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The need for high-quality, large-scale, goal-oriented dialogue datasets continues to grow as virtual assistants become increasingly wide-spread. However, publicly available datasets useful for this area are limited either in their size, linguistic diversity, domain coverage, or annotation granularity. In this paper, we present strategies toward curating and annotating large scale goal oriented dialogue data. We introduce the MultiDoGO dataset to overcome these limitations. With a total of over 81K dialogues harvested across six domains, MultiDoGO is over 8 times the size of MultiWOZ, the other largest comparable dialogue dataset currently available to the public. Over 54K of these harvested conversations are annotated for intent classes and slot labels. We adopt a Wizard-of-Oz approach wherein a crowd-sourced worker (the “customer”) is paired with a trained annotator (the “agent”). The data curation process was controlled via biases to ensure a diversity in dialogue flows following variable dialogue policies. We provide distinct class label tags for agents vs. customer utterances, along with applicable slot labels. We also compare and contrast our strategies on annotation granularity, i.e. turn vs. sentence level. Furthermore, we compare and contrast annotations curated by leveraging professional annotators vs the crowd. We believe our strategies for eliciting and annotating such a dialogue dataset scales across modalities and domains and potentially languages in the future. To demonstrate the efficacy of our devised strategies we establish neural baselines for classification on the agent and customer utterances as well as slot labeling for each domain.

Diastolic dysfunction is the early sign of myocardial ischemia that usually occurs earlier than ECG changes.To determine the existence of a correlation between ST segment shift and diastolic dysfunction among patients with AMI.Fourty six patients with significant ST segment elevation or depression and having symptoms of acute myocardial infarction for12 h were enrolled in this study. Patients were examined for serial ECG, cardiac enzymes, and echocardiography.There was no significant correlation between ST segment elevation or depression and majority of the diastolic indices. Few diastolic parameters; such as, E/A ratio of the mitral valve and deceleration time of the tricuspid valve showed a direct correlation with the ECG changes. Whereas, the Tei Index of the LV function showed a borderline correlation to the ST segment elevation at discharge.Overall, there was no correlation between either ST segment elevation or depression and the LV or RV diastolic function in patients with acute coronary syndrome (ACS). Improvement of the ST segment total score was associated with improvement of the diastolic function grades at discharge. Moreover, this association has shown an evidence of dose response relationship, the more improvement in total score at discharge the more improvement in diastolic function grade level.

Von den Cochlea-Implantat-Herstellern werden für einen optimalen Resthörerhalt immer dünnere Elektrodendesigns entwickelt. Diese begünstigen jedoch einen teilweisen Rückzug der Elektrode aus der Cochlea (Elektrodenmigration), der auch noch Monate nach dem Eingriff auftreten kann. Eine mögliche chirurgische Lösung ist die Fixierung des Elektrodenkabels in einer Rinne im Chorda-Fazialis-Winkel. Ziel der Arbeit war die Erarbeitung der idealen Geometrie der Rinne zur stabilen Aufnahme des Elektrodenkabels. Im Rahmen der experimentellen Untersuchung wurden mit einer CNC-Fräse Elektrodenrinnen in frischem porcinen Femurknochen angelegt. Hierbei wurden der Durchmesser und die Öffnungsbreite variiert. An einem Kraftmessstand wurden die auftretenden Kräfte beim Einpressen einer flex28®-Elektrode (MED-EL) in die Rinne sowie die Haltekraft der Rinne gemessen. Abschließend wurden die Elektrodenkabel mikroskopisch untersucht, um etwaige Beschädigungen zu evaluieren. Es wurden 180 Kraftmessungen durchgeführt. Hierbei zeigt sich ein Maximum der Haltekraft von über 80 mN bei einem Rinnendurchmesser von 1,10 mm und einer Öffnungsbreite von 0,90 mm. Die erforderliche Einpresskraft der Elektrode in die Rinne ist bei einer Öffnungsbreite von 0,95 mm minimal, liegt aber generell um Faktor 2 bis 3 höher als die Haltekraft. In keinem Fall fanden wir eine Beschädigung oder Quetschung des Elektrodenkabels. Die Anlage einer Rinne im Recessus facialis zur Aufnahme einer CI-Elektrode ist eine geeignete Maßnahme zur Verhinderung von Elektrodenmigration. Die klinische Erfahrung zeigt jedoch, dass diese Bohrung exakt ausgeführt werden muss, um einen sicheren Halt zu gewährleisten. Wir konnten die optimale Geometrie der Rinne ermitteln und gleichzeitig eine Gefährdung des Elektrodenkabels ausschließen. Der Erstautor gibt keinen Interessenkonflikt an., GMS Current Posters in Otorhinolaryngology - Head and Neck Surgery; 13:Doc142

Objectives The objectives of this study were to measure physician satisfaction with a recently introduced electronic medical record (EMR) system and to determine which of the individual attributes of EMR were related to physician satisfaction. Methods One year after introduction of an EMR system, physicians in an inpatient department were asked to answer a self-administered survey. Pearson's correlation coefficient was used to determine which attributes were significantly related to overall satisfaction with the system. Linear regression analysis was then performed to examine the association between the three main domains of the questionnaire and overall satisfaction with the system, with adjustment for physician demographic characteristics. Results A total of 115 physicians answered the survey. Only 40% were satisfied with the system overall. The best predictors of overall satisfaction were performance in the form of speed, integration with workflow, and patient information, such as accuracy, completeness and timeliness. Conclusion Physicians were generally not satisfied with the system. Continued evaluation of such systems and feedback from users should guide future selection and implementation.

Objectives Nonattendance at outpatient appointment is a major problem particularly in public hospitals that leads to long waiting time and inefficient use of hospital recourses. The aim of this study was to evaluate the effectiveness of sending short message service (SMS) reminders to the mobile phones of patients scheduled for an outpatient appointment on nonattendance rate. Methods A randomized controlled trial was conducted at three outpatient clinics (General Medicine (GM), Neurology (Neuro), Obstetrics and Gynecology (OB/GYN). Eligible patients were randomly allocated to either receive SMS reminder message of their outpatient appointment (intervention group) or receive no reminder (control group). The electronic database of the hospital was used to collect patient appointment information, mobile phone number, type of clinic and other patient characteristics. The primary outcome measure was nonattendance rate. Chi-square test and multivariate logistic regression were used to compare nonattendance rate between the two groups. Results A total of 1499 patients were entered in the two arms of the study between April 2011 and June 2011. These were divided as follows (GM = 502, Neuro = 297, and OB/GYN = 700). The nonattendance rate was significantly lower in the reminder groups compared to the non-reminder groups in the GM and Neuro clinics (26.3% vs. 39.8% and 29.3% vs. 43.9%, respectively P ⩽ 0.02). There was no significant difference in the nonattendance between the reminder and non-reminder groups in OB/GYN clinic (26.6% vs. 27.9%, P = 0.36). Conclusion SMS text message reminders are effective in reducing the nonattendance rate in outpatient clinics though may not be as effective in all specialities.

