Search

Background: Although suction-assisted lipoplasty (SAL) has been clinically practiced for more than 25 years, comparatively little investigation into fundamental physics of the instrumentation used in the procedure has been conducted. Moreover, relatively little is known about the clinical impact or merit of the wide variety of instrumentation currently available.Objective: In this study, we examined the physics related to the various components of instrumentation used in lipoplasty, and developed means to optimize performance based on quantified bench and clinical data.Methods: The components used to construct a lipoplasty system (vacuum pump, suction tubing, suction canister, and suction cannula) were first evaluated using methods of bench experimentation. A selected set of components/parameters were then evaluated in a clinical setting, and the results were correlated to the bench data. The following design parameters were analyzed: for cannulas-shaft length, shaft internal diameter, port size/pattern, and venting; for tubing-length, internal diameter, and collapsibility; for canisters-volume, pull-down speed, gradation precision, and splash-related issues; and for vacuum pumps-vacuum level and flow rate.Results: Each of the system components can have a significant impact on the overall performance of the system. A simple calculation is presented that can be used to quantify the relative "resistance" and, therefore, speed of any selected cannula or tube. Port area is shown to be an important aspect of cannula design and clinical performance. Clinical data are shown to correlate reasonably with bench data, which imparts credibility to the bench data and provides a platform from which to extrapolate other bench data to the clinical setting.Conclusions: With clinical objectives in mind, guidelines and recommendations are presented, based on the data we collected, to optimize a lipoplasty system with regard to choices of the vacuum pump, suction tubing, and canister. With the ideal system in place, the cannula becomes the only remaining variable. Cannula properties and performance were also studied and are discussed in detail. [ABSTRACT FROM AUTHOR]

Human sexuality is a complex dynamic concept that escapes simple definition. Within nursing there seems to be a preference for broad holistic definitions that emphasize sexuality as an aspect of the unique human character. Whilst the nursing literature mostly portrays sexuality as wholesome and good, it also notes that sexuality can be a vehicle for the expression of power, hostility or hatred. In this study, the authors did not prescribe or limit the definition of 'sexuality'. Rather the term 'sexuality' was used in a broad sense in order to embrace the range of variables within the concept and allow respondents to consider the issues according to their own perspective. Despite broad acceptance of sexuality as a legitimate focus of health care, clinicians remain ambivalent about actively broaching sexual issues and there is a potential for clients' needs to go unmet. A number of intertwining variables can influence sexuality-related nursing practice. Nurses' attitudes are regarded as major barriers that prevent open discussion on the topic. This study aims to explore a sample of community mental health nurses' views on the topic of sexuality in relation to their work with clients. The authors adapted a sexual ideology scale previously used for the purposes of teaching students and promoting discussion. The questionnaire was distributed to nurse delegates at an annual CPNA conference. Two of the authors were available throughout the conference to discuss the study. Delegates were asked to recruit CMHN colleagues following the conference in order to increase the sample. The data are described and analysed using SPSS for Windows. Respondent characteristics have been cross-tabulated with item responses and analysed using chi-square and other statistical tests of association. The respondents (n = 122) confirmed sexuality as a relevant clinical issue and there was an overwhelming affirmation of people with mental health problems as sexual beings. Sixty-three per cent (n = 77) of respondents anticipated that people with mental health problems who are in relationships might experience sexual problems, and 52.4% (n = 64) agreed that a sexual history should be routinely included in assessment. Seventeen per cent (n = 21) had encountered clients becoming sexually aroused during the administration of a depot injection in the community. The authors identify this as an area of concern that warrants further investigation. The results indicate that although awareness of sexuality issues may be high there may be less agreement as to how such awareness should translate into CMHN practice. [ABSTRACT FROM AUTHOR]

AbstractBackground: The symptoms of the chronic cholestatic liver disease primary biliary cirrhosis (PBC), in particular fatigue and chronic pruritus, adversely affect quality of life and respond only poorly to treatment. Recent studies have suggested that oxidative stress may play a role in tissue damage in cholestatic liver disease and may contribute to symptoms, such as fatigue. We have, therefore, examined, in an open-label pilot study, the therapeutic effects of antioxidant medication on the biochemistry and symptomatology of PBC. Methods: Patients were randomized to 3 months treatment with a compound antioxidant vitamin preparation (Bio-Antox), four tablets daily (n = 11, group 1), or the combination of Bio-Quinone Q10 (100 mg) with Bio-Antox (n = 13, group 2). Biochemical and symptomatic responses were assessed at 3 months. Results: Significant improvement in both pruritus and fatigue was seen in the patients in group 2. Mean itch visual analogue score improved from 2.4 ± 3.0 to 0.4 ± 0.7 post therapy (P < 0.05) while mean night itch severity score improved from 2.6 ± 1.9 to 1.3 ± 0.7 (P < 0.05). Nine of 13 of these patients reported less fatigue, while 10/13 showed an improvement in at least one domain of their Fisk Fatigue Severity Score. No significant improvement in itch and only limited improvement in fatigue were seen in the patients in group 1. No change in biochemical parameters was seen in either group. Conclusions: Antioxidant therapy, as a combination of Bio-Antox and Bio-Quinone Q10, may improve the pruritus and fatigue of PBC. This combination of therapy should be investigated further in a double-blind, placebo-controlled trial. © 1999 Blackwell Science Asia Pty Ltd. [ABSTRACT FROM AUTHOR]

Although traditionally described as taking a linear course, patients' pathways to mental health care might be better summarised in terms of one or more circular sequential Distress-Appraisal-Action cycles. Systematic examination of the referral pathways of patients attending an inner-city psychiatric outpatients clinic revealed that three-quarters of patients' referral routes involved two or three Distress-Appraisal-Action cycles. The remaining 25% of patients whose pathways were characterised by four or more cycles were significantly more likely to have reported changes in defining the problem for which they sought help, to be female, or to be male aged 35 and over. [ABSTRACT FROM AUTHOR]

