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PubMed2003

Improved outcome after extended gastric myotomy for achalasia.

HYPOTHESIS: There is general agreement that a Heller myotomy should extend 6 to 7 cm above the gastroesophageal junction. Results of most previous studies have recommended that the myotomy extend 1 to 1.5 cm below the gastroesophageal junction. We speculated that the effectiveness of the operation could be improved if a longer, 3-cm myotomy was carried out below the gastroesophageal junction, as it would more completely obliterate the lower esophageal sphincter. We, therefore, changed our technique in 1998. Concurrently, we converted from a Dor fundoplication to a Toupet fundoplication. This study analyzes the results of our new strategy. DESIGN: A case series using a prospectively maintained database. SETTING: Tertiary referral center. PATIENTS: One hundred ten consecutive patients with achalasia undergoing laparoscopic Heller myotomy. INTERVENTION: We analyzed the course of 52 patients treated with a standard laparoscopic esophagogastric myotomy (1.5 cm in the stomach) and a Dor fundoplication between September 1, 1994, and August 31, 1998, and 58 treated with an extended gastric myotomy (3 cm below the gastroesophageal junction) and a Toupet fundoplication between September 1, 1998, and August 31, 2001. MAIN OUTCOME MEASURES: Esophageal function testing (esophageal manometry and 24-hour pH monitoring), symptom questionnaire (frequency and severity), and postoperative interventions required. RESULTS: Postoperatively the lower esophageal sphincter pressure was significantly lower after extended gastric myotomy and a Toupet fundoplication vs standard myotomy and a Dor fundoplication (9.5 vs 15.8 mm Hg). Dysphagia was both less frequent (1.2 vs 2.1) and less severe (visual analog scale, 3.2 vs 5.3) after extended gastric myotomy and Toupet fundoplication. In the standard laparoscopic esophagogastric myotomy and a Dor fundoplication group, 9 patients (17%) had recurrent, severe dysphagia, which was treated by dilation in 5 patients and by reoperation in 4 patients. In the extended gastric myotomy and Toupet fundoplication group, 2 patients (3%) developed recurrent dysphagia that resolved with dilatation. There were no reoperations in the extended gastric myotomy and Toupet fundoplication group. No difference was noted in the frequency of heartburn (1.3 vs 1.7), regurgitation (0.3 vs 0.8), and chest pain (0.3 vs 0.6), nor was there a difference between the 2 groups in proximal (1.7% vs 2.3%) and distal (6.0% vs 5.9%) esophageal acid exposure. CONCLUSION: An extended gastric myotomy (3 cm) more effectively disrupts the lower esophageal sphincter, thus improving the results of surgical therapy for achalasia for dysphagia without increasing the rate of abnormal gastroesophageal reflux provided that a Toupet fundoplication is added.

Deglutition Disorders↗

PubMed2006

Concentrations of cortisol, testosterone and glycosylated haemoglobin (HbA1c) among construction workers with 12-h workdays and extended workweeks.

OBJECTIVES: Working on large scale construction sites have been shown to have severe health consequences in terms of increased risk of hospitalization and disability retirement compared to construction work in general. The aim of the present study was to investigate whether large scale construction work involving 12-h workdays and extended workweeks leads to insufficient recovery measured as increased catabolic and decreased anabolic metabolism. METHODS: The study group comprised 40 male construction workers of which 21 had 12-h workdays and extended workweeks (56 h/workweek). The comparison group consisted of 19 male construction workers, who worked regular hours (37 h/week, weekends off). Measurements of concentrations of cortisol in saliva and free testosterone and glycosylated haemoglobin (HbA(1c)) in blood were made in a repeated measures design during 2 workweeks for both groups supplemented with 1 week off for construction workers with extended workweeks. RESULTS: The diurnal profile of concentrations of salivary cortisol for construction workers with extended workweeks differed from the diurnal profile of salivary cortisol for those with regular work schedules (P < 0.001). The construction workers with extended workweeks tended to have 15% [95% CI -3%; 37%] higher concentrations of free testosterone in serum compared to construction workers with regular work schedules (P = 0.09). There were no differences between the two groups with respect to concentrations of HbA(1c). There was no increasing trend in concentrations of cortisol or decreasing trend in concentrations of testosterone during the extended workweek. The diurnal profile for concentrations of cortisol differed between workdays and days off for construction workers with extended workweeks (P = 0.003). CONCLUSION: In conclusion, we observed no indications of insufficient recovery in terms of increased catabolic or decreased anabolic metabolism in construction workers with 12-h workdays and extended workweeks compared to construction workers with regular work schedules.