Insertionswinkel bei der Cochlea Implantation (CI) werden durch Elektrodenträgerlänge und individuelles Ausmaß des Ductus cochlearis bestimmt. Aktuell liegt der Fokus auf der Versorgung mit verkürzten Elektroden, weil eine Schonung intracochleärer Strukturen die Chance auf Erhalt[zum vollständigen Text gelangen Sie über die oben angegebene URL], 87. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie

The Mauddud reservoir in the Raudhatain and Sabiriyah fields of north Kuwait includes production layers that were historically exploited using vertical wells. As lower layers begun producing water, horizontal producers from upper layers were planned. A recent simulation study was performed for electrical submersible pumps (ESPs) in the reservoir. ESPs must be placed vertically and as near to the target layer as possible for maximum sweep effect, and as a result, greater build rates in the build section of the well were required to enter the reservoir laterally at the optimal depth. With a requirement for these wells to be drilled with a rotary steerable system, a high build rate (HBR) rotary steerable system (RSS) is required. An upgraded true point-the-bit (PTB) RSS was run for the first time with a polycrystalline diamond compact (PDC) bit in a matched system. A logging-while-drilling (LWD) suite was used while drilling the build section and steer into the target reservoir. The RSS was modified to increase the effective bend angle at the bit and optimize the fulcrum point geometry for high dogleg capability. Bottomhole assembly (BHA) modeling was performed to optimize the stabilization while simultaneously managing stresses in the BHA. Bit designs were optimized with an integrated bit-BHA model to provide sufficient lateral aggressiveness and good hole quality. Extensive planning and BHA optimization exercises were performed to address the challenge. The initial field tests were performed in Kuwait, and the planned trajectory was initially designed with a +/- 10 deg/100 ft build rate. The proposed system was successfully run and exceeded requirements; While drilling the build section, the real-time LWD correlation showed the target formation coming in 19 ft shallower than was initially estimated, requiring a higher than planned dogleg to land the well in the target zone. The RSS deflection was increased to increase the dogleg output, based on the updated target location. The upgraded RSS responded immediately and the system was able to deliver in excess of 12 deg/100 ft build rate, producing a smooth curve at high rate of penetration (ROP) and with low vibration – achieving the target TVD required. A high build rate capability using the PTB system was proven while sustaining the PTB advantages, including superior hole quality, enhanced directional control, and reduced drilling time. This new development provides a unique capability to the industry in a true PTB RSS system with high dogleg capability. Good hole quality and steerability of a PTB RSS can now be achieved simultaneously in high dogleg applications. Good hole quality combined with precision in wellbore control improves drilling performance and completion installation in high dogleg applications. This capability enhances the project economics and enables increased production potential.

An interactive digital education aid for breast reconstruction patients was developed because of a perceived need to provide patients with more education regarding the treatment so that they can make better informed treatment decisions. A prospective randomized study was conducted to assess its effectiveness.Breast cancer patients who were candidates for breast reconstruction were recruited and randomized into a control group and a study group. Both groups received routine assessment and education in the plastic surgery clinic, but the study group also watched the interactive digital education aid. Questionnaires assessing knowledge, anxiety, and satisfaction were administered (1) before the initial plastic surgery consultation, (2) immediately before surgery, and (3) 1 month after surgery.A total of 133 women participated, 66 in the control group and 67 in the study group. Women in both groups showed decreased anxiety, increased knowledge, and enhanced satisfaction with their decision-making ability associated with preoperative instructions about reconstructive surgery. However, the study group was significantly more satisfied than the control group with the method of receiving information and showed a less steep learning curve regarding the different techniques of breast reconstruction. They also tended to have a reduced mean level of anxiety and increased satisfaction with the treatment choice compared with the control group.An interactive digital education aid is a beneficial educational adjunct for patients contemplating breast reconstruction. Patients who use an interactive digital education aid demonstrate greater factual knowledge, reduced anxiety, and increased postoperative satisfaction compared with patients given preoperative instructions using standard methods alone. The benefit of an interactive digital education aid is expected to be higher in a broad-based practice setting outside of a comprehensive cancer center.

Background: Expenditure on medications represents significant proportion of the total hospital budget. Establishing an effective drug cost management program is a priority area for hospitals that must begin with determining the current costs and pattern of use of medications. Objectives: The aim of the present study is to determine the cost and pattern of drug utilization at the study hospital in order to identify cost reduction opportunities. Methods: A descriptive retrospective design was used to examine the cost and pattern of drug utilization for all admissions during the period from: 1st January 2006 to 30th June 2006 in a university hospital in Eastern Saudi Arabis. Electronic patient data as well as manual drug cost data were obtained and merged to create the analysis database. Results: The study revealed that the total drug cost at the study hospital was SR 11,823,666.9 (mean per admission = SR 2123.5 and median per admission= SR 357.3) during the study period. Antibiotics were responsible for 35.8% of the total inpatient drug costs followed by blood products which accounted for 20.6% of the total inpatient drug costs. Further investigation of both groups revealed that the combination of piperacillin and tazobactam represented 4.5% of prescribed drugs and accounted for almost half of the inpatient antibiotic costs (SR 2,064,916.8) and 17.4% of the total hospital’s inpatient drug costs. Human albumin and intravenous immunoglobulin were responsible for the majority of cost of blood products. Conclusions: Piperacillin and tazobactam, human albumin, and intravenous immunoglobulin other than Rho (D) immunoglobulin are responsible for high percentage of drug expenditure at the study hospital while being prescribed to a limited number of patients. Designing a drug cost management program to target these three drugs will increase the likelihood of achieving significant cost reduction.