Sixty-six new patients attending a psychiatric outpatient clinic were interviewed by nurses, psychiatrists, psychologists, or medical students. Immediately after being interviewed, each patient recorded their opinions of the interviewer by giving ratings on 30 semantic differential scales. Factor analysis of the ratings suggested that patients perceived nurses as favourably as they perceived the other interviewers. Patients did, however, differentiate between interviewers in terms of their perceived age, seniority and experience. The study indicates that nurses can `clerk' psychiatric outpatients effectively and that this is acceptable to the patients. [ABSTRACT FROM AUTHOR]

Epigenetic "clocks" can now surpass chronological age in accuracy for estimating biological age. Here, we use four such age estimators to show that epigenetic aging can be reversed in humans. Using a protocol intended to regenerate the thymus, we observed protective immunological changes, improved risk indices for many age-related diseases, and a mean epigenetic age approximately 1.5 years less than baseline after 1 year of treatment (-2.5-year change compared to no treatment at the end of the study). The rate of epigenetic aging reversal relative to chronological age accelerated from -1.6 year/year from 0-9 month to -6.5 year/year from 9-12 month. The GrimAge predictor of human morbidity and mortality showed a 2-year decrease in epigenetic vs. chronological age that persisted six months after discontinuing treatment. This is to our knowledge the first report of an increase, based on an epigenetic age estimator, in predicted human lifespan by means of a currently accessible aging intervention., (© 2019 The Authors. Aging Cell published by the Anatomical Society and John Wiley & Sons Ltd.)

Background/aim: The aim of this study was to investigate the role of Neocarzinostatin (NCS) conjugated with epithelial cell adhesion molecule (EpCAM) aptamer in EpCAM-positive cancer cells. NCS is an antitumor antibiotic protein chromophore that has the ability to cleave double stranded DNA and can be used as a potential drug for the treatment of EpCAM-positive cancers. EpCAM aptamer is an oligonucleotide ligand that binds specifically to EpCAM, a protein overexpressed in tumor cells., Materials and Methods: NCS was conjugated with EpCAM aptamer using Sulfo-Succinimidyl 6-(3-(2-pyridyldithio) - propionamide hexanoate) LC-(SPDP) cross-linker to deliver it to EpCAM-positive tumor cells. The conjugates were characterized using polyacrylamide gel electrophoresis (PAGE) and high-performance liquid chromatography (HPLC). Flow cytometry was used to study the binding efficiency of the aptamer and the conjugates in cancer cells. The effect of the conjugate on cancer cells was studied using propidium iodide (PI) to analyze the cell cycle phase changes. The apoptosis assay was performed using the IC 50 concentration of NCS. Microarrays were performed to study the gene level changes in cancer cells upon treatment with NCS and the conjugate., Results: Flow cytometry revealed significant binding of aptamer and conjugate in the MCF-7 and WERI-Rb1 cell lines. Briefly, 62% in MCF and 30% in WERI-Rb1 cells with conjugate treated cells (p<0.005). The cell-cycle analysis indicated G 2 phase arrest in MCF-7 cells and S phase arrest in WERI-Rb1 cells (p<0.005). Microarray analysis showed differentially expressed genes involved in cell cycle, DNA damage, and apoptosis. The BrDU assay and the apoptosis assay showed that the expression of BrDU was reduced in conjugate-treated cells and the PARP levels were increased confirming the double stranded DNA breaks (p<0.005). In MCF-7 and WERI-Rb1 cells, most of the cells underwent necrosis (p<0.005)., Conclusion: The EpCAM aptamer conjugated NCS showed specificity to EpCAM-positive cells. The effect of the conjugates on cancer cells were impressive as the conjugate arrested the cell cycle and promoted apoptosis and necrosis. The high levels of PARP expression confirmed the DNA breaks upon conjugate treatment. Our study demonstrates that the NCS conjugated with EpCAM can be targeted to cancer cells sparing normal cells., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

The 1960s was a period of reform and innovation in the provision of care for people with mental health problems. The most important development was the move away from residential institutions and the development of community services based on district general hospitals.

This study investigated the role of relevant vs irrelevant fear cues in the flooding of phobic patients. Six specific phobics and 10 agoraphobics were treated in a balanced crossover design. Eight patients had eight sessions of imaginal flooding concerned with their phobias followed by eight imaginal sessions concerned with situations which are normally frightening to anybody. Another eight patients had the same two treatments in the reverse order. The combined effects of both treatments after 16 sessions resulted in significant improvement on clinical, attitudinal, and heart-rate measures. Improvement was maintained at six months follow-up. Eight sessions by each treatment alone also produced significant improvement on clinical and attitudinal measures. Irrelevant fear also produced significant improvement in heart-rate and skin-conductance measures. The two treatments did not differ significantly from each other in their effects, except that irrelevant fear produced significantly more improvement than did relevant flooding in subjective anxiety during phobic imagery. The two treatments had significantly different prognostic correlates. Heightened physiological activity at the start of treatment predicted a good outcome to relevant flooding but not to irrelevant fear. High subjective anxiety during imagery before treatment predicted poor outcome to irrelevant fear. High anxiety during treatment sessions predicted good outcome to irrelevant fear, but did not correlate with outcome to relevant flooding. The experience of relevant and irrelevant fear in fantasy reduced phobic anxiety and avoidance to a similar extent, but appeared to do so through different mechanisms. These mechanisms need not be mutually exclusive and might be additive., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Published clinical trials of the treatment of HCV are largely multicentre prospective pharmaceutical trials. Patients in clinical trials tend to have more favorable outcomes than patients in the 'real-world', due to strict patient selection and differences in treatment conditions and available resources., Objectives: To assess the outcomes of Hepatitis C infected patients treated at the Barwon Health Liver Clinic with combination Pegylated interferon (PEG-IFN) and Ribavirin (RBV) therapy and to determine factors associated with a treatment response., Methods: Retrospective review of patients who received treatment for Hepatitis C at our institution's Liver Clinic from January 2001-September 2011. Patient demographics, comorbidities, treatment-related parameters and side effects were extracted from medical records and analyzed., Results: A total of 190 patients (120 male, 70 female) with a mean age of 42.8 years (range 20-68 years) commenced treatment. The most common genotype was genotype 3 (48.9%), followed by genotype 1 (42.6%). 150 of 190 patients (78.9%) completed treatment and had end of treatment data available. 107 of 182 patients, (58.8%) for whom sustained virologic response (SVR) rate data was available achieved an SVR. Overall response rates were; 46.9%, 68.8% and 62.4% in genotypes 1, 2 and 3 respectively. The response rate was significantly lower in 29 patients with documented cirrhosis (20.7%). Age, diabetes and alcohol abuse did not predict treatment response in our cohort. Side effects reported in 81.6% of patients included general malaise, hematological disturbance and psychiatric issues, and necessitated cessation of therapy in 16 patients (8.4%) and dose reduction in 26 patients (13.7%)., Conclusions: Response rates to combination PEG-IFN and RBV therapy at our institution are comparable to other 'real-world' and pharmaceutical registration trials. Side effects of combination therapy were prominent but resulted in fewer discontinuations of therapy compared to pharmaceutical trials.