Adult↗

PubMed1999

Extended resection for intrahepatic cholangiocarcinoma in Japan.

To elucidate surgical outcome after extended surgery for intrahepatic cholangiocarcinoma (ICC), we retrospectively allocated 83 patients who had undergone resection to a standard surgery group (n = 56), in which the patients had undergone hepatectomy alone or hepatectomy with bile duct resection, and an extended surgery group (n = 27), in which the patients had undergone the standard operation combined with vessel resection and/or pancreatectomy. The incidence of mass-forming plus periductal-infiltrating type lesions (P = 0. 0129), lymph node metastasis (P = 0.0005), noncurative resection (P < 0.0001), mortality within 30 days and within 1 year after surgery (P = 0.0392, P = 0.0010), local recurrence (P = 0.0439), and peritoneal disseminated recurrence (P = 0.0241) was significantly higher in the extended surgery group than in the standard surgery group. The 5-year survival rate was significantly higher in the standard surgery group (30%) than in the extended surgery group (10%; P = 0.0061). The mortality rate within 1 year after extended surgery was significantly higher in the patients with infiltrating-spread type tumors than in the patients with non-infiltrating spread type tumors (P = 0.0032), and long-term (5-year) survival in the extended surgery group was significantly lower in the patients with infiltrating-spread type tumors than in the patients with non-infiltrating spread type tumors (P = 0.0253). We conclude that extended surgery does not improve the curative resection rate or the surgical outcome of ICC, and that extended surgery is not indicated for patients with infiltrating-spread type tumors.

Adult↗

PubMed1995

Fetal oxytocin and its extended forms at term with and without labor.

OBJECTIVE: We examined the concentrations of oxytocin and extended forms of oxytocin in umbilical plasma with and without labor. STUDY DESIGN: Umbilical venous and arterial blood were sampled in 27 term fetuses delivered vaginally and 13 delivered abdominally before labor. Extended forms and oxytocin were measured by radioimmunoassay and compared by analysis of variance or t test. RESULTS: Concentrations of extended forms were higher than oxytocin concentrations (24.7 +/- 3.1 vs 6.1 +/- 1.2 pg/ml, p < 0.01). Extended forms were higher in umbilical venous than in arterial plasma (29.6 +/- 5.0 vs 19.8 +/- 3.1 pg/ml, p < 0.05); oxytocin concentrations were not significantly different (4.7 +/- 1.6 vs 7.8 +/- 1.8 pg/ml). Concentrations of extended forms were markedly lower with than without labor (17.1 +/- 3.0 vs 37.1 +/- 5.7 pg/ml, p = 0.01). Ratios of extended forms over oxytocin decreased with labor. CONCLUSION: In umbilical plasma extended forms of oxytocin are more abundant than oxytocin. Extended forms originate in the uterus and decrease markedly with labor.

Female↗

PubMed1984

Extenders for preservation of canine and equine spermatozoa at 5 degrees C.

Two experiments were conducted to evaluate the effects of six extenders and three glycerol levels on the motility of sperm stored at 5 degrees C. Using a split-ejaculated design, semen from 10 dogs and 12 stallions was extended with egg-yolk-tris (EYT), egg-yolk-bicarbonate (EGB), Beltsville F-3 (BF-3), Cornell University (CUE), caprogen (CAP) and heated skim milk (SM) extenders. After cooling to 5 degrees C, additional extender containing 0% to 12% glycerol was added to provide a final concentration of 0%, 3% or 6% glycerol. Regardless of glycerol level, a higher (P<0.05) percentage of canine sperm retained their potential for progressive motility in CAP extender than in EYT, SM, CUE, EGB or BF-3 extenders. The SM extender was the best (P<0.05) for maintaining motility of equine sperm. The inclusion of 6% glycerol depressed (P<0.05) motility of canine sperm, but there was no effect (P>0.05) of glycerol concentration on the percentage of motile equine sperm. For both species, the interaction of glycerol level and extender was nonsignificant. CAP may be useful for storage of canine sperm at 5 degrees C and SM may be satisfactory for storage of equine sperm.