The various surgical procedures for early-stage breast cancer are equivalent in terms of survival. Therefore, other factors, such as the procedures’ effect on psychosocial adjustment and quality of life (QOL), take on great importance. The aim of the current study was to prospectively examine the short- and long-term effects of mastectomy with reconstruction, mastectomy without reconstruction, and breast conservation therapy on aspects of psychosocial adjustment and QOL in a sample of 258 women with breast cancer. Participants completed questionnaires before surgery and then again 1, 6, 12, and 24 months after surgery. Questionnaires assessed depressive symptoms, anxiety, body image, sexual functioning, and QOL. Adjustment patterns differed throughout the 2-year period after surgery. Some short-term changes in adjustment (less anxiety, less overall body satisfaction) were similar across surgery groups, whereas others (satisfaction with chest appearance, QOL in physical health domain) were higher for women who had breast conservation therapy. However, women who had mastectomy with reconstruction reported greater satisfaction with their abdominal area. During the long-term follow-up period (6 months to 2 years after surgery), women in all three groups experienced marked improvements in psychosocial adjustment (depressive symptoms, satisfaction with chest appearance, sexual functioning) and QOL in physical and mental health domains. In fact, the level for most variables returned to baseline levels or higher. Overall, the general patterns of psychosocial adjustment and QOL are similar among the three surgery groups.

Background: Over the years, the authors' preferred recipient vessels for microvascular autologous breast reconstruction have changed from the thoracodorsal to the internal mammary vessels. Methods: From 1994 to 2004, 1483 microvascular autologous breast reconstructions were performed in 1168 patients at the authors' institution. Potential factors involved in the selection of the recipient vessels were evaluated and compared between the thoracodorsal and internal mammary groups. Rates of recipient vessel unusability and flap-related complications were also analyzed and compared between the two groups. Results: The mean patient age was 48 years, and the mean follow-up time was 1.5 years. The vessel conversion rate was 2.8 percent for the thoracodorsal group and 1.9 percent for the internal mammary group. Preoperative radiotherapy and previous axillary node dissection were significantly associated with thoracodorsal vessel conversion (odds ratios, 4.7 and 2.6, respectively). The overall flap-related complication rate (12.6 percent versus 8.6 percent) and specific flap-related complications, including flap loss (2.6 percent versus 3.8 percent), vessel thrombosis (3.7 percent versus 5.0 percent), fat necrosis (4.5 percent versus 2.6 percent), infection (0.7 percent versus 0.7 percent), and hematoma (1.6 percent versus 1.9 percent), were comparable between the two groups, but the flap seroma rate was significantly higher in the thoracodorsal group (4.0 percent versus 0.7 percent; odds ratio, 4.2). Conclusion: In the authors' experience, use of internal mammary vessels is safe, with low rates of vessel conversion and flap-related complications.

Background Preoperative localization of the cutaneous perforators is an important step in designing anterolateral thigh flaps. The purpose of this study was to examine the accuracy of two commonly used Doppler devices in locating these perforators. Methods This study was conducted in 100 free anterolateral thigh flaps during a 2-year period. Cutaneous perforators of the anterolateral thigh flaps were localized in the clinic using the Huntleigh Mini Dopplex D-900 unit with an 8-MHz probe (Huntleigh Diagnostics Ltd., Cardiff, United Kingdom) and in the operating room just before surgery using the Koven ES-100X Mini Doppler unit with a 10-MHz sterile probe (Koven Technology, Inc., St. Louis, Mo.). The locations of Doppler signals and of the actual cutaneous perforators at surgery were plotted and compared. Results One to three cutaneous perforators of the anterolateral thigh flap were consistently found at specific locations; they were named perforators A, B, and C from proximal to distal. Perforators A, B, and C were present in 51, 89, and 62 cases, respectively, at surgery and were approximately 5 cm apart. The sensitivities and specificities in detecting perforator B were 100 percent and 0 percent, respectively, for the Huntleigh Doppler unit, and 91 percent and 55 percent for the Koven unit. The Doppler signal was within 1 cm of the actual perforator B location in 74 percent and 70 percent of the flaps with the Huntleigh and Koven units, respectively. The accuracy of Doppler examination decreased as body mass index increased. Conclusions Preoperative handheld Doppler examination is not always accurate and should be used with caution in flap design.

This study compared the use of the internal mammary and thoracodorsal recipient vessels in a uniform group of patients who underwent delayed TRAM flap reconstruction after radiotherapy, focusing on usability rates and outcomes. The authors identified 123 delayed TRAM flap patients who had undergone postmastectomy radiotherapy from a prospective database (1990 to 2001). Recipient vessel unusability rates were calculated on the basis of reports of inspection of a vessel, either by direct intraoperative dissection or by findings from color Doppler examination (internal mammary vessels only). Charts were reviewed for outcomes including flap loss, vascular complications, fat necrosis, and lymphedema; t-test and chi-square analyses were performed to compare outcomes and unusability rates, and multiple regression analysis was performed to determine factors influencing outcome. Of the 123 planned free TRAM flaps, 106 were completed as free flaps and 17 were performed as pedicled flaps because of unusable recipient vessels. Of the free flaps, 45 were anastomosed to the internal mammary vessels, 55 to the thoracodorsal vessels, and six to other vessels. The internal mammary and thoracodorsal groups did not differ significantly in body mass index, abdominal scars, smoking history, time delay between irradiation and TRAM flap reconstruction, or flap ischemia time. Radiation doses to the axilla (thoracodorsal), internal mammary chain, and supraclavicular fossa were similar between the groups. The internal mammary vessels were rejected in 11 (20 percent) of 56 cases, and the thoracodorsal vessels were rejected in 19 (26 percent) of 74 cases (p = 0.42). In cases with unusable internal mammary vessels, 46 percent (n = 5) had inadequate veins, 27 percent (n = 3) had inadequate arteries, and in 27 percent (n = 3) both vessels were inadequate. In the 19 cases with unusable thoracodorsal vessels, 84 percent (n = 16) were excessively scarred, 11 percent (n = 2) had inadequate vessels, and 5 percent (n = 1) were absent. Outcomes were similar regardless of recipient vessels used (internal mammary versus thoracodorsal): total flap loss, 0 percent versus 4 percent (p = 0.20); vascular complications, 6.7 percent versus 11 percent (p = 0.46); arm lymphedema, 4.4 percent versus 9 percent (p = 0.37); partial flap loss, 9 percent versus 6 percent (p = 0.54); and fat necrosis, 18 percent versus 15 percent (p = 0.69). Multivariate analysis revealed a trend for higher complication rates in smokers and with the use of the thoracodorsal vessels as the recipients. Overall, no discernible unusability or outcome differences were detected between the internal mammary and thoracodorsal groups.