Background: Hepatology and gastroenterology services are increasingly utilising the skills and experience of nurse practitioners and nurse specialists to help meet the increasing demand for healthcare. A new nurse-led assessment clinic has been established in the liver clinic at Geelong Hospital to utilise the expertise of nurses to assess and triage new patients and streamline their pathway through the healthcare system., Aim: The aim of this study is to assess quantitatively the first 2 years of operation of the nurse assessment clinic at Geelong Hospital, and to assess advantages and disadvantages of the nurse-led clinic., Methods: Data were extracted retrospectively from clinical records of new patients at the liver clinic. Quarterly 1-month periods were recorded over 2 years. Patients were categorised according to the path through which they saw a physician, including missed and rescheduled appointments. The number of appointments, the waiting time from referral to appointments and the number of 'did-not-attend' occasions were analysed before and after the institution of the nurse-led assessment clinic. The Mann-Whitney rank sum test of ordinal data was used to generate median wait times., Results: There was shown to be a statistically significant longer waiting time for physician appointment if seen by the nurse first. The difference in waiting time was 10 days. However, there was also a reduction in the number of missed appointments at the subsequent physician clinic. Other advantages have also been identified, including effective triage of patients and organisation of appropriate investigations from the initial nurse assessment., (© 2014 The Authors; Internal Medicine Journal © 2014 Royal Australasian College of Physicians.)

Background: Between 2000 and 2012 the number of multidrug-resistant (MDR) tuberculosis cases in the UK increased from 28 per year to 81 per year. We investigated the proportion of MDR tuberculosis cases arising from transmission in the UK and associated risk factors., Method: We identified patients with MDR tuberculosis notified in England, Wales, and Northern Ireland between Jan 1, 2004, and Dec 31, 2007, by linking national laboratory and surveillance data. Data for laboratory isolates, including drug sensitivities and 24-mycobacterial interspersed repetitive-unit-variable-number tandem repeat (MIRU-VNTR) typing were obtained routinely from the National Tuberculosis Reference laboratories as part of national tuberculosis surveillance. We investigated clusters of cases with indistinguishable MIRU-VNTR profiles to identify epidemiological links. We calculated transmission using the n-1 method and established associated risk factors by logistic regression. We also assessed the likelihood of transmission to additional secondary active tuberculosis cases, identified through conventional contact tracing., Findings: 204 patients were diagnosed with MDR tuberculosis in the study period; 189 (92·6%) had an MIRU-VNTR profile. We identified 12 clusters containing 40 individuals and 149 unique strains. The proportion of cases attributable to recent transmission, on the basis of molecular data, was 15% (40 cases clustered-12 clusters/189 with a strain type). The proportion of cases attributable to recent transmission (ie, transmission within the UK) after adjustment for epidemiological links was 8·5% (22 cases with epidemiological links-six clusters/189 cases with a strain type). Being UK born (odds ratio 4·81; 95% CI 2·03-11·36, p=0·0005) and illicit drug use (4·75; 1·19-18·96, p=0·026) were significantly associated with clustering. The most common transmission setting was the household but 21 of 22 of epidemiological links were missed by conventional contact tracing. 13 secondary active tuberculosis cases identified by conventional contact tracing were mostly contacts of patients with MDR tuberculosis from countries of high tuberculosis burden. 11 (85%) of 13 shared the same country of birth as the index case, of whom ten did not share a strain type or drug resistance pattern., Interpretation: Transmission of MDR tuberculosis in the UK is low and associated with being UK born or illicit drug use. MIRU-VNTR typing with cluster investigation was more successful at identifying transmission events than conventional contact tracing. Individuals with tuberculosis who have had contact with a known MDR tuberculosis source case from a country of high tuberculosis burden should have drug-sensitivity testing on isolates to ensure appropriate treatment is given., Funding: Public Health England., (Copyright © 2014 Anderson et al. Open Access article distributed under the terms of CC BY-NC-ND. Published by Elsevier Ltd. All rights reserved.)

United Kingdom (UK) guidelines recommend at least 18 months treatment for patients with multidrug-resistant tuberculosis (MDR-TB). Prior to 2008, data on treatment outcome were only available at 12 months and therefore the proportion completing treatment was unknown. This retrospective-prospective cohort study reports on treatment outcomes for MDR-TB patients notified between 2004 and 2007 and examines factors associated with successful outcomes. 70.6% (144/204) completed treatment in 24 months or more, 6.9% (14) stopped treatment, 6.9% (14) died, 7.8% (16) were lost to follow up, 0.5% (1) relapsed and 4.4% (9) were transferred overseas. Following adjustment for age, being non-UK born, non-compliance and having co-morbidities, treatment with a fluoroquinolone (OR 3.09; 95% CI 1.21-7.88; p<0.05) or bacteriostatic drug (OR 4.23; 95% CI 1.60-11.18; p<0.05) were independently associated with successful treatment outcome. Treatment completion for MDR-TB cases remains below the World Health Organization (WHO) target. Our findings support current WHO guidelines for MDR-TB treatment. The UK should consider adopting individualised regimens based on WHO recommended drugs, taking into account drug sensitivities. Improving treatment completion rates will be key to tackling further drug resistance and transmission from untreated infectious cases.

