Nipple Sparing Mastectomy Techniques: A Literature Review and an Inframammary Technique

Nipple sparing mastectomy (NSM) has quickly become an accepted technique for patients with selected cancers and for risk reducing surgery. Much of its surgical acceptance over the last decade has been based on the low risk of nipple areolar complex (NAC) occurrence in breast cancer patients. Improved patient satisfaction due to improved cosmetic outcomes with reconstruction have also driven its popularity. We reviewed current English journals to determine the NSM techniques which achieve the lowest complications, best outcomes, and best patient satisfaction. We researched studies showing reductions in complications with improved surgical techniques and patient selection which have been implicated in improved results. In the studies reviewed, incision placement, away from the nipple, resulted in the lowest rates of ischemic nipple complications and the best cosmetic outcomes. The effect of other factors such as surgeon experience and thickness of skin flap development were more difficult to prove. Leaving a 2-3 mm rim of tissue around the nipple bundle was shown to help preserve the nipple vascularity. Lower complication rates with improved outcomes and patient satisfaction were reported in the literature in patients with B or smaller cup sizes, non-smokers, and patients with lower body mass index (BMI). Incision placement, away from the nipple, with preservation of a 2-3 mm rim of tissue around the nipple bundle along with careful patient selection were the most significant variables reviewed which helped to lower complications rates of NSM. Coordinated surgical planning with the breast and plastic surgeons to determine the best surgical approach for each individual patient is necessary to obtain the best results. Although short-term oncologic follow-up seems to be acceptable, longer follow-up will still be needed to define the best breast cancer surgical candidates for the nipple sparing approach

Is off-pump superior to conventional coronary artery bypass grafting in diabetic patients with multivessel disease?

Objective: Diabetic patients often present with diffuse coronary disease than nondiabetic patients posing a greater surgical challenge during off-pump revascularization. In this study, the safety, feasibility, and completeness of revascularization for this subset of patients was assessed. Methods: From 2002 to 2008, 1015 diabetic patients underwent myocardial revascularization. Patients received either off-pump coronary artery bypass (OPCAB; n=540; 53%) or coronary artery bypass grafting (CABG; n=475; 47%). Data collection was performed prospectively and data analysis was done by propensity-score (PS)-adjusted regression analysis. Primary endpoints were mortality, major adverse cardiac and cerebrovascular events (MACCEs), and a composite endpoint including major noncardiac adverse events (MNCAEs) such as respiratory failure, renal failure, and rethoracotomy for bleeding was applied. An index of complete revascularization (ICOR) was defined to assess complete revascularization by dividing the total number of distal anastomoses by the number of diseased vessels. Complete revascularization was assumed when ICOR was >1. Results: OPCAB patients had a significantly lower mortality-rate (1.1% vs 3.8%; propensity-adjusted odds ratio (PAOR)=0.11; p=0.018) and displayed less frequent MACCE (8.3% vs 17.9%; PAOR=0.66; p=0.07) including myocardial infarction (1.3% vs 3.2%; PAOR=0.33; p=0.06) and stroke (0.7% vs 2.3%; PAOR=0.28; p=0.13). Similarly, a significantly lower occurrence of the noncardiac composite endpoint (MNCAE) (PAOR=0.46; confidence interval (CI) 95% 0.35-0.91; p1 was achieved clearly indicating complete revascularization (94.3% vs 93.7%; p=0.24). Conclusions: OPCAB offers a lower mortality and superior postoperative outcomes in diabetic patients with multivessel disease. Arterial grafts are used more frequently that may contribute to better long-term outcomes and the OPCAB approach does not come at the cost of less complete revascularizatio

Total arterial off-pump surgery provides excellent outcomes and does not compromise complete revascularization†