In cases of unilateral breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap, poorly perfused tissue, which is normally excised to avoid subsequent fat necrosis, must sometimes be used to achieve adequate breast size and projection. In such cases, incorporation of a second vascular pedicle into the flap design improves perfusion. The authors retrospectively examined their experience with bipedicled TRAM flap-based unilateral breast reconstruction to determine whether the use of microsurgical rather than conventional (nonmicrosurgical) techniques for flap transfer resulted in lower incidences of flap-site fat necrosis and donor-site hernia/bulge. The authors retrospectively reviewed the medical records of all patients who underwent unilateral breast reconstruction with a bipedicled TRAM or deep inferior epigastric perforator flap between January of 1991 and March of 2001. Group 1 consisted of patients who had undergone flap transfer using a conventional technique for both pedicles; group 2, patients who had flap transfer using a conventional technique for one pedicle and a microsurgical technique for the other; and group 3, patients who had flap transfer using a microsurgical technique for both pedicles. Of the 863 patients identified, 72 (8.3 percent) had undergone reconstruction using a bipedicled flap. There were 43 patients in group 1, 24 patients in group 2, and five patients in group 3. Only one case of total flap loss had occurred (group 1). Partial flap loss occurred in two patients in group 1 (5 percent) and three patients in group 2 (13 percent). Fat necrosis occurred more frequently in groups 1 (23 percent) and 2 (29 percent) than in group 3 (0 percent) (p = 0.5, Fisher's exact test). Similarly, bulge or hernia was more common in groups 1 (12 percent) and 2 (4 percent) than in group 3 (0 percent) (p = 0.6, Fisher's exact test). In this study, patients who received a bipedicled TRAM flap using microsurgical techniques alone (group 3) appeared to have better flap perfusion and less frequent hernia/bulge than did patients who underwent flap transfer using conventional (group 1) or combined techniques (group 2). However, these differences were not statistically significant, and this trend must be verified in a larger study.

To evaluate the outcomes among patients with adenoid cystic carcinoma of the lacrimal gland treated at various stages of their disease at a tertiary care cancer center.A retrospective case series of 20 patients with adenoid cystic carcinoma of the lacrimal gland treated at a single institution between 1952 and 2002. Clinical records were available for all 20 patients; histologic sections from 12 of the 20 patients were available for review. Disease-free survival was measured from the completion of treatment; overall survival was measured from the date of initial diagnosis.The study included 6 men and 14 women. The mean age at diagnosis was 39.5 years. The median follow-up time was 34 months (range, 6 to 264 months). The local/regional treatment modalities included exenteration with bone removal and radiation therapy (RT) in 5 patients, exenteration with RT (no bone removal) in 8 patients, exenteration (no RT or bone removal) in 1 patient, exenteration with bone removal (no RT) in 1 patient, local resection with RT in 3 patients, and local resection without RT in 2 patients. Overall, 16 patients had RT as part of their treatment regimen. Seven patients (35%) had local recurrence. Sixteen patients (80%) had distant metastasis during the study period. At the time of this report, 13 (65%) of the patients had died of disease. The median disease-free survival for the entire group was 18 months. Eight patients had a predominantly basaloid histologic pattern. Ten patients had verifiable histologic evidence of perineural invasion.This study underscores the generally grave prognosis for patients with adenoid cystic carcinoma of the lacrimal gland and the difficulty in making any conclusive recommendations for local therapy for this disease.

Erectile dysfunction following radical prostatectomy for treatment of clinically localized prostate cancer remains a problem that deters many men from seeking surgical treatment. Sparing the cavernous nerves has been popularized as a method of preserving potency, but men with locally advanced disease may be at increased risk for positive margins with this technique. In this study, sural nerve grafting of the cavernous nerve bundles, to preserve postoperative potency while potentially maximizing cancer control, was examined. Thirty men were enrolled in this prospective phase I study and underwent non-nerve-sparing radical prostatectomy performed by one of two protocol surgeons. Preoperative erectile function was assessed both objectively, using a RigiScan (Timm Medical Technologies, Inc., Eden Prairie, Minn.), and subjectively. The cavernous nerves were identified and resected during the operation with the use of an intraoperative mapping device (CaverMap; Alliant Medical Technologies, Norwood, Mass.). Bilateral autologous sural nerve grafting to the cavernous nerve stumps was performed by one of two protocol plastic surgeons. Postoperative erectile dysfunction therapy, using intracorporeal injection, a vacuum pump, and/or oral sildenafil therapy, was instituted 6 weeks after the operation. Spontaneous erectile activity was subjectively and objectively measured every 3 months after the operation. Follow-up periods ranged from 13 to 33 months (mean, 23 months). Overall, 18 of 30 patients (60 percent) demonstrated both objective and subjective evidence of spontaneous erectile activity. Of those 18 men, 13 (72 percent) were able to have intercourse (seven unassisted and six with the aid of sildenafil). No disease or biochemical recurrences have been noted in this group of patients with locally advanced disease. In conclusion, autologous sural nerve grafting after non-nerve-sparing radical prostatectomy is an effective means of preserving spontaneous erectile activity after the operation while maximizing cancer control potential.

All the components necessary for realizing location-aware computing are available in the marketplace today. What has hindered the widespread deployment of location-based systems is the lack of an integration architecture that scales with user populations. The authors have completed the initial implementation of Rover, a system designed to achieve this sort of integration and to automatically tailor information and services to a mobile user's location. Their studies have validated Rover's underlying software architecture, which achieves system scalability through high-resolution, application-specific resource scheduling at the servers and network. The authors believe that this technology will greatly enhance the user experience in many places, including museums, amusement and theme parks, shopping malls, game fields, offices, and business centers. They designed the system specifically to scale to large user populations and expect its benefits to increase with them.

Surgeons who perform transverse rectus abdominis musculocutaneous (TRAM) flaps have differing opinions about how many drains are required in the breast and abdomen to prevent seroma. The authors therefore decided to review their experience to determine whether the number of drains influenced the incidence of seroma. All patients who underwent breast reconstruction using TRAM or deep inferior epigastric perforator flaps at The University of Texas M. D. Anderson Cancer Center from January 1, 1995 to June 20, 2000 and whose charts could be retrieved were included in the study. The number of drains used was correlated with the presence or absence of seroma and wound infection in both the abdomen and the breast. Significance was analyzed using the Chi-squared and Fisher's exact tests. There were 608 patients and 768 reconstructive procedures in this series (160 reconstructions were bilateral). Of patients who had only one drain in the abdomen, seroma developed in 9 patients (7.1%), whereas of those having two drains in the abdomen, seroma developed in only 10 patients (2.1%) (p = 0.006). Also, of patients who had only one drain in the breast, seroma developed in the breast in 47 patients (9.1%), and in those with two drains, seroma developed in only 11 patients (4.3%) (p = 0.02). There were no significant differences in the infection rate in either the breast or the abdomen, although the trends favored a lower infection risk when two drains were used. The authors found that using two drains in both the abdomen and the breast can reduce the risk for seroma without increasing the risk for infection. This study supports the use of two drains in both the breast (one each beneath the TRAM flap and in the axilla) and abdomen (beneath the abdominoplasty flap) for patients undergoing breast reconstruction using the TRAM flap.