Background: Tuberculosis (TB) has increased within the UK and, in response, targets for TB control have been set and interventions recommended. The question was whether these had been implemented and, if so, had they been effective in reducing TB cases., Methods: Epidemiological data were obtained from enhanced surveillance and clinics. Primary care trusts or TB clinics with an average of > 100 TB cases per year were identified and provided reflections on the reasons for any change in their local incidence, which was compared to an audit against the national TB plan., Results: Access to data for planning varied (0-22 months). Sputum smear status was usually well recorded within the clinics. All cities had TB networks, a key worker for each case, free treatment and arrangements to treat HIV co-infection. Achievement of targets in the national plan correlated well with change in workload figures for the commissioning organizations (Spearman's rank correlation R = 0.8, P < 0.01) but not with clinic numbers. Four cities had not achieved the target of one nurse per 40 notifications (Birmingham, Bradford, Manchester and Sheffield). Compared to other cities, their loss to follow-up during treatment was usually > 6% (χ2 = 4.2, P < 0.05), there was less TB detected by screening and less outreach. Manchester was most poorly resourced and showed the highest rate of increase of TB. Direct referral from radiology, sputum from primary care and outreach workers were cited as important in TB control., Conclusion: TB control programmes depend on adequate numbers of specialist TB nurses for early detection and case-holding.Please see related article: http://www.biomedcentral.com/1741-7015/9/127.

Background: Continuing rises in tuberculosis notifications in the UK are attributable to cases in foreign-born immigrants. National guidance for immigrant screening is hampered by a lack of data about the prevalence of, and risk factors for, latent tuberculosis infection in immigrants. We aimed to determine the prevalence of latent infection in immigrants to the UK to define which groups should be screened and to quantify cost-effectiveness., Methods: In our multicentre cohort study and cost-effectiveness analysis we analysed demographic and test results from three centres in the UK (from 2008 to 2010) that used interferon-γ release-assay (IGRA) to screen immigrants aged 35 years or younger for latent tuberculosis infection. We assessed factors associated with latent infection by use of logistic regression and calculated the yields and cost-effectiveness of screening at different levels of tuberculosis incidence in immigrants' countries of origin with a decision analysis model., Findings: Results for IGRA-based screening were positive in 245 of 1229 immigrants (20%), negative in 982 (80%), and indeterminate in two (0·2%). Positive results were independently associated with increases in tuberculosis incidence in immigrants' countries of origin (p=0·0006), male sex (p = 0·046), and age (p < 0·0001). National policy thus far would fail to detect 71% of individuals with latent infection. The two most cost-effective strategies were to screen individuals from countries with a tuberculosis incidence of more than 250 cases per 100,000 (incremental cost-effectiveness ratio [ICER] was £17,956 [£1=US$1·60] per prevented case of tuberculosis) and at more than 150 cases per 100,000 (including immigrants from the Indian subcontinent), which identified 92% of infected immigrants and prevented an additional 29 cases at an ICER of £20,819 per additional case averted., Interpretation: Screening for latent infection can be implemented cost-effectively at a level of incidence that identifies most immigrants with latent tuberculosis, thereby preventing substantial numbers of future cases of active tuberculosis., Funding: Medical Research Council and Wellcome Trust., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Understanding energy landscapes is a major challenge in chemistry and biology. Although a wide variety of methods have been invented and applied to this problem, very little is understood about the actual mathematical structures underlying such landscapes. Perhaps the most general assumption is the idea that energy landscapes are low-dimensional manifolds embedded in high-dimensional Euclidean space. While this is a very mild assumption, we have discovered an example of an energy landscape which is nonmanifold, demonstrating previously unknown mathematical complexity. The example occurs in the energy landscape of cyclo-octane, which was found to have the structure of a reducible algebraic variety, composed of the union of a sphere and a Klein bottle, intersecting in two rings.

NICE (National Institute for Health and Clinical Excellence) guidelines for new entrant tuberculosis (TB) screening recommend chest x ray (CXR) for immigrants from countries with TB incidence >40/10(5), and tuberculin skin test (TST) for people with normal CXR from very high TB prevalence countries. A revised screening policy using first-line QuantiFERON-TB Gold (QFT) in high risk immigrants was piloted in 2007. Initially, TST was offered to immigrants from countries with TB incidence 200-339/10(5), and QFT to those from countries with incidence >340/10(5). When increased resources became available, all immigrants from countries with TB incidence >200/10(5) had QFT. Those with positive QFT were invited for CXR. 1336 immigrant were invited for screening, with a 32% attendance rate. 280 patients had QFT, of which 38% were positive, with <2% being indeterminate. Using the NICE approach, the cost of screening these 280 immigrants would be pound 13,346.75 ( pound 47.67 per immigrant) and would identify 83 cases of latent TB infection (LTBI). Using first-line QFT followed by CXR the cost was pound 9781.82 ( pound 34.94 per immigrant) and identified 105 cases of LTBI. The cost to identify one case of LTBI following NICE guidelines would be pound 160.81 and using the present protocol was pound 93.16. For immigrants from high risk countries QFT blood testing followed by CXR is feasible for TB screening, cheaper than screening using the NICE guideline and identifies more cases of LTBI.

