Mia Talmor

GENERATION OR LARGE NUMBERS OF IMMATURE AND MATURE DENDRITIC CELLS FROM RAT BONE MARROW CULTURES

We have defined conditions for generating large numbers of dendritic cells (DC) in marrow cultures from 10 – 12‐week‐old ACI or WF rats. The combination of granulocyte‐macrophage colony‐stimulating factor (GM‐CSF) and TNF‐α, known to induce DC from human CD34+ progenitors, was not effective with rat. In contrast, GM‐CSF plus IL‐4 generated DC in high yield, corresponding to 30 – 40 % of the initial number of plated marrow cells. The DC proliferated in distinctive aggregates, in which most cells had an immature phenotype marked by undetectable surface B7 and high levels of MHC class II products within intracellular lysosomes. When dislodged and dispersed, the aggregates gave rise to mature stellate DC with abundant surface MHC class II and B7, sparse MHC class II– lysosomes, and strong T cell‐stimulating capacity. Therefore, rat marrow progenitors can generate large numbers of immature DC, with abundant intracellular MHC class II compartments, and potent, stimulatory, mature DC.

Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy.

OBJECTIVE There is disagreement over the reliability of technetium Tc 99m (99mTc)-labeled erythrocyte scintigraphy in the localization of active lower gastrointestinal hemorrhage. A previous study at The New York Hospital-Cornell Medical Center that showed a superior sensitivity for localization of scintigraphy versus angiography in surgical patients led the authors to emphasize scintigraphy as the diagnostic test of first choice in the clinical diagnostic algorithm. The authors hypothesized that tagged erythrocyte scintigraphy can be used accurately as the primary diagnostic modality in localizing acute bleeding and guiding surgical intervention. METHODS The authors conducted a 5-year, retrospective analysis of 224 inpatients who underwent scintigraphic imaging for diagnosis and localization of active lower gastrointestinal bleeding. Using scintigraphy as the primary diagnostic test, with colonoscopy, upper endoscopy, and angiography as adjunctive studies, 99mTc-labeled erythrocyte scans were performed at the clinicians discretion and were reviewed again for study purposes by two nuclear radiologists who were blinded to clinical outcome. Adjunctive diagnostic tests also were ordered for clinical indications. RESULTS Using delayed periodic scintigraphic imaging, results of 115 scans (51.3%) demonstrated bleeding, with 96 scans (42.9%) localizing to a specific anatomic site. Patients with positive scans were five times more likely to require surgery (p < 0.005) than patients with negative scans, and surgical patients were twice as likely to localize by scintigraphy (p < 0.0001). Fifty patients (22.3%) required surgical intervention to control hemorrhage and had a bleeding site confirmed by both clinical and pathologic examinations. Forty-eight of those patients (96%) had a bleeding site determined preoperatively. For 37 patients with bleeding sites localized preoperatively by scintigraphy, 36 (97.3%) had correct localization based on surgical pathology. Only one patient required a subtotal colectomy solely because of nonlocalized bleeding. No patient bled postoperatively, and there was no mortality in either operated or nonoperated patients. The mean volume of transfused erythrocytes was similar in both scan-localized and nonlocalized surgical patients. CONCLUSION When performed correctly and interpreted conservatively, scintigraphy is a useful and safe means of guiding segmental resection, and should be the primary tool used in the diagnosis of patients with active lower gastrointestinal bleeding.

Beneficial effects of chest tube drainage of pleural effusion in acute respiratory failure refractory to positive end-expiratory pressure ventilation.