Objective The regional lymph nodes generally are believed to be the most common first site of metastasis for conjunctival malignant melanoma, but the pattern of nodal metastasis in this disease has not been well established. The goal of this study was to determine the frequency, location, and timing of regional lymph node metastasis in patients with conjunctival melanoma treated at one cancer center over four decades. Design Retrospective case series. Participants Twenty-seven patients. Methods The clinical records of 27 patients with conjunctival malignant melanoma were reviewed retrospectively. Main outcome measures The rates of local conjunctival recurrence, regional nodal metastasis, and distant metastasis were analyzed along with overall survival. The follow-up time ranged from 2.5 to 17 years (median, 6 years). Results Eleven patients (41%) experienced clinical regional lymph node metastasis 1.5 to 6.0 years (mean, 3.2 years) after the initial diagnosis. The involved lymphatics were the preauricular (parotid) nodes in 8 patients (73%), the submandibular nodes in 1 patient (9%), and the deeper cervical nodes in 2 patients (18%). In seven patients (26%), distant metastasis developed without evidence of prior or concurrent regional nodal disease. Patients in whom distant metastasis developed without clinical evidence of regional nodal involvement were more likely to have had local conjunctival recurrence ( P = 0.03) and a higher number of local recurrences ( P = 0.05) compared with patients with regional lymph nodes as the site of first metastasis. The 5- and 10-year overall survival rates were 74% and 41%, respectively. Conclusions Regional lymph node metastasis occurred in a higher percentage of patients with conjunctival malignant melanoma than has been reported previously. Preauricular lymph nodes were most commonly involved. Distant metastasis without prior or concurrent lymph node involvement was not a rare event.

Hospital management and researchers are increasingly using electronic databases to study utilization, effectiveness, and outcomes of healthcare provision. Although several studies have examined the accuracy of electronic databases developed for general administrative purposes, few studies have examined electronic databases created to document the care provided by individual hospitals. In this study, we assessed the accuracy of an electronic database in a major teaching hospital in Eastern Province, Saudi Arabia, in documenting the 17 comorbidities constituting the Charlson index as recorded in paper charts by care providers. Using the hospital electronic database, the researchers randomly selected the data for 1,019 patients admitted to the hospital and compared the data for accuracy with the corresponding paper charts. Compared with the paper charts, the hospital electronic database did not differ significantly in prevalence for 9 conditions but differed from the paper charts for 8 conditions. The kappa (K) values of agreement ranged from a high of 0.91 to a low of 0.09. Of the 17 comorbidities, the electronic database had substantial or excellent agreement for 10 comorbidities relative to paper chart data, and only one showed poor agreement. Sensitivity ranged from a high of 100.0 percent to a low of 6.0 percent. Specificity for all comorbidities was greater than 93 percent. The results suggest that the hospital electronic database reasonably agrees with patient chart data and can have a role in healthcare planning and research. The analysis conducted in this study could be performed in individual institutions to assess the accuracy of an electronic database before deciding on its utility in planning or research.

Cardiac tamponade is an unusual earliest presentation of undiagnosed metastatic adenocarcinoma of unknown origin. Malignant pericardial effusion requiring drainage is also a poor prognostic marker with reported median survival of 6.1 months. A choroidal mass may be the presenting sign of systemic malignancy; the diagnosis of metastatic ocular tumour is important as it portends poor prognosis. We are reporting an unusual presentation of an undiagnosed metastatic adenocarcinoma presenting in an elderly male primarily with loss of vision due to choroidal mass causing retinal detachment and repeated episodes of dyspnea due to recurrent pericardial effusion causing cardiac tamponade. Fluid analysis from pleura and breast biopsy revealed evidence of metastatic adenocarcinoma. Immunohistochemistry finding were suggestive of possible lung or gastrointestinal tract as a primary source. Imaging studies showed widely spread malignancy involving abdominal viscera, mediastinum, lung, pericardium, choroid and brain. He showed features of pericardial constriction on echocardiography after fluid drainage due to pericardial infiltration. He expired before he could have received palliative chemotherapy.

Clustering is a standard approach for achieving efficient and scalable performance in wireless sensor networks. Traditionally, clustering algorithms aim at generating a number of disjoint clusters that satisfy some criteria. In this paper, we formulate a novel clustering problem that aims at generating overlapping multi-hop clusters. Overlapping clusters are useful in many sensor network applications, including inter-cluster routing, node localization, and time synchronization protocols. We also propose a randomized, distributed multi-hop clustering algorithm (KOCA) for solving the overlapping clustering problem. KOCA aims at generating connected overlapping clusters that cover the entire sensor network with a specific average overlapping degree. Through analysis and simulation experiments we show how to select the different values of the parameters to achieve the clustering process objectives. Moreover, the results show that KOCA produces approximately equal-sized clusters, which allows distributing the load evenly over different clusters. In addition, KOCA is scalable; the clustering formation terminates in a constant time regardless of the network size.

Objective The delay between the availability of clinical evidence and its application to the care of patients with acute coronary syndrome (ACS) in the Kingdom of Saudi Arabia remains undefined. The Saudi Project for Assessment of Coronary Events (SPACE) registry provides a comprehensive view of the current diagnostic and treatment strategies for patients with ACS; thus, the registry may be used to identify opportunities to improve the care of these patients. Methods Eight hospitals in different regions of Saudi Arabia were involved in the pilot phase of the registry, from December 2005 to July 2006. The study patients included individuals with ST segment elevation myocardial infarction (STEMI), non-STEMI and unstable angina. Results A total of 435 patients (77% men and 80% Saudis) with a mean age of 57.1 years were enrolled. Medical history included previously diagnosed ischemic heart disease (32%), percutaneous coronary intervention (12%), diabetes mellitus (53%), hypertension (48%), current smoking (39%), hyperlipidemia (31%) and family history of premature coronary artery disease (11%). The median door-to-needle time for fibrinolytic therapy received by patients with STEMIs was 90 min. Inhospital medications included acetylsalicylic acid (98%), clopidogrel (73%), angiotensin-converting enzyme inhibitors (74%), beta-blockers (73%), statins (88%), unfractionated heparin (80%), low-molecular weight heparin (22%) and glycoprotein IIb/IIIa inhibitors (9%). The inhospital mortality rate was 5%. Conclusion The first nationwide registry of patients with ACS in the Kingdom of Saudi Arabia is presented. In contrast to registries from developed countries, our cohort is characterized by a younger age at presentation and a much higher prevalence of diabetes mellitus. Most patients with STEMIs did not receive fibrinolytic therapy within the time recommended in the American College of Cardiology/American Heart Association guidelines. The results of the present pilot study show potential targets for improvement in care.

