Syncope in adolescent girls.
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Adolescent↗
Biomedical subjects
R J Yetman
Publications and source records attributed to R J Yetman.
The acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous flap used in immediate breast reconstruction.
PURPOSE: To analyze the acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous (TRAM) flap reconstruction following modified radical mastectomy for breast cancer. METHODS AND MATERIALS: Twenty-five consecutive patients were treated with postoperative radiation therapy after TRAM flap reconstruction between 1985 and 1999. The radiation records for these patients were retrospectively reviewed. Information regarding treatment techniques, timing, and dose was obtained and correlated with the extent of erythema, desquamation, and the need for treatment break. RESULTS: The median age was 48 years. The median dose of chest wall radiation was 5040 cGy. Additional boost doses were delivered in 13 patients. Twelve patients (48%) developed mild erythema in the treatment field during the course of treatment and 13 patients (52%) developed moderate (40%) or brisk (12%) erythema. Only 10 patients (40%) developed any kind of desquamation; 5 patients (20%) developed dry desquamation and another 5 patients (20%) developed moist desquamation. No patients required a break in the course of treatment because of acute side effects. None of the parameters evaluated (the use of chemotherapy prior to radiation, the interval between surgery and radiation, smoking, prior incidence of fat necrosis, the use of bolus during radiation, and the use of a boost) were predictive of an increased incidence of either the extent of erythema or the development of desquamation in the treatment field. CONCLUSION: Postmastectomy radiation for TRAM flap reconstruction is well tolerated and is not associated with an increased incidence of acute side effects. Radiation technique and the use of preradiation chemotherapy do not appear to be correlated with an increased incidence of acute side effects.
Adult↗
Day-night pattern in accidental exposures to blood-borne pathogens among medical students and residents.
The purpose of this study was to determine whether the occurrence of accidental blood-borne pathogen exposure incidents in medical students and residents in training varies during the 24 h. A retrospective review of reported exposures was conducted in a large urban teaching institution--the University of Texas Health Science Center in Houston--between November 1993 and July 1998. Professional level (year of student or level of resident), time of exposure, means/route of exposure (needle stick, laceration, or splash), and type of medical service were recorded. Analysis of the clock time of the 745 reported blood-borne pathogen exposures showed they occurred more frequently during the day than night. Over the nearly 5-year span, 531 incidents took place between 06:00 and 17:59 in comparison to only 214 between 18:00 and 05:59. To account for the day-night difference in medical student and resident hospital staffing, the data were reexpressed as exposure rates, that is, in terms of the number of events per hour per 1000 medical students and residents. Based on the total number of reported exposures over the almost 5-year span of data collection, the average rate was 40 accidents per hour per 1000 doctors in training during the 12 h daytime span (6:00-17:59). It was 50% greater at night (18:00-05:59), with 60 incidents per hour per 1000 doctors in training. The day-night difference in rate of exposures was statistically significant (p < .04). The relative risk ratio for residents and students when working during the day shift compared to working the night shift was 0.67. This means that doctors in training are at a 1.50 higher risk of sustaining a blood-borne pathogen exposure when working nights than when working days.
Adult↗
Relationship of obesity and specimen weight to complications in reduction mammaplasty.