OBJECTIVES The combination of aortic ‘no-touch' off-pump surgery (OPCAB) and total arterial revascularization (TAR) can reduce peri-procedural morbidity and yields excellent long-term outcomes albeit at a reported risk of incomplete revascularization. The feasibility of OPCAB-TAR with specific regards to the complete revascularization (CR) in patients with multi-vessel disease was evaluated. METHODS From 2003 to 2010, 712 patients underwent TAR including 526 patients who had OPCAB-TAR and 186 patients who received on-pump TAR [(ONCAB grafting (ONCABG)-TAR)]. Of these, 52% (n=272; OPCAB) vs. 83% (n=155; ONCABG) had triple-vessel disease (TVD). To balance patient characteristics, a non-parsimonious, propensity score (PS) model was applied. Endpoints evaluated were mortality, stroke, major adverse cardiac and cerebrovascular events (MACCE). To evaluate CR, an ‘Index of CR' (ICOR) was calculated, defined as the number of distal anastomoses divided by the number of the diseased coronary vessels. CR was assumed when the following requirements were fulfilled: the number of distal anastomoses was equal to or higher than that of diseased vessels (ICOR≥1), and all affected coronary territories (left anterior descending, circumflex artery and/or right coronary artery) were grafted. RESULTS Mortality was comparable between groups, whereas OPCAB patients suffered from significantly decreased rates of MACCE [3.0 vs. 7.0%; propensity-adjusted odd ratio (PAOR)=0.24; confidence interval (CI) 95% 0.08-0.66; P=0.006] including a clear trend towards reduced stroke and myocardial infarction. In the subgroup with TVD, OPCAB patients presented with significantly reduced rates for MACCE (1.8 vs. 5.8%; PAOR=0.07; CI 95% 0.01-0.65; P=0.02), including a significantly lower rate for stroke. For all-comers, the number of diseased vessels was lower after OPCAB (2.36±0.73 vs. 2.87±0.39; P<0.001) and consequently, these patients received an overall lower number of distal anastomoses (2.42±1.15 vs. 3.06±0.98; P<0.001). Although the ICOR was slightly lower (1.04±0.37 vs. 1.07±0.37; P=0.02), CR was achieved more frequently in OPCAB patients (82.1 vs. 73.1%; P=0.01). In the subgroup with TVD, the number of distal anastomoses (2.99±1.14 vs. 3.10±0.98; P=0.19) and the ICOR (1.00±0.38 vs. 1.03±0.33; P=0.19) was comparable between groups. The frequency of CR was slightly higher (75 vs. 67.7%; P=0.11), and the proportion of complete in situ grafting was significantly higher after OPCAB (37.1 vs. 23.9%; P=0.005). CONCLUSIONS Aortic ‘no-touch' OPCAB-TAR leads to a significant reduction of MACCE. It does not compromise CR in patients with TVD and thus can be safely applied to these patient

Total arterial off-pump surgery provides excellent outcomes and does not compromise complete revascularization†

OBJECTIVES The combination of aortic ‘no-touch' off-pump surgery (OPCAB) and total arterial revascularization (TAR) can reduce peri-procedural morbidity and yields excellent long-term outcomes albeit at a reported risk of incomplete revascularization. The feasibility of OPCAB-TAR with specific regards to the complete revascularization (CR) in patients with multi-vessel disease was evaluated. METHODS From 2003 to 2010, 712 patients underwent TAR including 526 patients who had OPCAB-TAR and 186 patients who received on-pump TAR [(ONCAB grafting (ONCABG)-TAR)]. Of these, 52% (n=272; OPCAB) vs. 83% (n=155; ONCABG) had triple-vessel disease (TVD). To balance patient characteristics, a non-parsimonious, propensity score (PS) model was applied. Endpoints evaluated were mortality, stroke, major adverse cardiac and cerebrovascular events (MACCE). To evaluate CR, an ‘Index of CR' (ICOR) was calculated, defined as the number of distal anastomoses divided by the number of the diseased coronary vessels. CR was assumed when the following requirements were fulfilled: the number of distal anastomoses was equal to or higher than that of diseased vessels (ICOR≥1), and all affected coronary territories (left anterior descending, circumflex artery and/or right coronary artery) were grafted. RESULTS Mortality was comparable between groups, whereas OPCAB patients suffered from significantly decreased rates of MACCE [3.0 vs. 7.0%; propensity-adjusted odd ratio (PAOR)=0.24; confidence interval (CI) 95% 0.08-0.66; P=0.006] including a clear trend towards reduced stroke and myocardial infarction. In the subgroup with TVD, OPCAB patients presented with significantly reduced rates for MACCE (1.8 vs. 5.8%; PAOR=0.07; CI 95% 0.01-0.65; P=0.02), including a significantly lower rate for stroke. For all-comers, the number of diseased vessels was lower after OPCAB (2.36±0.73 vs. 2.87±0.39; P<0.001) and consequently, these patients received an overall lower number of distal anastomoses (2.42±1.15 vs. 3.06±0.98; P<0.001). Although the ICOR was slightly lower (1.04±0.37 vs. 1.07±0.37; P=0.02), CR was achieved more frequently in OPCAB patients (82.1 vs. 73.1%; P=0.01). In the subgroup with TVD, the number of distal anastomoses (2.99±1.14 vs. 3.10±0.98; P=0.19) and the ICOR (1.00±0.38 vs. 1.03±0.33; P=0.19) was comparable between groups. The frequency of CR was slightly higher (75 vs. 67.7%; P=0.11), and the proportion of complete in situ grafting was significantly higher after OPCAB (37.1 vs. 23.9%; P=0.005). CONCLUSIONS Aortic ‘no-touch' OPCAB-TAR leads to a significant reduction of MACCE. It does not compromise CR in patients with TVD and thus can be safely applied to these patient