Study design A retrospective study of 134 consecutive cases in 92 patients who underwent soft tissue reconstruction of the spinal region following tumor removal. Objective To better understand how to optimize outcomes in soft tissue reconstruction of the spine region. Summary of background data With the increasing use of instrumentation and the fact that many patients with spinal neoplasms have debilitated wound-healing capacity, most of these patients are at high risk for postsurgical wound complications. Unfortunately, the optimal strategy to prevent and to manage complex wound complications involving the spinal region remains unclear. Methods Factors potentially associated with the outcome of the reconstruction, including previous radiation therapy, chemotherapy, or surgery; medical comorbidities; timing of the reconstructive surgery; location of the defect; reconstructive approach; and presence of instrumentation, were evaluated and compared. Results Of 92 patients, 29 patients (32%) developed postoperative wound complications. Among 32 patients with instrumentation of the spine, the 10 patients who had prophylactic soft tissue reconstruction had a significantly lower incidence of complications than did the 22 patients who had not (20% vs. 45%, P = 0.018). Furthermore, those who had previous surgery to the spine had a significantly higher risk of developing exposed instrumentation than did those who did not (21% vs. 0%, P = 0.002). Of 9 patients with exposed instrumentation, all but 1 patient had successful coverage of the instrumentation. Ninety (98%) of 92 patients had successful closure of the wound at the time of their last follow-up. Conclusions In the presence of instrumentation, providing preemptive soft tissue reconstruction at the time of the initial spinal surgery can help minimize potentially serious wound complications. For management of wound complications that have developed, an aggressive debridement and coverage with well-vascularized tissue can allow for expedient wound healing while maintaining stabilized instrumentation.

Background: Regular exercise in athletes is associated with cardiac acclimation in the form of functional and structural changes. Its effect on the cardiac functions still debated. Objective: The objective was to detect the impact of long-term regular physical exercise on the cardiac systolic and diastolic function of soccer players. Materials and Methods: Thirty professional soccer players were examined twice, the first examination was made during the passive resting period before the beginning of the season (measurement I) and the second during the peak of the season (measurement II). At both examinations, players underwent electrocardiogram (ECG), conventional Echo-Doppler, pulsed tissue Doppler imaging on both septal and lateral sides of the mitral annulus and lateral tricuspid annulus. The (propagation velocity [Vp]) values were measured. Paired t -test was used for comparison. Results: The following changes between measurement I and measurement II were found: ECG Changes; 80% of the entire group showed early repolarization, 93% had left ventricular hypertrophy (LVH) by voltage criteria, 20% showed right atrial abnormalities, 20% left atrial abnormalities, 40% showed inverted T-wave in leads V1-V4, 5% showed mobitz type I second degree heart block, and 5% showed incomplete right bundle branch block. Echo changes; The mitral E/E` ratio increased from 6.18 ± 1.27 to 6.91 ± 1.18; the Vp decreased from 56.3 ± 9.23 to 50.67 ± 8.6; the tricuspid valve Ratio between the early and late peak pulsed Doppler velocities on tricuspid valve decreased from 1.67 ± 0.23 to 1.54 ± 0.23 while the E`/A` ratio decreased from 1.67 ± 0.53 to 1.28 ± 0.49; the (isovolumetric relaxation time) of the right ventricle increased from 52.4 ± 11.33 to 58.17 ± 10.73; the (isovolumetric contraction time) decreased from 70.47 ± 9.9 to 65.2 ± 7.9. All changes were statistically significant at P Conclusions: Long-term regular exercise in soccer players is associated with cardiac alterations in the form of bradycardia, early repolarization, inverted T-wave, concentric LVH, and a tendency toward diastolic impairment of both ventricles.

Clustering is a standard approach for achieving efficient and scalable performance in wireless sensor networks. Most of the published clustering algorithms strive to generate the minimum number of disjoint clusters. However, we argue that guaranteeing some degree of overlap among clusters can facilitate many applications, like inter-cluster routing, topology discovery and node localization, recovery from cluster head failure, etc. We formulate the overlapping multi-hop clustering problem as an extension to the k-dominating set problem. Then we propose MOCA; a randomized distributed multi-hop clustering algorithm for organizing the sensors into overlapping clusters. We validate MOCA in a simulated environment and analyze the effect of different parameters, e.g. node density and network connectivity, on its performance. The simulation results demonstrate that MOCA is scalable, introduces low overhead and produces approximately equal-sized clusters.

This paper presents the design, implementation and evaluation of the PinPoint location determination system. PinPoint is a distributed algorithm that enables a set of $n$ nodes to determine the RF propagation delays between every pair of nodes, from which the inter-node distances and hence the spatial topology can be readily determined. PinPoint does not require any calibration of the area of interest and thus is rapidly deployable. Unlike existing time-of-arrival techniques, PinPoint does not require an infrastructure of accurate clocks (e.g., GPS) nor does it incur the o(n2) message exchanges of "echoing" techniques. PinPoint can work with nodes having inexpensive crystal oscillator clocks, and incurs a constant number of message exchanges per node to determine the location of $n$ nodes. Each node's clock is assumed to run reliably but asynchronously with respect to the other nodes, i.e., they can run at slightly different rates because of hardware (oscillator) inaccuracies. PinPoint provides a mathematical way to compensate for these clock differences in order to arrive at a very precise timestamp recovery that in turn leads to a precise distance determination. Moreover, each node is able to determine the clock characteristics of other nodes in its neighborhood allowing network synchronization. We present a prototype implementation for PinPoint and discusses the practical issues in implementing the mathematical framework and how PinPoint handles the different sources of error affecting its accuracy. Evaluation of the prototype in typical indoor and outdoor environments shows that PinPoint gives an average accuracy of four to six feet, in different environments, allowing PinPoint to support accurate rapidly deployable localization scenarios.

