Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

OBJECTIVE: To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND: Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS: The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS: Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION: We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG

Breast cancer in young women

Although uncommon, breast cancer in young women is worthy of special attention due to the unique and complex issues that are raised. This article reviews specific challenges associated with the care of younger breast cancer patients, which include fertility preservation, management of inherited breast cancer syndromes, maintenance of bone health, secondary prevention, and attention to psychosocial issues

Search for dark matter candidates and large extra dimensions in events with a jet and missing transverse momentum with the ATLAS detector

Open Access, Copyright CERN, for the benefit of the ATLAS collaboration. This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution and reproduction in any medium, provided the original author(s) and source are credited

Sphenoid dysplasia in neurofibromatosis type 1: a new technique for repair

Purpose: Sphenoid bone dysplasia in neurofibromatosis type 1 is characterized by progressive exophthalmos and facial disfiguration secondary to herniation of meningeal and cerebral structures. We describe a technique for reconstruction of the sphenoid defect apt at preventing or correcting the ocular globe dislocation. Methods: After placement of spinal cerebrospinal fluid drainage to reduce intracranial pressure, the temporal pole is posteriorly dislocated extradurally. The greater sphenoid wing defect is identified. A titanium mesh covered by lyophilized dura, modeled in a curved fashion, is interposed between the bone defect and the cerebro-meningeal structures with its convex surface over the retracted temporal pole. Results: The particular configuration of the titanium mesh allows a self-maintaining position due to the pressure exerted by the brain over its convex central part with its lateral margins consequently pushed and self-anchored against the medial and lateral walls of the temporal fossa. Screw fixation is not needed. The technique utilized in four cases proved to be reliable at the long-term clinical and neuroradiological controls (6 to 19\ua0years). Conclusion: Sphenoid bone dysplasia in NF1, resulting in proptosis and exophthalmos, is usually progressive. It can be surgically repaired using a curved titanium mesh with the convexity faced to the temporal pole that is in the opposite fashion from all the techniques previously introduced. When utilized early in life, the technique can prevent the occurrence of the orbital and facial disfiguration

Polyetheretherketone (PEEK) cage filled with cancellous allograft in anterior cervical discectomy and fusion

From July 2004 to June 2005, 19 patients with 25 discs underwent anterior cervical discectomy and interbody fusion (ACDF) in which polyetheretherketone (PEEK) cages were filled with freeze-dried cancellous allograft bone. This kind of bone graft was made from femoral condyle that was harvested during total knee arthroplasty. Patient age at surgery was 52.9 (28–68) years. All patients were followed up at least 1 year. We measured the height of the disc and segmental sagittal angulation by pre-operative and post-operative radiographs. CT scan of the cervical spine at 1 year was used to evaluate fusion rates. Odom's criteria were used to assess the clinical outcome. All interbody disc spaces achieved successful union at 1-year follow-up. The use of a PEEK cage was found to increase the height of the disc immediately after surgery (5.0 mm pre-operatively, 7.3 mm immediately post-operatively). The final disc height was 6.2 mm, and the collapse of the disc height was 1.1 mm. The segmental lordosis also increased after surgery (2.0° pre-operatively, 6.6° immediately post-operatively), but the mean loss of lordosis correction was 3.3° at final follow-up. Seventy-four percent of patients (14/19) exhibited excellent/good clinical outcomes. Analysis of the results indicated the cancellous allograft bone-filled PEEK cage used in ACDF is a good choice for patients with cervical disc disease, and avoids the complications of harvesting iliac autograft

Pharmacokinetic/pharmacodynamic integration in drug development and dosage-regimen optimization for veterinary medicine

Pharmacokinetic (PK)/pharmacodynamic (PD) modeling is a scientific tool to help developers select a rational dosage regimen for confirmatory clinical testing. This article describes some of the limitations associated with traditional dose-titration designs (parallel and crossover designs) for determining an appropriate dosage regimen. It also explains how a PK/PD model integrates the PK model (describing the relationship between dose, systemic drug concentrations, and time) with the PD model (describing the relationship between systemic drug concentration and the effect vs time profile) and a statistical model (particularly, the intra- and interindividual variability of PK and/or PD origin). Of equal importance is the utility of these models for promoting rational drug selection on the basis of effectiveness and selectivity. PK/PD modeling can be executed using various approaches, such as direct versus indirect response models and parametric versus nonparametric models. PK/PD concepts can be applied to individual dose optimization. Examples of the application of PK/PD approaches in veterinary drug development are provided, with particular emphasis given to nonsteroidal anti-inflammatory drugs. The limits of PK/PD approaches include the development of appropriate models, the validity of surrogate endpoints, and the acceptance of these models in a regulatory environment

Investigation of proton-proton short-range correlations via the C-12(e,e'pp) reaction

5 pages, 4 figures, submitted to Physical Review Letters - SONDE, Bertin, submitted to Physical Review LettersWe investigated simultaneously the 12C(e,e'p) and 12C(e,e'pp) reactions at Q2 = 2 [GeV/c]2, x_B = 1.2, and in an (e,e'p) missing-momentum range from 300 to 600 MeV/c. At these kinematics, with a missing-momentum greater than the Fermi momentum of nucleons in a nucleus and far from the delta excitation, short-range nucleon-nucleon correlations are predicted to dominate the reaction. For(9.5 +/- 2)% of the 12C(e,e'p) events, a recoiling partner proton was observed back-to-back to the 12C(e,e'p) missing momentum vector, an experimental signature of correlations

Probing for high momentum protons in 4^4He via the 4He(e,e′p)X^4He(e,e'p)X reaction

Experimental cross sections for the $^4He(e,e'p)X$ reaction up to a missing momentum of 0.632 GeV/$c$ at $x_B=1.24$ and $Q^2$=2(GeV/$c$)$^2$ are reported. The data are compared to Relativistic Distorted Wave Impulse Approximation(RDWIA) calculations for $^4He(e,e'p)^3H$ channel. Significantly more events in the triton mass region are measured for $p_{m}$>0.45 GeV/$c$ than are predicted by the theoretical model, suggesting that the effects of initial-state multi-nucleon correlations are stronger than expected by the RDWIA model