Background: At the authors' institution, the superior gluteal artery musculocutaneous flap has been replaced by the superior gluteal artery perforator flap for autologous breast reconstruction. The authors present a head-to-head comparison of the two techniques., Methods: A retrospective chart review of 102 gluteal flap transfers in 80 patients compared the two methods with regard to perioperative details, complications (especially anastomotic), and the number of secondary procedures required to achieve optimal outcome. Statistical analysis was carried out, and a value of p < 0.05 was considered significant., Results: Seventy superior gluteal artery and 32 superior gluteal artery perforator flap procedures were performed over a period of 10 years. Patients in the superior gluteal artery perforator group tended to lose significantly less blood (375 cc versus 241 cc). There was no significant difference in the duration of surgery, hospital stay, or the overall complication rate. Even though the difference in the rate of anastomotic thrombosis (10 percent and 6 percent, respectively) was not statistically significant, patients in the superior gluteal artery group were prone to venous thrombosis, were more likely to require vein grafting, and had a higher rate of reoperation for anastomotic problems. There was no difference in the number of secondary operations., Conclusions: This report provides some evidence of the superiority of the superior gluteal artery perforator flap over the superior gluteal artery flap for breast reconstruction, particularly with regard to ease and reliability of the microvascular anastomosis. However, in the expert hands of its early proponents, the superior gluteal artery flap did remarkably well.

Objectives: To investigate the use of new gamma-interferon (IFN-gamma)-based blood tests to determine whether or not a higher-than-expected proportion of positive tuberculin skin tests (TSTs) were due to tuberculosis infection., Study Design: When an unexpectedly high proportion of children in a high school in Leeds were found to have positive TSTs, a cohort study was undertaken based on blood tests and long-term follow-up of the affected children. IFN-gamma-based blood tests are reported to be more specific for tuberculosis infection than TSTs., Methods: One hundred and ninety children, aged 13-14 years, were screened and 28 (15%) had a positive TST. None had any known risk factor for tuberculosis infection. Parental consent was requested for testing with QuantiFERON-TB Gold (Cellestis, Carnegie, Victoria, Australia). Active cases of tuberculosis with any possible connection to the school or the children were sought through the routine diagnosis and reporting service over the next 36 months., Results: Consent was given for 26 children with Heaf Grade 2 results to be tested using QuantiFERON-TB Gold, and blood was obtained from 24 of these children. All tested negative. None of these children developed active tuberculosis, and no cases of active tuberculosis were identified with any connection to the children or the school., Conclusion: QuantiFERON-TB Gold testing appeared to identify false-positive TSTs correctly in this group. This supports the recent recommendation to use IFN-gamma-based blood tests in people with positive TSTs to confirm or refute the diagnosis of tuberculosis infection.

Dimensionality reduction approaches have been used to exploit the redundancy in a Cartesian coordinate representation of molecular motion by producing low-dimensional representations of molecular motion. This has been used to help visualize complex energy landscapes, to extend the time scales of simulation, and to improve the efficiency of optimization. Until recently, linear approaches for dimensionality reduction have been employed. Here, we investigate the efficacy of several automated algorithms for nonlinear dimensionality reduction for representation of trans, trans-1,2,4-trifluorocyclo-octane conformation--a molecule whose structure can be described on a 2-manifold in a Cartesian coordinate phase space. We describe an efficient approach for a deterministic enumeration of ring conformations. We demonstrate a drastic improvement in dimensionality reduction with the use of nonlinear methods. We discuss the use of dimensionality reduction algorithms for estimating intrinsic dimensionality and the relationship to the Whitney embedding theorem. Additionally, we investigate the influence of the choice of high-dimensional encoding on the reduction. We show for the case studied that, in terms of reconstruction error root mean square deviation, Cartesian coordinate representations and encodings based on interatom distances provide better performance than encodings based on a dihedral angle representation.

Background: The lower abdomen is the most popular donor site for autologous tissue breast reconstruction. Several studies have reported abdominal morbidity following pedicled and free flap reconstructions using this donor site, yet few studies have compared the various types of free flaps and investigated specific operative and patient-related factors that are associated with higher rates of abdominal complications., Methods: The authors conducted a retrospective review of all free flap breast reconstructions performed at University of California Los Angeles Medical Center between July of 2002 and July of 2005., Results: A total of 279 patients underwent 211 unilateral and 68 bilateral reconstructions, totaling 347 flaps. Eleven percent were free transverse rectus abdominis myocutaneous (TRAM) flaps, 52 percent were muscle-sparing free TRAM flaps, and 37 percent were deep inferior epigastric perforator (DIEP) flaps. Mean follow-up was 29.9 months. There were 30 total abdominal complications (10.9 percent of patients), including 17 rectus bulges and five hernias. Free TRAM reconstructions had a significantly higher rate of donor-site complications than did DIEP reconstructions. Bilateral flap harvests and obesity (body mass index >30) were significant risk factors for (1) any donor-site complication and (2) rectus bulge/hernia formation. There was no significant increase in donor-site complications associated with various prior abdominal operations., Conclusions: Donor-site complications are not uncommon, but paying careful attention to patient comorbidities when selecting an operative approach (bilateral versus unilateral, free TRAM versus DIEP, and so on) can minimize postoperative abdominal complications. Furthermore, the results corroborate the recent literature suggesting there is little functional difference in patients receiving muscle-sparing free TRAM versus DIEP reconstructions.

Introduction: Despite high success rates with free-tissue transfer, flap loss continues to be a devastating event. Flap salvage is often successful if vascular complications are recognized and treated early. However, delayed presentation of flap compromise is an ominous predictor of flap loss. Late free-flap salvage has been described with poor long-term results. Catheter-directed thrombolysis (CDT) has only been described in context with free-tissue transfer in a case of distal bypass salvage., Objectives: The authors examined the efficacy of highly selective CDT in late salvage of free-flaps with vascular compromise., Methods: Two patients underwent highly selective CDT after delayed presentation (>5 days) of flap compromise. Patient 1 is a 59-year-old woman who underwent delayed breast reconstruction with a free TRAM flap and presented with arterial thrombosis 12 days postoperatively. Patient 2 is a 53-year-old man who underwent fibular osteocutaneous free-flap reconstruction of a floor of mouth defect who developed venous thrombosis 6 days postoperatively. Patient 2 underwent two attempted operative anastamotic revisions with thrombectomies and local thrombolysis prior to CDT., Results: The average time of presentation was 9 days, with the average time to CDT being 9.5 days. Patient 1 had an arterial thrombosis, whereas Patient 2 had a venous thrombosis. Both patients underwent successful thrombolysis after super-selective angiograms. Continuous infusions of thrombolytic agents were used in both patients for approximately 24 h. Average length of stay postCDT was 7 days with no perioperative complications. Long-term follow-up demonstrated complete flap salvage with no soft tissue loss., Conclusion: Despite extremely delayed presentation, aggressive CDT was successful in both breast, and head and neck reconstructions with excellent long-term flap results. CDT appears to be a useful modality in managing difficult cases of free-flap salvage., ((c) 2008 Wiley-Liss, Inc. Microsurgery, 2008)