Obesity and specimen weight have both been associated with a higher incidence of complications for patients undergoing reduction mammaplasty. However, obesity has been arbitrarily and inconsistently defined, and the degree of obesity has not been considered in these previous studies. Because insurance companies are increasingly demanding weight loss before authorizing surgery, the relationship of obesity and breast size to complications is of great importance. Upon critical review of the literature, a number of fundamental questions remain unanswered. If complications are more frequent in the obese patient, are these complications directly proportional to the degree of obesity? Also, if the patient is required to lose weight before surgery, is weight loss effective in reducing complication rates? In an attempt to clarify these issues, 395 patients who underwent reduction mammaplasty over a 10-year period were reviewed retrospectively. Patients were arbitrarily divided into five groups in which, depending on their degree of relative obesity, they were classified as less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, or greater than 20 percent above average body weight. To evaluate the relationship of specimen weight to complications, patients were also arbitrarily divided into five groups according to weight of the breast reduction specimen, which was classified as less than 300 g, 300 to 600 g, 600 to 900 g, 900 to 1200 g, and greater than 1200 g reduction per breast. Complications were then divided into local and systemic and major and minor. When bilateral reductions alone were analyzed (n = 267), there was a statistically significant increase in complication rate in the obese (p = 0.01). However, when the obese population was further subdivided according to their degree of obesity (less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, and greater than 20 percent above average body weight), no further correlation was found. However, the relationship between specimen weight per breast and complications was much stronger with a direct correlation existing between increasing specimen weight and the incidence of complications. Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. The implications of these findings and their relationship for denying patients surgery on the basis of weight alone are discussed in detail.
Adolescent↗
Patient care guidelines in pediatrics.
The increase in availability of patient care guidelines is consistent with the expansion of managed care health care systems and enhanced efforts of health care providers to deliver evidence-based patient care. When used effectively, guidelines support: 1) the reduction of unexplained variation in health care practice; 2) education of practitioners and health care delivery systems; and 3) the continuous improvement in processes that improve patient outcomes. It is with these goals in mind that Milliman and Robertson released its latest publication of Health Care Management Guidelines entitled Pediatric Health Status Improvement and Management (HSIM). This publication contains comprehensive information on many aspects of pediatric care, from the prenatal period through adolescence, from preventive medicine through chronic care. Like other Milliman and Robertson Health Care Management Guidelines publications, Pediatric HSIM offers both treatment guides and benchmarks that enable health care professionals to provide optimal levels of care and to measure their performance against peers. The primary focus of Pediatric HSIM is on wellness across a child's lifetime, an objective that fits well with our goal as providers of care to children of keeping patients healthy through preventive medicine.
Child↗
T-cell adoptive immunotherapy of metastatic renal cell carcinoma.
OBJECTIVES: To determine the feasibility and toxicity of the adoptive transfer of ex vivo-activated T lymphocytes that have been sensitized to autologous tumor vaccine in vivo. METHODS: Twenty patients with extensive metastatic renal cell carcinoma received systemic adoptive immunotherapy with autologous T cells in the absence of conjunctional interleukin-2 (IL-2) administration. Patients were vaccinated intradermally with irradiated autologous tumor cells and granulocyte-macrophage colony-stimulating factor as an adjuvant to stimulate an immune response. Inguinal lymph nodes draining the vaccine site were surgically removed, and the cells were stimulated with staphylococcal enterotoxin A followed by expansion in 60 IU/mL IL-2, and in some cases additionally stimulated with anti-CD3 monoclonal antibody and IL-2, to obtain a large number of cells. RESULTS: The staphylococcal enterotoxin A/IL-2 activation induced vigorous proliferation of T cells (median expansion 26-fold) that were a mixture of CD4 and CD8 T lymphocytes. Activated cells were infused intravenously at doses ranging from 2x10(9) to 9.5x10(10). There was minimal toxicity consisting of grade 1 or 2 fever and nausea, and the entire treatment was delivered as outpatient therapy. One patient had a partial response, one had a mixed response, and 8 had stable disease lasting at least 5 months. CONCLUSIONS: Adoptive transfer of ex vivo-activated, tumor vaccine-primed lymph node cells is feasible and is associated with minimal toxicity when used alone. These results warrant further study in a Phase II trial.
Adult↗
Comparison of arbitrary definitions of circadian time periods with those determined by wrist actigraphy in analysis of ABPM data.