Journal Article↗

PubMed1995

Effect of a serum extender containing growth factors on development of IVM and IVF bovine embryos.

The present experiments were conducted to determine if supplementation of the culture medium with a serum extender containing growth factors would increase development of bovine embryos into morulae or blastocysts, following in vitro maturation (IVM) and in vitro fertilization (IVF). In Experiment 1, bovine zygotes were cultured in CR1 medium supplemented with 0, 0.01, 0.1, 1 or 10% serum extender. In Experiment 2, bovine zygotes were cultured in the presence of cumulus cells in CR1 medium supplemented with 0, 0.01, 0.1, 1 or 10% serum extender. In Experiment 3, bovine oocytes were matured in Medium 199 supplemented with 0, 0.01, 0.1, 1 or 10% serum extender. In Experiment 4, oocytes were matured in Medium 199 with 10% fetal bovine serum (FBS) or 5% FBS with serum extender. Following maturation, zygotes were cultured in CR1 medium with 10% FBS or 5 % FBS and serum extender. In all 4 experiments, the embryos were cultured in vitro until Day 7 after IVF, and development to the morula or blastocyst stage was assessed. The findings of the first 2 experiments showed that the serum extender did not directly influence embryo development but did stimulate development when cumulus cells were included in the culture system. The remaining 2 experiments showed that the serum extender did influence development through its interactions with cumulus cells during maturation and/or culture. These findings suggest that although growth factors or other products do not directly stimulate bovine embryo development their effects may be mediated through secondary cell systems.

Journal Article↗

PubMed2005

Comparison of two dilution rates on canine semen quality after cryopreservation in a coconut water extender.

The objective of the present study was to evaluate the effect of sperm dilution (one part semen:one part extender or at 200 x 10(6) spermatozoa/mL) using a coconut water extender on the post-thaw sperm quality. Twelve ejaculates were collected from six dogs. Semen was divided into two aliquots, one for dilution one part semen:one part extender (group 1) and another for a concentration of 200 x 10(6) spermatozoa/mL (group 2). Semen was initially extended at 37 degrees C at a proportion of one part semen:half part extender (1:1/2) for group 1 (A-fraction). For group 2, the volume for a concentration of 200 x 10(6) spermatozoa/mL was calculated and a half of this volume was used for the initial dilution (A-fraction, 37 degrees C). Coconut water extender containing 20% egg yolk was used for this initial dilution in both groups. After dilution, the semen was cooled for 40 min in a thermal box (15 degrees C) and for 30 min in a refrigerator. The other half of the extender (B-fraction) containing egg yolk and glycerol (12%) was added to semen in both groups. Subsequently, the final concentration of glycerol in the extender was 6%. Ejaculates were frozen in 0.25 mL straws 5 cm above the surface of liquid nitrogen and stored at -196 degrees C. After 1 week, straws were thawed at 37 degrees C for 1 min and the microscopic criteria were evaluated. The dilution method had no influence on sperm motility, vigor and normal spermatozoa (71.4 compared with 67.7%). There was no effect of dog, ejaculate within male on post-thaw semen quality. Moreover, there was not a male x treatment interaction. Both treatments were efficient in preserving sperm quality.

Animals↗

PubMed2006

Randomized controlled noninferiority trial to compare extended release acetaminophen and ibuprofen for the treatment of ankle sprains.