BACKGROUND As part of an ongoing prospective evaluation of the response of acute respiratory failure (ARF) to ventilation with titrated amounts of positive end-expiratory pressure (PEEP), a subset of patients with a poor response to the initial application of PEEP and radiographic evidence of pleural effusion was identified. The effusion(s) were treated by tube thoracostomy (TT) to test the hypothesis that drainage would have a favorable effect on oxygenation and compliance in critically ill patients with substantial pulmonary dysfunction. METHODS Consecutive patients with ARF underwent a titrated progressive application of PEEP if arterial oxygen saturation was less than 90% on fraction of inspired oxygen less than 0.5. One or two thoracostomy tubes (TT) were placed afterward in patients with radiologic evidence of effusion who had a poor response to PEEP therapy. The lung injury score (LIS), PaO2:FiO2 (P:F), peak airway pressure, dynamic compliance, and TT output were recorded. Changes over time were analyzed by one-way analysis of variance with repeated measures. RESULTS Nineteen of 199 patients needed TT. LIS was 3.0 +/- 0.1. Maximum PEEP was 16.6 +/ 1.0 cm H2O. TT drainage was 863 +/- 164 ml in the first 8 hours. Mortality was 63% (12 of 19) but only 41% (74 of 180) in the patients who did not require TT (p = 0.11). TT improved oxygenation and compliance immediately after insertion in 17 of 19 patients, and P:F remained statistically higher (245 +/- 29 versus 151 +/- 13, p < 0.01) 24 hours after TT drainage. There was no correlation between the volume of fluid removed and P:F either immediately (R2, 0.16) or 24 hours after TT (R2, 0.07). CONCLUSIONS Drainage of pleural fluid resulted in a significant improvement in oxygenation in ARF patients with pleural effusions who were refractory to treatment with mechanical ventilation and PEEP. TT represents a simple and safe alternative for aggressive management of selected patients, obviating the inherent risk of pneumothorax with thoracentesis and possibly avoiding the need for more complex forms of support in this critically ill patient population.

Acute Paranasal Sinusitis in Critically Ill Patients: Guidelines for Prevention, Diagnosis, and Treatment

Nosocomial sinusitis is common in critical illness. Randomized trials indicate that radiographic sinusitis (RS) occurs in 25%-75% of all critically ill patients and that 18%-32% of endotracheally intubated patients will develop sinusitis. Variability in the estimated incidence of RS stems from the many radiographic techniques used for diagnosis. Critically ill patients with suspected sinusitis should undergo computed tomographic scanning of all paranasal sinuses. If the scans are positive (opacification, mucosal thickening, air-fluid level), aspiration is performed after meticulous nasal disinfection. Infection is confirmed if a pathogen is identified along with neutrophils. Nosocomial sinusitis is usually caused by gram-negative bacilli or is polymicrobial. Pseudomonas aeruginosa, the most common causative organism, represents 15.9% of isolates. The most common gram-positive isolate is Staphylococcus aureus (10.6%); fungi represent 8.5% of isolates. Infection is treated with aspiration and systemic antibiotics. Treatment failures are common; drainage with indwelling catheters is sometimes necessary.

Acquired trichomegaly of the eyelashes: A cutaneous marker of acquired immunodeficiency syndrome

Acquired trichomegaly of the eyelashes was found in seven patients infected with human immunodeficiency virus type 1. These patients had advanced infection with severe T-helper cell depletion, high levels of p24 antigenemia, and inability to tolerate zidovudine therapy. Control of infection with other antiretroviral agents caused the trichomegaly to regress. Acquired trichomegaly may be a useful clinical marker for assessment of severity of infection.

Intestinal perforation after suction lipoplasty: a case report and review of the literature.

Intrabdominal penetration with intestinal perforation is a relatively uncommon complication after liposuction. Seven cases have been reported in the literature, with a mortality rate >50%. Here we present a case of a perforated viscus after suction lipoplasty of the abdomen using the tumescent technique. Multiple small-bowel enterotomies were made with the suction cannula. It is our hope that a heightened awareness of this potentially life-threatening complication will promote early and aggressive diagnosis and treatment of liposuction patients who present with gastrointestinal complaints in the early postoperative period.

Facial atrophy in HIV-related fat redistribution syndrome: anatomic evaluation and surgical reconstruction.

The use of highly active antiretroviral therapy (HAART) with protease inhibitors can result in a syndrome of peripheral wasting, facial fat atrophy, and central adiposity in as many as 64% of patients infected with human immunodeficiency virus (HIV) who are treated with this regimen for 1 year. In this study the authors evaluated 9 consecutive patients who presented with this disease to define further its anatomic features and to explore techniques for surgical correction. Three of these patients presented with severe facial atrophy, and underwent surgical exploration and reconstruction with submalar silicone implants. Two patients required additional soft-tissue augmentation with synthetic fillers and/or autologous fat. Outcomes were determined through clinical impressions of the patient and surgeons, and comparison of pre- and postoperative photographs. No extrusion or infection was encountered, although 1 patient required repositioning on one side. Both surgeons and patients were satisfied with the results at the long-term follow-up. Detailed anatomic evaluation revealed the presence of a fat pad of Bichat in all patients. Facial atrophy in HIV-related fat redistribution syndrome (HARS) is secondary to atrophy of the subcutaneous fat, but not of the deeper fat pads, as has been described. Durable surgical reconstruction is achieved with a combination of submalar silicone implantation and augmentation of the nasolabial fold. HARS causes noticeable disfigurement that stigmatizes the HIV-infected patient. Given the overall benefit of decreased morbidity and prolonged survival associated with HAART therapy, it is beneficial to attempt surgical correction of these debilitating sequelae before discontinuation of these drugs.

