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This study compared patient outcomes of a single surgeon experience between those with inferior and medial pedicle breast reductions. A cohort of 84 patients was analyzed. In all, 49 inferior pedicle reductions and 35 medial pedicle reductions were performed. The average weight of tissue removed per breast was 639 g with the inferior pedicle technique and 450 g with the medial pedicle technique. Nipple transposition distance averaged 8.6 cm for the inferior pedicle group and 6.3 cm for the medial pedicle group. Scar revision surgery within 18 months was required in 5.7% of the medial pedicle group as compared with 0% in the inferior pedicle group. The overall complication rate was higher for the inferior pedicle group (28.6%) compared with the medial pedicle group (14.3%). In this study, medial pedicle reductions resulted in lower complication rates. The amount of tissue removed was less with medial pedicle reductions. Hypertrophic scarring was reduced in the medial pedicle reduction mammoplasty.

On November 5, 2009, a US Army psychiatrist allegedly opened fire with one or more handguns, killing 12 military personnel and one civilian at Fort Hood in Killeen, Texas. The most severely wounded casualties were transported to Scott and White Memorial Hospital, a Level I trauma center and tertiary care teaching hospital in Temple, Texas associated with the Texas A&M University College of Medicine. Ten victims arrived in a 1-h period with another two arriving in the second hour, necessitating an emergency response to a mass casualty event. Our radiology department's response was largely unplanned and was therefore the result of many spontaneous actions and ideas. We share our experiences and from them formulate guidelines for a general radiology surge model for mass casualty events. It is our hope to raise awareness and help other radiology departments to prepare for such an unexpected event.

Leadership can be defined as not only the position of a leader, but the ability to function as one. This brief review of leadership is focused on what is involved in leading a plastic surgery unit in an institution. Characteristics of a good leader, identified by those who are being led, are discussed. In addition to that, the character of the individual leading is also reviewed, because it is such a critical ingredient in a person's capacity to lead others. Leadership characteristics can be learned and opportunities for growth in this area are discussed. The result of good leadership of a plastic surgery unit will indubitably result in the enhancement of the plastic surgery unit in an institution and plastic surgery as a specialty.

Immunoglobulin A nephropathy is now recognized as the glomerular disease most often associated with progressive renal failure in patients around the world. In many cases it is not known when the disease starts to inflict glomerular injury, but recent studies that have shown genetically determined abnormalities in glycosylation of the IgA molecule suggest that this may begin in early life. This review focuses on recent advances in our understanding of IgA nephropathy, with special emphasis on clinical aspects of the disease when it presents in children and adolescents. In addition, the sections dealing with therapeutic options for patients with IgA nephropathy concentrate on studies that have been carried out on children. Whenever possible, data from randomized controlled clinical trials have formed the basis for recommendations. Unfortunately, this is not always possible, because of the lack of such trials in patients with IgA nephropathy.

Background and Objectives: Bochdalek hernias are congenital diaphragmatic defects resulting from the failure of posterolateral diaphragmatic foramina to fuse in utero. Symptomatic Bochdalek hernias in adults are infrequent and may lead to gastrointestinal dysfunction or severe pulmonary disease. We describe our experience with this rare entity., Methods: A retrospective chart review was performed on a single patient for data collection purposes., Results: The patient is a morbidly obese 53-year-old female who presented with epigastric pain and diffuse abdominal tenderness. Computed tomography scans of the chest and abdomen revealed a small posterior diaphragmatic defect containing gastric fundal diverticulum. Laboratory work and imaging revealed no other findings. Laparoscopic repair of the Bochdalek hernia was done via an abdominal approach and utilized primary closure with an AlloDerm patch apposed to the defect. The patient has had significant clinical improvement and continues to do well at 9 months postoperatively., Conclusion: Laparoscopic repair of symptomatic adult Bochdalek hernias can be performed successfully and may result in significant clinical improvement.

The authors report the first case of perineurioma of the adrenal gland. The tumor was composed of elongated wavy spindle cells focally arranged in a fascicular pattern. It was positive for epithelial membrane antigen (EMA) and claudin-1, and was negative for S-100 protein and glial fibrillary acidic protein (GFAP). Electron microscopy showed long, slender cytoplasmic processes coated by discontinuos basal lamina and presence of many pinocytotic vesicles.