Determining blood pressure (BP) values at different daily time periods is a well recognised measure to assess the risk of end-organ damage. However, the use of various definitions of these periods, eg, day vs night, sleep vs wake or arbitrary definitions, makes clinical decisions based on available data difficult. In the present study, we compared BP loads in actual sleep-wake periods to default day-night definition provided by the ambulatory BP monitoring (ABPM) software (day 06.00-22.00; night 22.00-06.00) as well as to an arbitrary definition of sleep-wake periods in children published in Journal of Pediatrics (Soergel et al, 1997) (awake 08.00-20:00 and sleep 00.00-06.00). We used an actigraph, an accelerometer, to define the actual sleep-wake periods in 46 patients with essential hypertension who are on various treatment regimens. BP data were obtained by using Spacelabs 90207 monitors for a full 24 hours. There were significant differences between actual sleep-wake and default definition for BP load. No similar findings were noted when arbitrary definition was used. The proportion of hypertensives was not significantly different when default and arbitrary definitions were used. Classification of dippers and non-dippers is greatly affected by the definition of sleep interval using the default method. Although some of the misclassifications were not statistically significant, their clinical importance must be considered. Determination of sleep and wake periods for analysis of ABPM data should be based on careful determination of actual periods. Using other definitions may not provide complete information or accommodate for individual variation.
Adolescent↗
Comparison of arbitrary definitions of circadian time periods with those determined by wrist actigraphy in analysis of ABPM data.
Determining blood pressure (BP) values at different daily time periods is a well recognised measure to assess the risk of end-organ damage. However, the use of various definitions of these periods, eg, day vs night, sleep vs wake or arbitrary definitions, makes clinical decisions based on available data difficult. In the present study, we compared BP loads in actual sleep-wake periods to default day-night definition provided by the ambulatory BP monitoring (ABPM) software (day 06.00 to 22.00; night 22.00 to 06.00) as well as to an arbitrary definition of sleep-wake periods in children published in Soergel et al (J Pediatr 1997; 130: 178-184)1 (awake 08.00 to 20.00 and sleep 00.00 to 06.00. We used an actigraphy, an accelerometer, to define the actual sleep-wake periods in 46 patients with essential hypertension who are on various treatment regimens. BP data was obtained by using Spacelabs 90207 monitors for a full 24 h. There were significant differences between actual sleep-wake and default definition for BP load. No similar finding was noted when arbitrary definition was used. The proportion of hypertensives was not significantly different when default and arbitrary definitions were used. Classification of dippers and non-dippers is greatly affected by the definition of sleep interval using the default method. Although some of the misclassifications were not statistically significant, their clinical importance must be considered. Determination of sleep and wake periods for analysis of ABPM data should be based on careful determination of actual periods. Using other definitions may not provide complete information or accommodate for individual variation.
Adolescent↗
Rebound bilirubin levels in infants receiving phototherapy.
A retrospective medical record review was completed for 264 consecutive newborns receiving phototherapy for hyperbilirubinemia to determine whether a "rebound" increase in total serum bilirubin (TSB) level occurs after termination of phototherapy. The difference between mean TSB levels at discontinuation of phototherapy and at rebound was calculated by paired t test. TSB levels at rebound were significantly lower than at discontinuation of phototherapy for infants weighing > 1800 g (positive and negative Coombs' test results). There were no statistically significant differences among infants in the smaller weight categories, regardless of Coombs' test results. Infants completing phototherapy for hyperbilirubinemia who are otherwise healthy do not require follow-up solely to identify a rebound bilirubin level.
Bilirubin↗
Problems in physician's classification and reporting of congenital syphilis.
The diagnosis of congenital syphilis (CS) in newborns can only be made through a review of the mothers' testing and treatment history and through the infants' clinical and laboratory findings. We describe difficulties in the classification of CS by physicians and the health department during a recent syphilis epidemic. The records of infants identified as potential cases of CS by laboratory testing, discharge diagnosis, or health department records were reviewed by epidemiologists. The reasons for concordance and discordance in classification between the physician and the epidemiologist were determined. Congenital syphilis was identified in 126 infants. Seventeen cases were discordant and 12 cases concordant but the physician's classification was for incorrect reasons. Misclassification occurred because physicians lacked data known to the health department (n=7), health departments lacked data known to the physician (n=1), and physicians misinterpreted the case definition for CS (n=21). Suggestions for improving the diagnosis and reporting of CS are included.