Botox and collagen for glabellar furrows: advantages of combination therapy.

Plastic surgeons frequently administer botulinum toxin A (Botox) or collagen as monotherapy to treat glabellar furrows. This study evaluates the possible advantages of combination therapy. Sixty-five patients with moderate to severe glabellar rhytids were prospectively randomized to receive standard injections of Botox, Zyderm II collagen, or a combination. Improvement in rhytids was assessed over 3 months using patient satisfaction scores and an independent physician evaluation. Baseline wrinkle severity was similar in all 3 groups. By 1 month posttreatment, the combination arm showed significantly greater improvement in furrows (79% compared with only 56% and 50% in the Botox and Zyderm arms, respectively; P < 0.05). At 3 months postinjection, the dual-therapy arm maintained better improvement (57% versus 33% and 27% in the monotherapy arms; P < 0.05). Patient satisfaction further highlighted the superiority of the combination approach. By simultaneously addressing the static and dynamic aspects of glabellar furrows, dual therapy provides optimal treatment of this problem.

Nipple-areolar complex ischemia after nipple-sparing mastectomy with immediate implant-based reconstruction: risk factors and the success of conservative treatment.

BACKGROUND Nipple-sparing mastectomy performed via an inframammary fold incision with implant-based reconstruction is an oncologically safe procedure that provides excellent cosmesis. OBJECTIVES The authors report their experience with conservative treatment of postoperative nipple-areolar complex (NAC) ischemia and an analysis of risk factors for NAC ischemia and conservative treatment failure. METHODS A retrospective chart review was conducted of 318 nipple-sparing mastectomies performed through inframammary fold incisions with implant-based reconstruction between July 2006 and October 2012. NAC dressings consisted of topical nitroglycerin, external warming for 24 hours, antibacterial petrolatum gauze, and a loose bra for 1 week. Patients were monitored for NAC ischemia as the primary endpoint. NAC ischemia was treated with bacitracin ointment. In cases of full-thickness ischemia, expanders were also partially deflated. RESULTS Partial- and full-thickness NAC ischemia occurred in 44 (13.8%) and 21 (6.6%) cases, respectively. All partial- and 17 full-thickness cases resolved with conservative treatment. Of these, 7 partial- and 2 full-thickness cases suffered residual depigmentation. Four full-thickness cases required operative debridement. Factors associated with NAC ischemia included increasing age (P = .035), higher body mass index (P = .0009), greater breast volume (P = .0023), and diabetes (P = .0046). Factors associated with conservative treatment failure included increasing age (P < .0001), higher body mass index (P = .014), greater breast volume (P = .020), smoking (P = .0449), acellular dermal matrix use (P < .0001), and single-stage reconstruction (P = .0090). CONCLUSIONS Postoperative NAC ischemia can be effectively managed conservatively to preserve cosmesis and implant viability. Knowledge of risk factors for NAC ischemia and conservative treatment failure may improve future patient counseling and outcomes.

Squamous cell carcinoma of the breast after augmentation with liquid silicone injection.

Squamous cell carcinoma of the breast is an extremely rare neoplasm. Approximately 50 cases have been reported in the English literature since 1917. The pathogenesis of squamous cell carcinoma of the breast is puzzling because epithelial elements are not normally identified in breast tissue. It has been suggested that epithelial cells are derived from epidermoid cysts deposited during early embryological development, from metaplastic transformation of ductal cells, or after trauma or surgical manipulation. Although no evidence has been published to support a causal relationship between liquid silicone-induced mastopathy and breast carcinoma, squamous cell cancers are known to arise in the setting of prolonged inflammation often seen after liquid silicone injection. This case of primary squamous cell carcinoma of the breast, arising 25 years after augmentation with liquid silicone injections, occurred in a 70-year-old patient with silicone-induced mastopathy.