STUDY OBJECTIVE: To compare acetaminophen extended release 1,300 mg 3 times daily and ibuprofen 400 mg 3 times daily for treatment of signs and symptoms of grade I or II lateral ankle sprains. METHODS: Patients (N=260) 18 years or older and with grade I or II lateral ankle sprains were randomized to receive acetaminophen extended release 1,300 mg 3 times daily or ibuprofen 400 mg 3 times daily for 9 days. Primary endpoint was change from baseline at day 4 in pain on walking. Other endpoints included change from baseline at day 9 in pain on walking; change from baseline at days 4 and 9 in ability to walk and ankle swelling, bruising, and range of motion; satisfaction with treatment on days 4 and 9; percentage of patients with positive anterior drawer test on day 4; and time to resume normal activity. Safety assessments consisted of reported adverse events. This study had a noninferiority design in which the hypothesis was that acetaminophen extended release was not inferior to ibuprofen for treatment of signs and symptoms of grade I or II lateral ankle sprains. RESULTS: The difference in least squares means (acetaminophen extended release, ibuprofen) with respect to the primary endpoint within the per-protocol population was -0.88; acetaminophen extended release was comparable to ibuprofen for the primary endpoint because the upper limit (3.26) of the 1-sided 95% confidence interval (CI) for the difference in least squares means did not exceed the noninferiority limit of 6.90. The intention-to-treat population was used to test the second step of the 2-step testing process because the null hypothesis was rejected in the noninferiority test. For this analysis, the difference between acetaminophen extended release and ibuprofen in the least squares mean change from baseline for the primary endpoint was -1.63 (not significant). Results showed that acetaminophen extended release was noninferior to ibuprofen with respect to the secondary endpoints. No serious drug-related adverse events were reported. The most common adverse events, reported by 6.5% of patients, were in the gastrointestinal system (mainly nausea and upper abdominal pain). CONCLUSION: Acetaminophen extended release 3,900 mg daily was comparable to ibuprofen 1,200 mg daily for treatment of grade I or II lateral ankle sprains. Both treatments were well tolerated.

Acetaminophen↗

PubMed2004

Preliminary study on the cryopreservation of tropical bagrid catfish (Mystus nemurus) spermatozoa; the effect of extender and cryoprotectant on the motility after short-term storage.

The effects of different extenders, and cryoprotectants on the motility of tropical bagrid catfish (Mystus nemurus) spermatozoa were evaluated after short-term storage. Three extenders, physiological saline, Ringer or saline at three levels of sperm to extender dilutions (1:20, 1:30, or 1:40) and four cryoprotectants (DMSO, ethanol, glycerol or methanol) at three concentrations (5, 10, or 15%) were examined in two separate experiments. In the first experiment, milt was suspended in the respective extender at the three milt to extender dilution ratios in two sets of tubes. Extended milt in the first set of tubes was stored at -4 degrees C, and motility assessed after 24h, while the second set was kept at 23 degrees C and sperm motility was assessed immediately and at 30-min intervals thereafter. Ringer retained sperm motility better than the other extenders at all dilution levels at temperatures of 23 and -4 degrees C respectively. At 23 degrees C, the sperm motility was almost completely lost after 150 min except for those in Ringer at 1:20 dilution level which still had a motility of 18% (compared to those kept at -4 degrees C for 24, which had motility from 39 to 71%, regardless of extender). In the second experiment, various cryoprotectants were added to solutions of milt (that was diluted in Ringer at 1:20 ratio and cryopreserved in liquid nitrogen for 15 days). Sperm cryopreserved in 10% methanol had the highest motility (58%) compared with those in the other cryoprotectants at all concentrations.

Animals↗

PubMed2000

Field investigations of bacterial contaminants and their effects on extended porcine semen.

Field investigations (n=23) were made over a 3-yr period at North American boar studs and farms in which the primary complaint was sperm agglutination in association with decreased sperm longevity of extended semen, and increased regular returns to estrus and/or vaginal discharges across parity. Microscopic examination of extended semen from these units revealed depressed gross motility (usually <30%), sperm agglutination, and sperm cell death occurring within 2 d of semen collection and processing regardless of the semen extender used. The extended semen exhibited a high number of induced acrosome abnormalities (>20%). Sample pH was acidic (5.7 to 6.4) in 93% of the submitted samples. Aerobic culture yielded a variety of bacteria from different genera. A single bacterial contaminant was obtained from 66% of the submitted samples (n=37 doses); 34% contained 2 or more different bacterial genera. The most frequently isolated contaminant bacteria from porcine extended semen were Alcaligenes xylosoxydans (n=3), Burkholderia cepacia (n=6), Enterobacter cloacae (n=6), Escherichia coli (n=6), Serratia marcescens (n=5), and Stenotrophomonas [Xanthomonas] maltophilia (n=6); these 6 bacteria accounted for 71% of all contaminated samples, and were spermicidal when re-inoculated and incubated in fresh, high quality extended semen. All contaminant bacteria were found to be resistant to the aminoglycoside gentamicin, a common preservative antibiotic used in commercial porcine semen extenders. Eleven genera were spermicidal in conjunction with an acidic environment, while 2 strains (E. coli, S. maltophilia) were spermicidal without this characteristic acidic environment. Bacteria originated from multiple sources at the stud/farm, and were of animal and nonanimal origin. A minimum contamination technique (MCT) protocol was developed to standardize hygiene and sanitation. This protocol focused on MCT's during boar preparation, semen collection, semen processing and laboratory sanitation. Implementation of the MCT, in addition to specific recommendations in stud management, resulted in the control of bacterial contamination in the extended semen.