Background: Unfortunately, patients who desire repair of contour deformities after partial mastectomy unually present after radiation therapy, which may increase the risk of complications an result in a poor aesthetic outcome. The authors reviewed their experience with repair of partial mastectomy defects to determine the optimal approach to breast reconstruction ater partial mastectomy. Methods: Sixty-nine patients who underwent repair of a partial mastectomy defect and received radiation therapy were included in this analysis. The reconstructive techniques were categorized as local tissue rearrangement (LTR), breast reduction, or use of a latissimus dorsi myocutaneous flap or thoracoepigastric skin flap (here-after referred to as flap). Results: fifty patients underwent immediate reconstruction before radiation therapy, and 19 underwent delayed rreconstruction after radiation therapy. The reconstructive techniques in patients with immediate reconstruction were local tissue rearrangement in 28 percent, breast reduction in 66 percent, and flaps in 6 percent. In patient with delayed reconstruction, 32 percent had local tissue rearrangement, 42 percent had breast reduction, and 26 percent had flaps. The complication rates for immediate and delayed reconstruction were 26 percent and 42 percent, respectively. Overall, and in the setting of immediate reconstruction, the flap technique was associated with a higher complication rate than local tissue rearrangement and breast reduction. However, in the setting of delayed reconstruction, the flap technique was associated with a lower complication rate than the other two techniques. Fifty-seven percent of the immediate reconstructions performed with the local tissue rearrangement or breast reduction technique, but only 33 percent of the immediate reconstructions performed with the flap technique, were associated with an excellent or good aesthetic outcome. Conclusion: Immediate repair of partial mastectomy defects with local tissues results in a lower risk of complications and better aesthetic outcomes than immediate repair of partial mastectomy defects with a latissimus dorsi flap.

There has been a growing interest in the applications of wireless sensor networks in unattended environments. In such applications, sensor nodes are usually deployed randomly in an area of interest. Knowledge of accurate node location is essential in order to correlate the gathered data to the origin of the sensed phenomena and assure the relevance of the reported information. In this paper, we present an efficient anchor-free protocol for localization in wireless sensor networks. Each node discovers its neighbors that are within its transmission range and estimates their ranges. Our algorithm fuses local range measurements in order to form a network wide unified coordinate systems while minimizing the overhead incurred at the deployed sensors. Scalability is achieved through grouping sensors into clusters. Simulation results show that the proposed protocol achieves precise localization of sensors and maintains consistent error margins.

This study compared the use of the internal mammary and thoracodorsal recipient vessels in a uniform group of patients who underwent delayed TRAM flap reconstruction after radiotherapy, focusing on usability rates and outcomes. The authors identified 123 delayed TRAM flap patients who had undergone postmastectomy radiotherapy from a prospective database (1990 to 2001). Recipient vessel unusability rates were calculated on the basis of reports of inspection of a vessel, either by direct intraoperative dissection or by findings from color Doppler examination (internal mammary vessels only). Charts were reviewed for outcomes including flap loss, vascular complications, fat necrosis, and lymphedema; t-test and chi-square analyses were performed to compare outcomes and unusability rates, and multiple regression analysis was performed to determine factors influencing outcome. Of the 123 planned free TRAM flaps, 106 were completed as free flaps and 17 were performed as pedicled flaps because of unusable recipient vessels. Of the free flaps, 45 were anastomosed to the internal mammary vessels, 55 to the thoracodorsal vessels, and six to other vessels. The internal mammary and thoracodorsal groups did not differ significantly in body mass index, abdominal scars, smoking history, time delay between irradiation and TRAM flap reconstruction, or flap ischemia time. Radiation doses to the axilla (thoracodorsal), internal mammary chain, and supraclavicular fossa were similar between the groups. The internal mammary vessels were rejected in 11 (20 percent) of 56 cases, and the thoracodorsal vessels were rejected in 19 (26 percent) of 74 cases (p = 0.42). In cases with unusable internal mammary vessels, 46 percent (n = 5) had inadequate veins, 27 percent (n = 3) had inadequate arteries, and in 27 percent (n = 3) both vessels were inadequate. In the 19 cases with unusable thoracodorsal vessels, 84 percent (n = 16) were excessively scarred, 11 percent (n = 2) had inadequate vessels, and 5 percent (n = 1) were absent. Outcomes were similar regardless of recipient vessels used (internal mammary versus thoracodorsal): total flap loss, 0 percent versus 4 percent (p = 0.20); vascular complications, 6.7 percent versus 11 percent (p = 0.46); arm lymphedema, 4.4 percent versus 9 percent (p = 0.37); partial flap loss, 9 percent versus 6 percent (p = 0.54); and fat necrosis, 18 percent versus 15 percent (p = 0.69). Multivariate analysis revealed a trend for higher complication rates in smokers and with the use of the thoracodorsal vessels as the recipients. Overall, no discernible unusability or outcome differences were detected between the internal mammary and thoracodorsal groups.

Background: Treatment for soft tissue sarcoma of the upper extremity has evolved to include limb salvage techniques. We reviewed our experience with limb salvage therapy for upper extremity sarcomas with an emphasis on functional outcomes following the reconstructive surgery. Methods: A retrospective analysis was performed of 81 consecutive patients with soft tissue sarcoma of the upper extremity who had limb salvage therapy with reconstruction by a plastic surgeon. Univariate and multivariate regression analyses of relevant outcome variables were performed. Enneking functional scores were obtained from 43 patients. Results: The study included 16 microvascular reconstructions and 67 non-microvascular reconstructions for a total of 83 reconstructions in 81 patients. The mean defect size was 129 cm2 (standard deviation: 106 cm2). The mean total functional score was 23.1 (range, 9 to 30). Any reconstruction-related complication and preoperative chemotherapy use were associated with a 7.3 point (P = .03) and 4.7 point (P = .01) decrease in total functional score, respectively. Kaplan-Meier product-limit analysis showed 82% 5-year overall survival and 67% 5-year disease-free survival rates. Conclusions: For soft tissue sarcoma of the upper extremity, limb salvage with good functional outcome is possible with a judicious approach to reconstruction.

Breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap plus an implant has been proposed as an option for women with a thin body habitus who do not have sufficient abdominal tissue to permit reconstruction with a TRAM flap alone. The standard autologous tissue reconstructive procedure in these women is a combined latissimus dorsi myocutaneous flap and breast implant. We reviewed our experience performing TRAM flap/implant and latissimus dorsi flap/implant breast reconstruction to compare complication rates and aesthetic outcomes between these two types of reconstruction. Between 1992 and 1999, 88 breasts were reconstructed at our institution using an autologous tissue flap combined with a breast implant (44 with a TRAM flap/ implant and 44 with a latissimus dorsi flap/implant). Recipient-site and donor-site complications for the two procedures were compared using Fisher's exact test; a panel f nonbiased, blinded judges compared the aesthetic outcomes. The recipient-site complication rate was lower for the TRAM flap/implant group than for the latissimus dorsi flap/implant group (18 percent versus 34 percent, p = 0.09). Most recipient-site complications in the TRAM flap/implant group were related to fluid collection around the implant. In the TRAM flap/implant group, complications occurred in 37 percent of the reconstructions that had immediate implant placement and in none of the reconstructions with delayed implant placement (p = 0.01). In the TRAM flap/implant reconstructions with immediate implant placement, the recipient-site complication rate was 50 percent when implants were completely filled with saline, but no complications occurred with incompletely filled, postoperatively adjustable implants (p = 0.03). No microvascular complications occurred with immediate placement of breast implants under TRAM flaps. Donor-site complications included a hematoma, a seroma, and an umbilical necrosis in the TRAM flap/ implant group and six cases of seroma formation in the latissimus dorsi flap/implant group. The comparison of aesthetic outcome was statistically significant for the TRAM flap/implant group, which had a higher overall mean score than the latissimus dorsi flap/implant group did (3.29 versus 2.85, p = 0.01). The results of this study suggest that the TRAM flap/implant breast reconstruction should be considered as an alternative to the latissimus dorsi flap/implant breast reconstruction in women with a thin body habitus.

To evaluate the practice patterns among surgeons who treat melanomas of the eyelid skin with respect to margins of excision and to look for possible correlation between margins of excision and the incidence of local and regional recurrence and distant metastasis.A retrospective survey of the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the European Society of Ophthalmic Plastic and Reconstructive Surgery yielded 44 cases. The patients' age, sex, date of diagnosis, histologic classification of melanoma, Breslow thickness, Clark level, location of melanoma, size of margins of excision, and findings of local or regional recurrence or distant metastasis were recorded in each case. Patients were stratified on the basis of margins of excision:/=5 mm;5 mm but10 mm; and/=10 mm. Patients were also stratified by Breslow thickness. A Cox regression model was used to evaluate the predictive value of each factor for recurrence. Main outcome measures were the incidences of local and regional recurrence and distant metastasis as a function of margins of excision and Breslow thickness.The majority of patients for whom reliable information was available had excision margins of/=5 mm. The Breslow thickness of most of the tumors was/=1 mm. Eleven patients (25%) had local recurrence. Five patients (11%) had regional lymph node metastasis. All patients with regional nodal metastasis were men. Distant metastasis developed in 3 patients (7%)-2 men and 1 woman. The follow-up times ranged from 10 to 108 months (mean, 34 months; median, 21 months). The incidence of local recurrence was higher among patients with melanomas at least 2 mm thick and margins of excision/=5 mm than among patients with melanomas at least 2 mm thick but with margins/=10 mm, but this difference was not statistically significant because very few patients had melanomas at least 2 mm thick. Breslow thickness was the only statistically significant predictor of local, regional, and distant metastasis. Margins of excision did not have a statistically significant effect on local, regional, or distant recurrence.Breslow thickness is an important prognostic indicator for eyelid skin melanomas. A 5-mm margin of excision may be adequate for thin melanomas of the periocular skin, but because of the small number of patients in this series who had5-mm margins, a definitive comparison of outcome with larger margins of excision cannot be made. For melanomas/=2 mm, wider margins of excision may be prudent, and careful surveillance for local and regional recurrence is indicated.

As the population ages, the treatment of breast cancer among elderly women is becoming increasingly common. Decisions with regard to breast reconstruction require not only consideration of patient age and comorbidities but also a need to balance life expectancy with quality of life. Although it is often assumed that implant-based breast reconstruction is the least disruptive method, especially among patients who may be facing limited survival times, it was hypothesized that autogenous tissue breast reconstruction is a well-tolerated and perhaps preferable means of reconstruction for older women who choose to undergo reconstruction following mastectomy. No large series of autogenous tissue reconstructions in this age group has been presented. A retrospective study of 84 postmastectomy reconstructions (66 unilateral and 18 bilateral; 78.6 percent immediate) performed at the authors' institution for 81 women 65 years of age or older, between April of 1987 and December of 2000, was undertaken. Reconstructions were implant-based ( = 26), latissimus dorsi flap-based ( = 24), or transverse rectus abdominis myocutaneous (TRAM) flap-based ( = 34). Of the 34 TRAM flaps, 21 were free or supercharged. Breast complications were more frequent ( < 0.05) among recipients of implant-based reconstructions (76.9 percent) than among recipients of latissimus dorsi flap (41.7 percent) or TRAM flap (35.3 percent) reconstructions. In multivariate logistic regression analyses, comorbidities, smoking, radiotherapy, and body mass index had no effect. Medical complications without long-term sequelae were observed for two patients who underwent latissimus dorsi flap reconstructions and two patients who underwent free TRAM flap reconstructions; the difference in the rates of medical complications was not significant. At the mean follow-up time of 4.2 years, 92.8 percent of all study patients exhibited no evidence of disease. Notably, despite being free of disease, seven of the 26 patients (27 percent) who underwent implant-based reconstructions abandoned further reconstructive efforts after complications necessitated implant removal. It was concluded that age alone should not determine the type of breast reconstruction and that autogenous tissue breast reconstruction can be a safe successful alternative for women 65 years of age or older.

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.

Background. Perineal wound complications may occur after visceral pelvic surgery. We reviewed our experience to determine indications for immediate tissue transfer (TT) to prevent complications. Methods. Hospital records and computerized data were reviewed on 175 perineal repairs in 156 patients treated at The University of Texas M.D. Anderson Cancer Center for tumors involving the alimentary tract (135 of 175), genitourinary tract (15 of 175), perineum (19 of 175), or sacrum (6 of 175). Patients had either resection of only the colorectum and anus (APR) (46 of 175) or multivisceral resection (MVR) (129 of 175), and the perineal wound was closed by using TT (108 of 175) or primary closure (PC) (67 of 175) on the basis of the surgeon's judgment. Complications were compared between PC and TT groups. Results. Complications occurred in 57% (100 of 175). There was no significant difference overall in PC and TT procedures or in the APR subgroup. There were significantly fewer complications for TT patients in the MVR subgroup (P =.0001). There were significantly fewer complications for TT patients with prior irradiation in both APR (P =.01) and MVR (P =.007) subgroups. Conclusions. Immediate TT for perineal wound closure is associated with fewer healing complications than PC in a subset of patients with multivisceral resection or prior radiotherapy. Surgical planning in these cases should consider immediate soft tissue reconstruction. (Surgery 2001;130:463-9.)