Leo R. Otake

Web-based medicine as a means to establish centers of surgical excellence in the developing world.

The growth of the Internet has provided a unique opportunity for rapid, global communication. Web-based medicine uses this technology to help surgeons in developing regions of the world gain direct access to recognized experts. This serves to empower local surgeons in the developing world through direct skill-transfer and encouraging academic pursuit. Web-based medicine follows the paradigm of a university without borders, therefore requiring exacting patient record keeping, monthly peer review, and continuing medical education of all its participants. All those who participate in Web-based medicine have undergone a credentialing process to guarantee that they possess adequate credentials. Patient confidentiality is strictly maintained. Web-based medicine also provides a follow-up strategy for medical volunteer groups who provide overseas services. Interplast, Inc., has administered a Web-based medicine site at http://www.wiredmd.com since July of 1999. A total of 767 cleft malformation cases performed locally by participating host surgeons in the developing world have been reviewed through the site. Additionally, 16 consultations have been posted and discussed by participating surgeons worldwide. Financing remains the major impediment to the globalization of this technology.

The trans-spliceosomal U4 RNA from the monogenetic trypanosomatid Leptomonas collosoma: cloning and identification of a transcribed tRNA-like element that controls its expression.

U4 small nuclear RNA is essential fortrans-splicing. Here we report the cloning of U4 snRNA gene from Leptomonas collosoma and analysis of elements controlling its expression. The trypanosome U4 RNA is the smallest known, it carries an Sm-like site, and has the potential for extensive intermolecular base pairing with the U6 RNA. Sequence analysis of the U4 locus indicates the presence of a tRNA-like element 86 base pairs upstream of the gene that is divergently transcribed to yield a stable small tRNA-like RNA. Two additional tRNA genes, tRNAPro and tRNAGly, were found upstream of this element. By stable expression of a tagged U4 RNA, we demonstrate that the tRNA-like gene, but not the upstream tRNA genes, is essential for U4 expression and that the B box but not the A Box of the tRNA-like gene is crucial for expression in vivo. Mapping the 2′-O-methyl groups on U4 and U6 small nuclear RNAs suggests the presence of modifications in canonical positions. However, the number of modified nucleotides is fewer than in mammalian homologues. The U4 genomic organization including both tRNA-like and tRNA genes may represent a relic whereby trypanosomatids “hired” tRNA genes to provide extragenic promoter elements. The close proximity of tRNA genes to the tRNA-like molecule in the U4 locus further suggests that the tRNA-like gene may have evolved from a tRNA member of this cluster.

Changing attitudes toward hand allotransplantation among North American hand surgeons.

ObjectivesAlthough more than 70 hand transplants have been performed worldwide, the appropriate clinical indications for this operation are still being determined. Cost and patient exposure to the challenges of lifelong immunosuppression for what is a quality of life-improving (but not life-saving) operation are the focus of the ongoing discussion. A study performed in 2007 showed that surgeons’ opinions on the issue varied widely. Recently, more information has been made available regarding long-term patient outcomes, and significant improvements in immunotherapy protocols have been reported. In light of this, we sought to examine changing attitudes regarding hand allotransplantation and its indications by surveying hand surgeons. MethodsAn email-based survey was sent to members of the American Society for Surgery of the Hand. Demographic information and practice profiles were identified, followed by their risk assessment of hand allotransplants and endorsement of performing the operation in different clinical scenarios. Additional questions focused on the appropriate indications for hand allotransplantation, as well as the procedure’s associated ethical and financial implications. ResultsA total of 385 surgeons responded to the survey (14% response rate). The majority (82%) considered hand transplantation to be a high-risk operation (as opposed to 27% in hand replantation), with 78% citing lifelong immunosuppression as the primary factor impacting their overall risk assessment. The most commonly accepted indication for hand vascularized composite allotransplantation was loss of bilateral hands (80% in favor). Dominant hand loss (with an intact contralateral hand) was a far less frequently accepted indication (36% in favor). Patient adherence to immunosuppressive regimens (51%) and expectations of functional/aesthetic outcome (38%) were the most frequently chosen top psychosocial issues that must be addressed by the surgical/medical teams involved in the operation. ConclusionsOur study’s results demonstrate increasing overall support for hand allotransplantation and increasing acceptance of today’s immunosuppressive regimens compared to prior literature. Bilateral hand loss remains the primary agreed-upon indication for transplantation. Despite increasing acceptance in the surgical community, the dangers of chronic immunosuppression, cost and patient adherence continue to be the primary concerns hindering its broader acceptance.

Teaching core competencies of reconstructive microsurgery with the use of standardized patients.

AbstractThe Accreditation Council of Graduate Medical Education has defined 6 core competencies that residents must master before completing their training. Objective structured clinical examinations (OSCEs) using standardized patients are effective educational tools to assess and teach core competencies. We developed an OSCE specific for microsurgical head and neck reconstruction. Fifteen plastic surgery residents participated in the OSCE simulating a typical new patient consultation, which involved a patient with oral cancer. Residents were scored in all 6 core competencies by the standardized patients and faculty experts. Analysis of participant performance showed that although residents performed well overall, many lacked proficiency in systems-based practice. Junior residents were also more likely to omit critical elements of the physical examination compared to senior residents. We have modified our educational curriculum to specifically address these deficiencies. Our study demonstrates that the OSCE is an effective assessment tool for teaching and assessing all core competencies in microsurgery.

A preliminary report of the virtual craniofacial center: development of Internet-/Intranet-based care coordination of pediatric craniofacial patients.