Alcaligenes↗

PubMed2003

Effect of milk- and TRIS-based extenders on the fertility of sheep inseminated vaginally once or twice with liquid semen.

We studied the influence of two different extenders, a milk-based versus a TRIS-based extender, using a split-sample technique, on fertility after single and double vaginal inseminations in natural estrous in Norwegian Crossbred ewes. Semen from 21 Norwegian Crossbred rams, all aged approximately 0.5 years, was used for AI of totally 561 Norwegian Crossbred ewes housed at 37 different farms. The farmers performed the inseminations themselves. The ewes were allocated to four parallel groups based on the two extenders and single or double inseminations (2 x 2). The farmers were recommended to inseminate the ewes between 12 and 24 h after detection of natural standing estrous. Vaginal insemination with cooled liquid semen diluted in the milk-based extender resulted in a statistically significant (P<0.01) better fertility of about 10% units both as 25-day NR (non return rate)-and lambing rates, compared with semen diluted in the TRIS-based extender. Double inseminations gave significantly higher (P=0.03) fertility results for both extenders expressed as 25-day NR results, but was not quite statistically significant when expressed as lambing rates (P=0.06) compared with single insemination. The overall 25-day NR results for the milk-based extender (66.4%) after single inseminations is in accordance with both the national results (67.1%) based on vaginal inseminations of 11,377 ewes, as well as with the results from a previous study in the same region achieving a 25-day NR results of 63.3%. In conclusion, liquid ram semen diluted in a milk-based extender and vaginally inseminated once in natural heat, with a semen dose of 150 x 10(6) spermatozoa, gave acceptable fertility results and is to be recommended as the method of choice in Norway.

Animals↗

PubMed2006

Hydroxymalonyl-acyl carrier protein (ACP) and aminomalonyl-ACP are two additional type I polyketide synthase extender units.

Combinatorial biosynthesis of type I polyketide synthases is a promising approach for the generation of new structural derivatives of polyketide-containing natural products. A target of this approach has been to change the extender units incorporated into a polyketide backbone to alter the structure and activity of the natural product. One limitation to these efforts is that only four extender units were known: malonyl-CoA, methylmalonyl-CoA, ethylmalonyl-CoA, and methoxymalonyl-acyl carrier protein (ACP). The chemical attributes of these extender units are quite similar, with the exception of the potential hydrogen bonding interactions by the oxygen of the methoxy moiety. Furthermore, the incorporated extender units are not easily modified by using simple chemical approaches when combinatorial biosynthesis is coupled to semisynthetic chemistry. We recently proposed the existence of two additional extender units, hydroxymalonyl-ACP and aminomalonyl-ACP, involved in the biosynthesis of zwittermicin A. These extender units offer unique possibilities for combinatorial biosynthesis and semisynthetic chemistry because of the introduction of free hydroxyl and amino moieties into a polyketide structure. Here, we present the biochemical and mass spectral evidence for the formation of these extender units. This evidence shows the formation of ACP-linked extender units for polyketide synthesis. Interestingly, aminomalonyl-ACP formation involves enzymology typically found in nonribosomal peptide synthesis.

Acyl Carrier Protein↗

PubMed2007

Piperacillin-tazobactam for Pseudomonas aeruginosa infection: clinical implications of an extended-infusion dosing strategy.