Adult↗
Primary lymphedema of the genitalia in children and adolescents.
PURPOSE: Congenital lymphedema is a rare disorder that may result in disfiguring edema of the male genitalia. We reviewed our experience with 5 cases to advance our understanding of this challenging problem. MATERIALS AND METHODS: Four boys with significant lymphedema underwent excision of the involved subcutaneous genital tissue and coverage with local skin flaps. Two boys in whom this approach failed later underwent complete excision of the involved subcutaneous tissue and skin, and coverage with split thickness skin grafts. The boy with minimal edema was observed. RESULTS: Two of the 4 boys who underwent subcutaneous genital tissue resection and coverage with local skin flaps are markedly improved, although 1 requires further revision. In the other 2 boys treatment failed, necessitating repeat genital tissue excision and grafting. While there have been no recurrences in the grafted areas, each patient has required additional operations to manage recurrent edema in adjacent tissues of the perineum and inguinal region, and in 1 significant contraction of the grafted skin developed. Mild genital lymphedema in the remaining patient has remained stable during 10 years of followup. CONCLUSIONS: Congenital lymphedema of the genitalia is a challenging problem. Recurrences requiring multiple operations are common. We recommend expectant management of mild cases. In more severe cases excision without grafting should be attempted. While skin grafting may be the most definitive solution, it does not prevent recurrence in adjacent regions, and it carries the risk of skin contraction. Skin grafts should only be used when other techniques have failed.
Adolescent↗
Temporal blood pressure patterns in children.
Circadian rhythms of BP are established early in life. The ABPM coupled with an objective measure of activity is a powerful tool for the management of hypertension and is a sensitive tool for the dissection of the determinants of hypertension. The challenge for pediatricians in the future includes such important goals as establishing normal values for the circadian assessment of BP for a growing child, coupling of BP determinations with activity, using the ABPM to better understand BP tracking, studying the rhythms of families using the ABPM, educating the medical and lay communities of the importance of rhythmic phenomena, studying longitudinally patients with varying forms of hypertension, using the ABPM to test and optimize antihypertensive medications, and determining the proper diagnosis of hypertension in children based on end-organ damage rather than surrogate measures.
Blood Pressure↗
The submental artery flap: an anatomic study.
Coverage of facial defects is frequently challenging. Despite the numerous flaps described, the search for additional flaps with good color match and minimal donor-site morbidity continues. We present a flap based on the submental vessels. The anatomy based on 24 fresh cadaver dissections injected with Microfil is outlined. The submental artery is a branch of the facial artery after it exits from the submandibular gland. It runs over the mylohyoid and below the mandible. It continues either superficial or deep to the anterior belly of the digastric muscle. It supplies the skin of almost the entire triangle of the neck and a variable area across the midline. The facial artery diameter is 2.0 to 2.8 mm, and that of the submental artery is 1.0 to 1.5 mm. The facial vein provides venous drainage. From the anatomic study, the submental artery flap appears to have a long vascular pedicle and should be useful in facial and intraoral reconstructions. The size of the pedicle also makes it attractive as a free-tissue transfer. We feel that this flap has great clinical potential.
Arteries↗
Treatment of recurrent cerebrospinal fluid rhinorrhea with a free vascularized omental flap: a case report.
Cerebrospinal fluid fistulas after pericranial surgery are a major source of morbidity. A patient who underwent transsphenoidal sinus surgery for a recurrent pituitary adenoma was presented. The patient developed a chronic CSF leak despite standard management, including subarachnoid CSF drainage and transnasal endoscopic closure of the dura. Successful closure of the CSF fistula was obtained using a free omental flap to the sphenoid sinus. This case is the first reported use of a free microvascularized omental flap in an intracranial position for treating chronic CSF rhinorrhea. A description of the indications and the surgical technique for free omental closure of CSF fistulas was provided. The etiology, diagnosis, and management of CSF rhinorrhea are reviewed for the reconstructive surgeon.
Adult↗
Partial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustment, body image, and sexuality.