Search extension transforms Wiki into a relational system: A case for flavonoid metabolite database

<p>Abstract</p> <p>Background</p> <p>In computer science, database systems are based on the relational model founded by Edgar Codd in 1970. On the other hand, in the area of biology the word 'database' often refers to loosely formatted, very large text files. Although such bio-databases may describe conflicts or ambiguities (e.g. a protein pair do and do not interact, or unknown parameters) in a positive sense, the flexibility of the data format sacrifices a systematic query mechanism equivalent to the widely used SQL.</p> <p>Results</p> <p>To overcome this disadvantage, we propose embeddable string-search commands on a Wiki-based system and designed a half-formatted database. As proof of principle, a database of flavonoid with 6902 molecular structures from over 1687 plant species was implemented on MediaWiki, the background system of Wikipedia. Registered users can describe any information in an arbitrary format. Structured part is subject to text-string searches to realize relational operations. The system was written in PHP language as the extension of MediaWiki. All modifications are open-source and publicly available.</p> <p>Conclusion</p> <p>This scheme benefits from both the free-formatted Wiki style and the concise and structured relational-database style. MediaWiki supports multi-user environments for document management, and the cost for database maintenance is alleviated.</p

Negative microbiological results are not mandatory in deep sternal wound infections before wound closure†

OBJECTIVES To define the outcome of treatment for deep sternal wound infections (DSWIs) using direct wound closure (DC) or vacuum-assisted therapy (VAT) based on negative vs. positive microbiological results. METHODS Between 1999 and 2008, 7746 patients underwent median sternotomy for cardiac surgery at our institution. Patients were screened for DSWI and out of the cohort 159 were identified (2%). These patients were treated, either using DC or VAT with delayed wound closure. Outcomes were retrospectively analysed to determine the effect of negative cultures at the time of closure. RESULTS The indication for sternotomy was CABG 51%, isolated valve 18%, CABG/valve 18% and other related cardiovascular procedures 14%. Sixty-five percent of the wound infections was diagnosed during rehabilitation period. One hundred and five (66%) patients were treated with VAT vs. 54 (34%) patients with direct closure. Coagulase negative staphylococci were found in 48% of bacterial cultures. In 75% of the patients, the microbiological results were positive at time of wound closure (69.2% VAT vs. 87.0% direct closure, P=0.014). Out of 159 patients, 5.0% were with positive microbiological results at the time of closure readmitted vs. 5.1% with negative microbiological results (P=1.0). Patients with VAT stayed significantly longer in the hospital (mean 21±16 vs. 13±12, P=0.002). CONCLUSIONS Negative microbiological results are not mandatory before wound closure, as the rate of readmissions for recurrence of infection showed no difference between groups. Our results also suggest that shortening of VAT despite positive microbiological results may be feasibl

A Generalization of the Stillinger-Lovett Sum Rules for the Two-Dimensional Jellium

In the equilibrium statistical mechanics of classical Coulomb fluids, the long-range tail of the Coulomb potential gives rise to the Stillinger-Lovett sum rules for the charge correlation functions. For the jellium model of mobile particles of charge $q$ immersed in a neutralizing background, the fixing of one of the $q$-charges induces a screening cloud of the charge density whose zeroth and second moments are determined just by the Stillinger-Lovett sum rules. In this paper, we generalize these sum rules to the screening cloud induced around a pointlike guest charge $Z q$ immersed in the bulk interior of the 2D jellium with the coupling constant $\Gamma=\beta q^2$ ($\beta$ is the inverse temperature), in the whole region of the thermodynamic stability of the guest charge $Z>-2/\Gamma$. The derivation is based on a mapping technique of the 2D jellium at the coupling $\Gamma$ = (even positive integer) onto a discrete 1D anticommuting-field theory; we assume that the final results remain valid for all real values of $\Gamma$ corresponding to the fluid regime. The generalized sum rules reproduce for arbitrary coupling $\Gamma$ the standard Z=1 and the trivial Z=0 results. They are also checked in the Debye-H\"uckel limit $\Gamma\to 0$ and at the free-fermion point $\Gamma=2$. The generalized second-moment sum rule provides some exact information about possible sign oscillations of the induced charge density in space.Comment: 16 page