BACKGROUND: Piperacillin-tazobactam is frequently used to treat Pseudomonas aeruginosa infections in critically ill patients. In an effort to improve clinical outcomes, an extended-infusion dosing scheme for piperacillin-tazobactam therapy was devised using a Monte Carlo simulation and was adopted into clinical practice at Albany Medical Center (Albany, New York). This study evaluates the clinical implications of extended infusion of piperacillin-tazobactam therapy for critically ill patients with P. aeruginosa infection. METHODS: We performed a cohort study of patients who received piperacillin-tazobactam therapy for a P. aeruginosa infection that was susceptible to piperacillin-tazobactam during the period January 2000-June 2004. Prior to February 2002, all patients received intermittent infusions of piperacillin-tazobactam (3.375 g intravenously for 30 min every 4 or 6 h); after this time, all patients received extended infusions of piperacillin-tazobactam (3.375 g intravenously for 4 h every 8 h). Data on demographic characteristics, disease severity, and microbiology were collected, and outcomes were compared between groups. RESULTS: A total of 194 patients comprised the 2 study groups: 102 patients received extended infusions of piperacillin-tazobactam, and 92 patients received intermittent infusions of piperacillin-tazobactam. No differences in baseline clinical characteristics were noted between the 2 groups. Among patients with Acute Physiological and Chronic Health Evaluation-II scores > or =17, 14-day mortality rate was significantly lower among patients who received extended-infusion therapy than among patients who received intermittent-infusion therapy (12.2% vs. 31.6%, respectively; P=.04), and median duration of hospital stay after collection of samples for culture was significantly shorter for patients who received extended-infusion therapy than for patients who received intermittent-infusion therapy (21 days vs. 38 days; P=.02).Conclusions. These results indicate that extended-infusion piperacillin-tazobactam therapy is a suitable alternative to intermittent-infusion piperacillin-tazobactam therapy, and they strongly suggest that improved outcomes may be realized by administering extended-infusion piperacillin-tazobactam therapy to critically ill patients with P. aeruginosa infection.

APACHE↗

PubMed2005

Effect of extended diapause on evolution of resistance to transgenic Bacillus thuringiensis corn by northern corn rootworm (Coleoptera: Chrysomelidae).

We develop a population genetics model for the northern corn rootworm, Diabrotica barberi Smith & Lawrence, to examine the effect of extended diapause on the evolution of resistance to transgenic Bacillus thuringiensis (Bt) corn, Zea mays L. We model conditions found in the center of the extended diapause problem along the Minnesota-South Dakota-Iowa borders. The proportion of resistance alleles in eggs oviposited after 15 simulated years is used to measure the evolution of resistance. Sensitivity analysis indicates that although population genetics parameters (fecundity, initial egg density, density-dependent larval survival, random mating, insecticide mortality, and gene expression) affect the evolution of resistance, product characteristics (e.g., Bt toxin dose) and farmer management practices (e.g., insecticide use on refuge corn and rotation pattern) generally have a larger impact on the development of resistance. Exceptions to this generalization exist: 1) if the resistance allele is dominant, resistance evolves quickly; 2) the level of random mating is an important determinant of how quickly resistance evolves for a theoretical high dose product; and 3) small differences in insecticide mortality imply large differences in resistance for medium- and low-dose products with high levels of Bt corn adoption and a predominance of 1- and 2-yr corn rotations. When extended diapause spreads into a new area, it typically reduces resistance to Bt corn, assuming Bt corn is used only on continuous corn. In the study region where extended diapause already exists, increasing extended diapause (increasing hatch rates after two or three winters while holding total hatch constant), tends to increase resistance because the resistance increasing effect of the hatch rate after two winters dominates the resistance decreasing effect of the hatch rate after three winters. However, this is not always the case, because combinations of rotation pattern, toxin dose, and soil insecticide use exist for which the net effect of extended diapause decreases resistance. Results are interpreted as a combination of two offsetting effects. First, extended diapause injects older alleles with lower resistance allele frequencies into the breeding population, which slows resistance. Second, extended diapause speeds the population's recovery from perturbations (reduces the undercompensating density dependence of population dynamics), which accelerates resistance.