The authors present preliminary information regarding the development of an Internet-based Virtual Craniofacial Center that provides access to a patient database with visual and textual data. Patients are photographed by digital camera with standardized images. Through a Web site linked to a remote database, patient demographics, management data, reports, and acquired digital photographic images are stored and retrieved. The database can be used to sort and to present data as desired by multiple specialists. Confidentiality is maintained by unique identification numbers and password access to the server for craniofacial team members. The current system uses economical equipment (i.e., digital camera, personal computer with modem, and access to a remote Windows NT-based server), using data that can be entered in a variety of cross-platform personal computer systems and transmitted on a wide range of bandwidths—from a relatively low-bandwidth (28.8 KB per second) modem to a high-speed T-3 line connection. Long-term goals include archival data storage and analysis, as well as the development of multicenter telemedicine links for active craniofacial centers.

Clinical Significance of Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: Review of 264 Cases.

Background: Despite the knowledge of alternate lymphatic draining patterns of the breast, routine evaluation of the internal mammary lymph node basin is still not considered standard of care. The advent of microsurgical breast reconstruction using the internal mammary vessels as recipients, however, has allowed sampling of internal mammary lymph nodes with technical ease, thus revisiting their role in breast cancer management. In the present study, the authors reviewed their experience with this practice. Methods: A retrospective analysis of patients who underwent internal mammary lymph node biopsy at the time of autologous breast reconstruction using the internal mammary vessels between 2004 and 2012 was performed. Parameters of interest included patient age, timing of reconstruction (immediate versus delayed), disease stage, and pathologic findings of internal mammary lymph nodes. Results: A total of 264 autologous breast reconstructions using the internal mammary vessels were performed in 204 patients with a median age of 44.5 years. The majority of reconstructions were immediate [n = 211 (79.9 percent)]. Seventy-two percent of patients had either stage I [72 patients (35.3 percent)] or stage II disease [75 patients (36.8 percent)]. Six patients were found to have internal mammary lymph node metastasis. Stage migration and alteration in adjuvant therapy occurred in all patients. Conclusion: Internal mammary lymph node sampling at the time of autologous breast reconstruction using the internal mammary system should become routine practice, as the morbidity associated with internal mammary lymph node harvest is low and the impact in cases of nodal involvement is quite substantial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complex incisional hernias repaired in conjunction with the Bony Anchoring Reinforcement System (BARS) prevents hernia recurrence

BackgroundComplex abdominal wall reconstruction and incisional hernia repair have been plagued by high recurrence rates, especially after multiple repair attempts and in those patients with high body mass index. We present an adjunct technique to validated procedures of hernia repair.MethodsThis study is a retrospective analysis of 63 patients between January 2006 and August 2012. Patients had bony suture anchoring of synthetic polypropylene mesh to the anterior superior iliac spine bilaterally, and the pubic symphysis after the abdominal fascia was reconstructed.ResultsPatient mean follow-up was 3.1 years (range 6 months to 6 years). None of the 63 patients had recurrent abdominal wall hernias. One patient, from early in the series, had post-operative bulging, which was retreated successfully using the current revised bone anchoring protocol. Five patients developed mesh infections; none of whom required radical debridement or removal of mesh.ConclusionsThe BARS technique for abdominal wall reconstruction provides an excellent reinforcement of fascial reconstruction with decreased hernia recurrence rates.Level of Evidence: Level IV, therapeutic study.

The Matrix Rib Plating System: improving aesthetic outcomes in microvascular breast reconstruction.

IntroductionDuring microvascular breast reconstruction, exposure of internal mammary vessels (IMVs) is facilitated by the removal of a portion of the rib resulting in occasional chest contour deformity (CCD). The use of rib plating may reduce CCD and reduce postoperative pain. MethodsAll patients underwent microvascular breast reconstruction using IMVs. In the retrospective arm, photographs were assessed by a blinded reviewer for CCDs. In the prospective cohort, patients were randomized to rib plating with the Synthes Matrix Rib Plating System or no rib plating. Postoperatively, patients were assessed for CCD and pain. ResultsIn the retrospective arm, 11 of 98 (11.2%) patients representing 12 of 130 (9.2%) breast reconstructions had a noticeable contour deformity. The average body mass index (BMI) of patients with CCDs was 26.6 kg/m2. In the prospective arm, there was 16% (3 of 19) rate of visible and palpable CCDs among controls, compared to 0% rate of palpable and visible contour deformity in the rib plating group. Pain was decreased in the rib plating group on all postoperative days. The pain reduction was statistically significant at rest by postoperative day 30. ConclusionThe majority of patients (9 of 11) with compromised aesthetic outcomes had a BMI less than 30 kg/m2, suggesting a paucity of overlying soft tissue contributed to visibility of these bony defects. Rib plating prevented chest contour deformity, reduced postoperative pain, and added limited additional morbidity. We believe that rib plating is a safe, useful adjunct to microvascular breast reconstruction using IMVs, as it may improve aesthetic outcomes and reduce postoperative pain.

The use of Permacol for the reconstruction of a complex thoraco-abdominal wall defect from a recurrent leiomyosarcoma

Complex thoraco-abdominal wall defects following tumor resection create a unique reconstructive challenge, which centers on anatomically re-establishing the thoracic and abdominal compartments to prevent visceral herniation. Autologous tissue may not be available or adequate to reconstruct these defects; therefore, the use of alternative options, such as non-autologous material, is often necessary. To our knowledge, very little has been described about the use of biologic mesh for the reconstruction of large thoracic defects. We present a review of the literature and present a novel approach to address a difficult defect with the use of cross-linked porcine dermal collagen (Permacol) to bridge a thoraco-abdominal defect while stabilizing the diaphragm.Level of Evidence: Level V, therapeutic study.