BACKGROUND: This retrospective study compared psychosocial adjustment, body image, and sexual function in women who had either breast conservation or reconstruction for early stage disease. METHODS: Questionnaires were completed at a mean of 4 years after surgery by 72 women who had partial mastectomy and 146 women who had immediate breast reconstruction after mastectomy. RESULTS: In general, fewer than 20% of women reported poor adjustment on the domains measured. The two groups did not differ in overall psychosocial adjustment to illness, body image, or satisfaction with relationships or sexual life. There was a specific advantage of partial mastectomy over breast reconstruction in terms of maintaining pleasure and frequency of breast caressing during sexual activity. Women who had undergone chemotherapy had more sexual dysfunction, poorer body image, and more psychological distress. Hormonal therapy and radiation therapy, however, did not measurably affect quality of life. Factors predictive of greater psychosocial distress included a troubled marriage, a poor body image, sexual dissatisfaction, less education, and treatment with chemotherapy. CONCLUSIONS: The choice of local treatment had little psychosexual impact, whereas chemotherapy was associated with long term impairments.
Antineoplastic Agents↗
Desmoplastic malignant melanoma: a clinicohistopathologic review.
Desmoplastic malignant melanoma is an unusual variant of cutaneous melanoma. Arising from either an occult or recognized superficial melanotic lesion, it evolves into an aggressive, locally recurrent and frequently metastasizing, deep, hard, fibrous tumefaction. A highly confusing clinical and histologic picture makes accurate diagnosis especially difficult. Appropriate treatment is often delayed until time of recurrence. Prognosis is invariably poor if the tumor is not adequately treated primarily. Close follow-up is essential. Since its original description by Conley et al. in 1971, in which 7 cases were presented, fewer than 150 additional cases have been cited. We provide a detailed report of 11 cases of this distinct histopathologic entity. Clinical course, histopathology, surgical management, and prognosis are discussed. It is our hope that this comprehensive review will instill a high index of suspicion among surgeon and pathologist alike, enabling earlier diagnosis and definitive therapy.
Aged↗
Clinical uses of ambulatory blood pressure monitoring.
Traditional office measurements of blood pressure are commonly used to initiate and monitor therapy for hypertension, but these measurements are limited in their ability to provide information from the patient's normal work or play environment and do not include data from the overnight period when the patient is asleep. Thus, much potentially important information is lost. The ambulatory blood pressure monitor offers the attractive advantage of providing multiple blood pressure measurements from a subject's normal environment during his normal activities, thereby revealing important patterns of blood pressure in health and in illness. Further, the results of ambulatory monitoring have an excellent correlation with end-organ damage and these data can be obtained in a very short time period. This review will discuss the chronobiology of blood pressure, the clinical uses of the ambulatory blood pressure monitor in health and in disease, including the patterns of blood pressure identified, correlation with end-organ damage and its uses in clinical trials of antihypertensive medications; the experience in children with this technology will also be discussed.
Blood Pressure↗
The AO system for primary mandibular reconstruction.
We reviewed the records of 27 patients who underwent primary mandibular reconstruction with AO plates to investigate the outcome and complications of this procedure. Immediate soft-tissue flap coverage was required in 26 patients. Early complications were seen in 44% of the patients, with the highest incidence after irradiation (P = 0.02). Late complications were mostly related to tumor recurrence (12). Late complications not associated with recurrence were persistent pain (2), minor infections (3), plate exposure (3), and plate fracture (1). Good to excellent cosmetic results were obtained in all but 1 patient. Full mastication was not possible for any of our patients, and therefore function was not fully restored. Speech and deglutition were mostly influenced by the amount of soft-tissue resection. Mean follow-up was 20 months (range 3 to 52). At last evaluation, 12 patients were alive and free of disease, and 15 were dead of disease or other causes. Our results show that primary mandibular reconstruction with rigid plates is a safe, effective, and reliable technique to restore mandibular continuity and cosmesis. For lateral defects, this method is a viable alternative to free vascularized osseocutaneous flaps.
Adult↗