Animals↗

PubMed2002

Autologous breast reconstruction with the extended latissimus dorsi flap.

The extended latissimus dorsi myocutaneous flap can provide autogenous tissue replacement of breast volume without an implant. Nevertheless, experience with the extended latissimus dorsi flap for breast reconstruction is relatively limited. In this study, the authors evaluated their experience with the extended latissimus dorsi flap for breast reconstruction to better understand its indications, limitations, complications, and clinical outcomes. All patients who underwent breast reconstruction with extended latissimus dorsi flaps at the authors' institution between January of 1990 and December of 2000 were reviewed. During the study period, 75 extended latissimus dorsi flap breast reconstructions were performed in 67 patients. Bilateral breast reconstructions were performed in eight patients, and 59 patients underwent unilateral breast reconstruction. There were 45 immediate and 30 delayed reconstructions. Mean patient age was 51.5 years. Mean body mass index was 31.8 kg/m2. Flap complications developed in 21 of 75 flaps (28.0 percent), and donor-site complications developed in 29 of 75 donor sites (38.7 percent). Mastectomy skin flap necrosis (17.3 percent) and donor-site seroma (25.3 percent) were found to be the most common complications. There were no flap losses. Patients aged 65 years or older had higher odds of developing flap complications compared with those 45 years or younger (p = 0.03). Patients with size D reconstructed breasts had significantly higher odds of flap complications compared with those with size A or B reconstructed breasts (p = 0.05). Obesity (body mass index greater than or equal to 30 kg/m2) was associated with a 2.15-fold increase in the odds of developing donor-site complications compared with patients with a body mass index less than 30 kg/m2 (p = 0.01). No other studied factors had a significant relationship with flap or donor-site complications. In most patients, the extended latissimus dorsi flap alone, without an implant, can provide good to excellent autologous reconstruction of small to medium sized breasts. In selected patients, larger breasts may be reconstructed with the extended latissimus dorsi flap alone. This flap's main disadvantage is donor-site morbidity with prolonged drainage and risk of seroma. Patients who are obese are at higher risk of developing these donor-site complications. In conclusion, the extended latissimus dorsi flap is a reliable method for total autologous breast reconstruction in most patients and should be considered more often as a primary choice for breast reconstruction.

Body Mass Index↗

PubMed2005

Width of the extended facial recess: a numerical study of ultrahigh-resolution computed tomography and its implications in minimally invasive otologic surgery.

BACKGROUND: Methods of minimally invasive computer-assisted otologic surgery lag behind other fields. The reason seems to be the extremely small dimensions of the corridors between important structures in the temporal bone and the fact that these structures are encased in bony frameworks, are obscured before drilling, and are not movable. The extended facial recess is a surgical pass to the tympanic cavity. It is bounded medially by the facial nerve and laterally by the tympanic annulus, and varies among individuals. For computer-assisted, minimally invasive temporal bone surgery, high-resolution definition is critically important. AIMS: To determine the width of the extended facial recess and evaluate the computerized findings as a pre- and intraoperative aid to otologic surgery planning. METHODS: Bilateral temporal bone high-resolution computed tomographic images of 100 male and 100 female patients were measured twice at five levels (caudal to cephalic), first using a window-independent algorithm (extended facial recess, full-width at half-maximum), implemented in a computed tomographic image-processing workstation, and then manually with calipers on the same axial computed tomographic images. RESULTS: As expected, the extended facial recess, full-width at half-maximum method yielded the widest values superiorly (4.15 +/- 0.41 mm in the female patients and 4.32 +/- 0.54 mm in the male patients). From this level down, the extended facial recess, full-width at half-maximum method yielded values that tapered gradually to 2.50 +/- 0.56 mm in the female patients and 2.42 +/- 0.46 mm in the male patients at the most interior level. The manual method (extended facial recess, computed tomographic images) yielded a significantly higher value than that obtained with the objective, window-independent method at all levels, and at some levels was higher by as much as one-third. At Level 2, which corresponded roughly to the round window, the extended facial recess was 4.00 +/- 0.65 in the female study group and 4.11 +/- 0.67 mm in the male study group. CONCLUSION: Image processing methods such as extended facial recess, full-width at half-maximum method might lead to fine tuning and thus improvement of computer-assisted otologic surgery. Before clinical application and complete dependence on these automated methods during otologic surgery, their reliability should be further validated.