Background: Reconstruction is an important adjunct to breast cancer management. This study evaluated the frequency of major and minor complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction., Methods: All patients treated with microvascular breast reconstruction at the University of California, Los Angeles, Medical Center over an 11-year period were identified using a retrospective analysis. Frequency of complications was assessed., Results: A total of 1195 breast reconstructions were performed in 952 patients. Transverse rectus abdominis musculocutaneous flaps were used in most cases (81.8 percent), whereas the superior gluteal musculocutaneous flap (10.1 percent) and other free flaps were used in the remaining patients. The overall complication rate was 27.9 percent and consisted primarily of minor complications (21.7 percent). Major complications were noted in 7.7 percent, including six total flap losses (0.5 percent). Obesity was a major predictor of complications. Smoking was not associated with increased rates of overall or microsurgical complications. Neoadjuvant chemotherapy was also an independent predictor of complications and was associated with wound-healing problems and fat necrosis. Prior abdominal surgery in transverse rectus abdominis musculocutaneous flap patients increased the risk of partial flap loss, fat necrosis, and donor-site complications., Conclusions: Microsurgical breast reconstruction is a safe and highly effective technique. Complications tend to be minor and do not affect postreconstruction adjuvant therapy. Obesity is a major predictor of flap and donor-site complications, and these patients should be appropriately counseled. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications.

Purpose: To highlight the diversity of clinical presentations with tubercular uveitis in a nonendemic setting, and discuss the diagnostic approach and an effective treatment., Method: Descriptive case series., Results: A total of 12 cases of varied presentations of tubercular uveitis diagnosed over a period of 1 year of which six cases are described in detail. Presentations included choroidal tuberculomas, multifocal choroiditis, recurrent granulomatous uveitis, panuveitis with cystoid macular oedema, and serpiginous choroiditis. All cases had a chronic or recurrent course and responded very well to antitubercular treatment. Diagnosis was mainly assisted by positive tuberculin testing., Conclusion: A high index of suspicion helps diagnose ocular tuberculosis in areas of low prevalence of the disease. It forms part of the differential diagnosis of any chronic or recurrent uveitis, especially in an at-risk patient. Antitubercular treatment seems highly effective.

Background: There are conflicting guidelines and variations in clinical practice in the management of bone tuberculosis (TB), including spinal TB. A case who received 6 months of treatment in line with current British Thoracic Society (BTS) guidelines, and subsequently relapsed, prompted a survey of treatment and outcomes of spinal and other bone TB., Methods: A retrospective study examining the clinical features, treatment duration and outcome of patients presenting with spinal and other bone TB to the Leeds Teaching Hospitals National Health Service Trust, between 1998 and 2002., Results: Forty-two patients were identified. Notes from 34 patients with spinal TB and four patients with TB of other bones were reviewed. Of eight patients who received 6 months of therapy, five relapsed. Of 30 patients who received treatment for 9 months or longer, none relapsed (P < 0.05)., Conclusion: Six months of treatment, as currently recommended by the BTS, may be inadequate for bone TB, including spinal TB.

Recent international guidelines published in 1997 and 1999 have proposed diagnostic and treatment criteria for disease caused by nontuberculous mycobacteria (NTM). In this paper, the epidemiological data, diagnostic criteria, treatment regimens and outcomes from 117 HIV-negative patients who had a positive culture for NTM between 1995-1999 are reviewed. The authors wished to identify factors associated with improved outcome in these patients. A total of 71 patients were believed to have a clinical disease caused by NTM, as defined by international criteria. A total of 72% patients were found to have had pulmonary disease. There was a rise in infections between 1995-1999, with a peak in infections in 1997. The most striking rise was in Mycobacterium avium intracellulare complex infections (1995: 33% infections; 1996: 36% infections; 1997: 41% infections; 1998: 61% infections; 1999: 57% infections). There was a link between deprivation and number of positive NTM isolates (34.4% isolates occurred in the areas of lowest Carstairs deprivation index versus 20.6% isolates from areas of least deprivation). There was a significant association between appropriate therapy, defined by American Thoracic Society and British Thoracic Society guidelines, and successful outcome (74%) in contrast to those who received inappropriate treatment prior to the publication of these guidelines. Nontuberculous mycobacteria infections remain a significant problem in non-HIV patients. Adherence to published guidelines may improve patient outcomes.

Representations are formalized as encodings that map the search space to the vertex set of a graph. We define the notion of bit equivalent encodings and show that for such encodings the corresponding Walsh coefficients are also conserved. We focus on Gray codes as particular types of encoding and present a review of properties related to the use of Gray codes. Gray codes are widely used in conjunction with genetic algorithms and bit-climbing algorithms for parameter optimization problems. We present new convergence proofs for a special class of unimodal functions; the proofs show that a steepest ascent bit climber using any reflected Gray code representation reaches the global optimum in a number of steps that is linear with respect to the encoding size. There are in fact many different Gray codes. Shifting is defined as a mechanism for dynamically switching from one Gray code representation to another in order to escape local optima. Theoretical results that substantially improve our understanding of the Gray codes and the shifting mechanism are presented. New proofs also shed light on the number of unique Gray code neighborhoods accessible via shifting and on how neighborhood structure changes during shifting. We show that shifting can improve the performance of both a local search algorithm as well as one of the best genetic algorithms currently available.

