from subcutaneous fat, nipple, breast tissue, liver, spleen, and axillary nodes. Nine of 10 cadavers had silicon levels in various tissues. Measurements were performed by direct current atomic emission spectroscopy. The baseline data were compared with those from four augmented patients who underwent capsulectomies and implant removal. Silicon levels were fivefold higher in the augmented patients than in the nonaugmented cadavers. No difference in levels was noted if the patient had an intact or ruptured implant and/or was symptomatic versus asymptomatic for immunologic disease. This study was designed to measure baseline silicon levels in the normal population. It also has established an accurate level of measurement of tissue silicone.
Aged↗
Quantitation of sensibility in gigantomastia and alteration following reduction mammaplasty.
A vibrometer and Semmes-Weinstein monofilaments were used to delineate the sensory threshold for quickly and slowly adapting fibers in 13 women with gigantomastia (bra size D or greater) as compared with small-breasted women (bra size A or B). It was found that the mean thresholds for gigantomastia patients were significantly higher (i.e., they were less sensitive) for vibration (p < 0.001) and pressure (p < 0.02). After amputation and free nipple grafting (six patients) or a McKissock-type breast reduction (four patients), six patients had improved sensation, two patients were less sensitive, one patient was unchanged, and one patient was lost to follow-up. These results suggest (1) that preoperatively, there is a chronic traction injury to the fourth, fifth, and sixth intercostal nerves in women with gigantomastia (this is corrected after breast reduction, and sensation improves), (2) that breast reduction surgery itself divides some intercostal nerve fibers, the number dependent on the extent and type of skin and glandular resection (this decreases sensation), and (3) that postoperatively, reinnervation from intercostal and supraclavicular nerves occurs (this improves sensation with time). The postoperative sensory outcome of the breast depends on a combination of these factors; the majority of our patients with gigantomastia have improved sensation after breast reduction.
Adult↗
The sensational transverse rectus abdominis musculocutaneous (TRAM) flap: return of sensibility after TRAM breast reconstruction.
Normal breast sensation was objectively quantitated with a biothesiometer, Semmes-Weinstein monofilaments, and two-point discrimination in 10 patients. Ten patients, 2 to 7 years after pedicled transverse rectus abdominis musculocutaneous flap (TRAM) breast reconstruction, were tested in a similar manner. The majority of these patients were found to have recorded measurable sensibility in the TRAM reconstruction. Recovered sensation was best in the medial and superior quadrants and improved with time. Although sensibility was present, it was still significantly different from normal sensory thresholds. A method to improve sensation by intercostal nerve repair is described. Three patients who have undergone this reconstruction have better sensibility in the reinnervated breast compared with the control breast. Sensory reeducation programs may also improve subsequent sensibility return.
Adult↗
Technical modifications for on-site nipple-areola reconstruction.
There have been numerous techniques and refinements for nipple-areola reconstruction described that have required the use of distant donor sites. A further modification of the skate flap is described, whereby the entire reconstruction can be performed on site, thus avoiding a second scar and any subsequent morbidity. This technique is easy to perform and has all the advantages of the skate flap as described by Little.
Female↗
Platelet-mediated cytotoxicity. Role of antibody and C3, and localization of the cytotoxic system in membranes.
Platelets are one of several cell types capable of mediating antibody-dependent cellular cytotoxicity. We have developed a plasma-free system in which washed mouse platelets lyse washed antibody and complement-sensitized SRBC targets in the presence of EDTA. The dose-response curve is concave to the abscissa, indicating that lysis is a one-hit reaction. Determination of the actual number of platelets required to lyse a target shows that each platelet could lyse a single target. A limited degree of lysis is observed when platelets are incubated with SRBC sensitized with monoclonal IgG2a alone, but no lysis occurs with SRBC bearing comparable amounts of other isotypes. In the presence of C1 through C3, but not C1 through C2, efficient lysis is triggered by complement-fixing monoclonal IgG2a, IgG2b, and IgG3. In contrast, IgM and non-complement-fixing IgG1 and IgE are inactive. To achieve efficient lysis, it appears that platelets require both target cell-bound antibody and C3 fragments in close proximity. It is unlikely that proteases, pore-forming proteins, or toxic oxygen metabolites are involved in platelet-mediated lysis. Freezing and thawing of platelets, sonication, or sonication followed by hypotonic shock causes severe depletion of cytoplasmic and granular contents, as shown by electron microscopy and marker assays. However, the membrane fraction of these preparations retains cytolytic activity. When platelets are treated with trypsin or heated, lytic activity is eliminated, indicating that at least one component of this system is protein. These findings, as well as the fact that platelets do not lyse unsensitized innocent bystander SRBC, suggest that the complete cytotoxic system of platelets capable of specific recognition and lysis resides in their membranes.
Animals↗