Adolescent↗

PubMed2003

Preoperative portal vein embolization for extended hepatectomy.

OBJECTIVE: To examine the authors' experience with preoperative ipsilateral portal vein embolization (PVE) and assess its role in extended hepatectomy. SUMMARY BACKGROUND DATA: Extended hepatectomy (five or more liver segments) has been associated with higher complication rates and increased postoperative liver dysfunction than have standard hepatic resections involving lesser volumes. Recently, PVE has been used in patients who have a predicted (postresection) future liver remnant (FLR) volume less than 25% of total liver volume in an attempt to increase the FLR and reduce complications. METHODS: Sixty patients from 1996 to 2002 were reviewed. Thirty-nine patients had PVE preoperatively. Eight patients who had PVE were not resected either due to the discovery of additional unresectable disease after embolization but before surgery (n = 5) or due to unresectable disease at surgery (n = 3). Therefore, 31 patients who had PVE subsequently underwent extended hepatic lobectomy. A comparable cohort of 21 patients who had an extended hepatectomy without PVE were selected on the basis of demographic, tumor, and liver volume characteristics. Patients had colorectal liver metastases (n = 30), hepatocellular carcinoma (n = 15), Klatskin tumors (n = 9), peripheral cholangiocarcinoma (n = 3), and other tumors (n = 3). The 52 resections performed included 42 extended right hepatectomies, 6 extended left hepatectomies, and 4 right hepatectomies extended to include the middle hepatic vein and the caudate lobe but preserving the majority of segment 4. Concomitant vascular reconstruction of either the inferior vena cava or hepatic veins was performed in five patients. RESULTS: There were no differences between PVE and non-PVE groups in terms of tumor number, tumor size, tumor type, surgical margin status, complexity of operation, or perioperative red cell transfusion requirements. The predicted FLR was similar between PVE and non-PVE groups at presentation. After PVE the FLR was higher than in the non-PVE group. No complications were observed after PVE before resection. There was no difference in postoperative mortality, with one death from liver failure in the non-PVE group and no operative mortality in the PVE group. Postoperative peak bilirubin was higher in the non-PVE than the PVE group, as were postoperative fresh-frozen plasma requirements. Liver failure (defined as the development of encephalopathy, ascites requiring sustained diuretics or paracentesis, or coagulopathy unresponsive to vitamin K requiring fresh-frozen plasma after the first 24 hours postresection) was higher in the non-PVE patients than the PVE patients. The hospital stay was longer in the non-PVE than the PVE group. CONCLUSIONS: Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.

Adult↗

PubMed1993

Gametic association of HSP70-1 promoter region alleles and their inclusion in extended HLA haplotypes.

Gametic associations of a three-allele polymorphism of the HSP70-1 promoter region were analyzed in a random North Italian population, in 69 HLA homozygous cell lines and in 29 families in Boston, all typed for HLA class I, class II and complement alleles. Significant phenotypic associations were detected in the random population between HSP70-1 alleles and several HLA markers carried by extended haplotypes. The inclusion of HSP70-1 alleles in extended haplotypes, suggested by population analysis, was confirmed in genotyped cells, including 10W HLA homozygous cell lines and families, selected for the presence of the whole set of alleles reported for conserved extended haplotypes. Every tested extended haplotype was exclusively associated with a given HSP70-1 allele, except those carrying DR1. HSP70-1 C was included in both [HLA-B8, SC01, DR3] and [HLA-B18, F1C30, DR3] extended haplotypes, accounting for the previously observed strong association with DR3. In addition the same allele was found on the [HLA-B13, SC31, DR7], on the [HLA-B62, SB42, DR4] and on the [HLA-B60, SC02, DR13] extended haplotypes. The HSP70-1 A allele was carried by all DR4+ extended haplotypes except the one above cited. HSP70-1 B correlated with DR10, DQB1*0501 and BF*F. Thus the HSP70-1 promoter alleles provide new precisely located markers of extended haplotypes.

Alleles↗