Microvascular tissue transfer has become the gold standard for breast reconstruction. The primary drawback to these procedures is the technical expertise required for microsurgical anastomosis. This problem is compounded by the difficulties in the exposure of recipient vessels deep within the axilla. Previous techniques used for exposure of these vessels are difficult to setup, provide less than optimal exposure, and have been associated with brachial plexus injuries. The authors retrospectively review their experience using the pediatric OMNI retractor for exposure of recipient vessels during microvascular breast reconstruction. Patient demographics, flap choice, recipient vessels, the incidence of neuropraxia/brachial plexopathy, and microvascular complications were analyzed. Patients in whom more traditional methods of vessel exposure were used (ie, Gelpi retractors, arm positioning, fish hooks; 517 reconstructions in 392 patients) were compared with patients in whom vessel exposure was performed using the pediatric OMNI retractor (699 reconstructions in 571 patients). No differences were noted in comorbid conditions or the incidence of microvascular complications. However, the use of the pediatric OMNI was associated with a significant reduction in operative time in unilateral reconstructions (6:23 +/- 0.05 h vs 7:48 +/- 0.05 h; P <0.01) and decreased incidence of brachial plexus injury (0.17% vs 3.3%; P <0.01). The authors think the decreased neuropraxia rate is the result of better exposure afforded by the pediatric OMNI retractor, which improves exposure and eliminates the need for excessive arm abduction or awkward positioning during the dissection and anastomosis of axillary recipient vessels.

Microsurgical reconstruction of composite through-and-through defects of the oral cavity involving mucosa, bone, and external skin has often required two free flaps or double-skin paddle scapular or radial forearm flaps for successful functional and aesthetic outcomes. A safe, reliable technique using a double-skin paddle fibular osteocutaneous flap to restore the intraoral lining, mandibular bone, and external skin is described. A large elliptical or rectangular skin paddle is designed 90 degrees to the longitudinal axis of the fibula, over the junction of the middle and distal thirds of the lower leg, based only on the posterolateral septocutaneous perforators. This skin flap can be draped anteriorly and posteriorly over the fibular bone to reconstruct both the intraoral defect and the external skin defect. The area between the two skin islands of the intraoral flap and the external flap is deepithelialized and left as a dermal bridge between the two skin islands, as opposed to the creation of two separate vertical skin paddles, each based on a septocutaneous perforator. The transverse dimension of the flap can be as great as 14 cm, extending to within 1 to 2 cm of the tibial crest anteriorly and as far as the midline posteriorly, and with a length of up to 26 cm, this flap should be more than sufficient for reconstruction of most through-and-through defects. This technique has allowed the successful reconstruction of large composite defects, with missing intraoral lining, mandibular bone, and external skin, for 16 patients, with 100 percent survival of both skin islands in all cases and without the development of any orocutaneous fistulae.

The lack of adequate recipient vessels often complicates microvascular breast reconstruction in patients who have previously undergone mastectomy and irradiation. In addition, significant size mismatch, particularly in the outflow veins, is an important contributor to vessel thrombosis and flap failure. The purpose of this study was to review the authors' experience with alternative venous outflow vessels for microvascular breast reconstruction. In a retrospective analysis of 1278 microvascular breast reconstructions performed over a 10-year period, the authors identified all patients in whom the external jugular or cephalic veins were used as the outflow vessels. Patient demographics, flap choice, the reasons for the use of alternative venous drainage vessels, and the incidence of microsurgical complications were analyzed. The external jugular was used in 23 flaps performed in procedures with 22 patients. The superior gluteal and transverse rectus abdominis musculocutaneous (TRAM) flaps were used in the majority of the cases in which the external jugular vein was used (72 percent gluteal, 20 percent TRAM flap). The need for alternative venous outflow vessels was usually due to a significant vessel size mismatch between the superior gluteal and internal mammary veins (74 percent). For three of the external jugular vein flaps (13 percent), the vein was used for salvage after the primary draining vein thrombosed, and two of three flaps in these cases were eventually salvaged. In three patients, the external jugular vein thrombosed, resulting in two flap losses, while the third was salvaged using the cephalic vein. A total of two flaps were lost in the external jugular vein group. The cephalic vein was used in 11 flaps (TRAM, 64.3 percent; superior gluteal, 35.7 percent) performed in 11 patients. In five patients (54.5 percent), the cephalic vein was used to salvage a flap after the primary draining vein thrombosed; the procedure was successful in four cases. In three patients, the cephalic vein thrombosed, resulting in two flap losses. One patient suffered a thrombosis after the cephalic vein was used to salvage a flap in which the external jugular vein was initially used, leading to flap loss, while a second patient experienced cephalic vein thrombosis on postoperative day 7 while carrying a heavy package. There was only one minor complication attributable to the harvest of the external jugular or cephalic vein (small neck hematoma that was aspirated), and the resultant scars were excellent. The external jugular and cephalic veins are important ancillary veins available for microvascular breast reconstruction. The dissection of these vessels is straightforward, and their use is well tolerated and highly successful.

The incidence of breast cancer is increasing each year. Concomitantly, cosmetic breast augmentation has become the second most often performed cosmetic surgical procedure. As the augmented patient population ages, an increasing number of breast cancer cases among previously augmented women can be anticipated. The surgical treatment of these patients is controversial, with several questions remaining unanswered. Is breast conservation therapy feasible in this patient population and can these patients retain their implants? A retrospective review of all breast cancer patients with a history of previous augmentation mammaplasty who were treated at the Revlon/UCLA Breast Center between 1991 and 2001 was performed. During the study period, 58 patients were treated. Thirty patients (52 percent) were treated with a modified radical mastectomy with implant removal. Twenty-eight patients (48 percent) underwent breast conservation therapy, which consisted of lumpectomy, axillary lymph node dissection, and radiotherapy. Twenty-two of the patients who underwent breast conservation therapy initially retained their implants. Eleven of those 22 patients (50 percent) ultimately required completion mastectomies with implant removal because of implant complications (two patients), local recurrences (five patients), or the inability to obtain negative margins (four patients). Nine additional patients experienced complications resulting from their implants, including contracture, erosion, pain, and rupture. The data illustrate that breast conservation therapy with maintenance of the implant is not ideal for the majority of augmented patients. Breast conservation therapy with explantation and mastopexy might be appropriate for rare patients with large volumes of native breast tissue. Mastectomy with immediate reconstruction might be a more suitable choice for these patients.

Setting: Kota Kinabalu and surrounding communities in Sabah, Malaysia., Objectives: To establish factors affecting compliance of patients with anti-tuberculosis chemotherapy, their knowledge of the disease, and views on improving the DOTS strategy., Design: Interviews with compliant patients attending clinics for DOTS treatment and with non-compliant patients in their homes, in August and September 2000., Results: A total of 63 compliant and 23 non-compliant patients were interviewed. For non-compliant patients, reaching the treatment centre entailed greater cost (P < 0.005) and travel time (P < 0.005) compared to compliant patients. Cost of transport was the reason most frequently given for non-attendance. Non-compliant patients were more likely to have completed secondary education (P < 0.05), and to be working (P < 0.01). More non-compliant patients had family members who had had the disease (P < 0.01). There was no difference between the groups for overall tuberculosis knowledge scores; however, non-compliant patients were more likely to think that treatment could be stopped once they were symptom free (P < 0.01). Most patients (73%) felt that the DOTS system could be improved by provision of more information about tuberculosis., Conclusion: Compliance with DOTS in the Kota Kinabalu area is affected by travel expenses, time spent travelling to treatment centres, and having family members who have had the disease. Patients would like more information on tuberculosis.

Unsedated diagnostic gastroscopy has become widely accepted as a diagnostic procedure which avoids the risk of an anaesthetic. It also provides advantages for patients and hospitals in converting the procedure to an ambulatory care investigation. Patient perception of the procedure can sometimes differ from that of medical and nursing staff. We have decided to report our usual clinical practice by auditing 100 consecutive patients undergoing this procedure in a large rural private hospital. Patient tolerance was analyzed in various categories including degree of comfort, degree of pain, ease of breathing and willingness to repeat the procedure under the same conditions. The perceived comfort rating was compared between the patient, the endoscopist and the endoscopy nurse. A total of 100 consecutive patients were evaluated; 55 chose to be sedated and 45 were unsedated. Of the 100 patients tested, 88% stated they would have the procedure the same way if a repeat procedure was required. There was no significant difference between male/female or sedated/unsedated patients. The most important consideration for patients who chose to have the procedure unsedated was the ability to speak to the endoscopist immediately post-procedure. Patient rating of pain was not significantly different between the sedated and unsedated groups. There was no significant difference in the independent assessment by the endoscopist and the nurse with respect to patient comfort in both the sedated and the unsedated groups. However, their assessment differed significantly from the patients own rating, as endoscopists and gastrointestinal (GI) nurses rated the patient degree of comfort as higher than the patients themselves (P < 0.01 for doctor/patient and nurse/patient score, Student's t-test). No complications were reported in either group of patients during the audit. Unsedated diagnostic gastroscopy is perceived to be an acceptable alternative to a sedated procedure by the majority of patients. Patients rate the procedure as more uncomfortable than their health care professionals, but the majority of patients would still have the repeat procedure the same way.

Evidence suggests that the majority of lung cancer patients have tumour-derived genetic alterations in circulating plasma DNA, and that this may be developed as a diagnostic tool. To this end, we have studied 60 individuals attending bronchoscopy clinic, with symptoms suspicious of lung cancer, for genetic alterations in bronchial mucosa biopsy (n = 47) and plasma (n = 40) DNA. Thirteen of 47 individuals from whom biopsies were taken displayed allelic loss of heterozygosity (LOH) in biopsy DNA for at least 1 of 4 markers. All 13 of these individuals had neoplastic tumour cells in their biopsies and were subsequently diagnosed with cancer. Thirteen of 40 individuals from whom plasma was taken displayed a plasma DNA LOH, and 12 of these 13 individuals were subsequently diagnosed with cancer. LOH in plasma was generally representative of LOH in the corresponding biopsy. In terms of sensitivity, using just 4 markers, biopsy LOH and plasma LOH were found in 13 of 44 (30%) and 12 of 29 (41%), respectively, of those patients subsequently diagnosed with cancer. Two patients were positive for LOH in plasma samples that pre-dated a diagnosis of cancer by several months. These data suggest that assay of genetic alterations in circulating plasma DNA may be developed as a useful addition to conventional techniques for the diagnosis of lung cancer.

Background: Argon plasma coagulation is a diathermy-based non-contact therapeutic endoscopic modality that may have a lower risk of perforation than other tissue ablation techniques., Methods: Its effect was studied on three fresh esophageal and three fresh gastric resection specimens using power settings from 40 to 99 Watts at 90 degrees, with 1 mm separation using pulse durations of 1 and 3 seconds. A scoring system for depth of tissue damage was created and samples were analyzed blindly by a gastrointestinal histopathologist., Results: There was significantly greater damage to gastric tissue using a 3-second (compared with 1-second) pulse (p = 0.003) and marginally significantly greater damage to esophageal tissue using the 3-second pulse (p = 0.053). Tissue damage was related to power setting for gastric (p = 0.031) but not for esophageal tissue (p = 0. 065). Only 1 of 42 esophageal samples and 2 of 42 gastric samples examined showed damage extending into the muscularis propria., Conclusions: Deep tissue damage that could lead to perforation was rare with argon plasma coagulation. The depth of gastric mucosal damage increased with increased pulse duration and increasing power settings, and, although the depth of esophageal mucosal damage was marginally related to pulse duration, it was not related to the power setting. (Gastrointest Endosc 2000;52:342-5).