Objective: To validate a vasoepididymostomy (VE) predictor nomogram., Design: Data were collected prospectively. A previously published VE predictor model was then applied to all patients. Predicted outcomes were analyzed with respect to outcomes with consideration of actual procedures performed. The maximum follow-up was 30 months, with a median follow-up of 16 months., Setting: A tertiary referral center in central Texas., Patient(s): One hundred fifteen consecutive patients who underwent vasectomy reversals by the fibrin glue technique were included., Result(s): Forty patients who would have been predicted to require VE on one or both sides by the predictor model actually underwent vasovasostomy (VV) bilaterally. Follow-up data were available in 62% of these patients, of which 88% were patent and 52% have achieved pregnancies thus far. Seventy patients who would have been predicted to only require VV by the predictor model underwent VV. Follow-up data were available in 60% of these patients, of which 98% were patent and 36% have achieved pregnancies thus far. The five patients not accounted for included two who would have been predicted to require VV and underwent VE because of intraoperative decision making and three who were predicted to require VE and underwent VE., Conclusion(s): The predictor model designed to identify which patients need VE versus those who will need simply VV is not a reliable predictor in our patient population of patients seeking a fibrin glue vasectomy reversal.

The objective of this pictorial essay is to review uncommon abdominal hernias, many of which present to the Emergency Department with abdominal pain. These hernias may be congenital, post-traumatic, or iatrogenic in origin. They may present as an acute (surgical) abdomen without localizing signs or symptoms. They may present with an obvious antecedent event such as motor vehicle trauma or simply present as an incidental finding. Multi-detector computed tomography is currently the study of choice to diagnose abdominal hernia and to evaluate the possible complications such as small bowel obstruction and/or strangulation. This modality can delineate a "zone of transition" (abnormally dilated bowel transitioning to normal or decreased bowel caliber) or identify the involved anatomy. It can also suggest compromised blood supply.

Background: Surgical-site infection is a common postoperative nosocomial infection. Surgeons frequently treat operative patients with protective antibiotics and often choose cefazolin as the drug. Treatment schemes include both preoperative intravenous dosing and intraoperative dosing by irrigation. This study was designed to measure cefazolin concentrations both in serum and in wound drain fluid after intravenous dosing and after irrigation., Methods: The authors conducted an institutional review board-approved study involving randomized allocation of breast reduction patients to group 1 (preoperative intravenous dosing) or group 2 (intraoperative dosing by irrigation). Each patient had serum and wound drainage specimens measured over time for cefazolin concentrations. Cefazolin dosing was based on preparations commonly used in the authors' hospital. Results from 24 patients are reported., Results: Patients treated by conventional preoperative intravenous dosing displayed the expected serum degradation curve. These patients also demonstrated wound drainage concentrations (peak, 22.49 microg/ml) for approximately 4 to 5 hours. Measured concentrations were above the minimum therapeutic concentration (8 microg/ml) for Staphylococcus aureus. Patients treated by wound irrigation also demonstrated serum concentrations above minimum therapeutic concentration. In addition, these patients' wound drain fluid demonstrated very high cefazolin concentrations (peak, 4185.93 microg/ml), which remained high for 24 hours., Conclusions: Protective cefazolin concentrations in the wound can be achieved by both intravenous and irrigation delivery. Wound irrigation produces higher concentrations for longer periods of time.

Use of information technology in diabetes management has been shown to improve self-care. We determined whether enhancing type 2 diabetes (T2DM) self-care with a personal digital assistant (PDA) by patients in the ambulatory setting would improve glycemic control. A pretest/posttest intervention study was conducted in four family practice clinics in a large multispecialty group practice associated with an 186,000-member Health Maintenance Organization. Adults with T2DM and last measured glycosylated hemoglobin (HbA1c) of > or = 8.00% received one-on-one training on the use of a loaned PDA pre-installed with "Diabetes Pilot." Changes in HbA1c and other outcomes were assessed at 6 months from baseline for all participants and by participant-reported PDA use patterns, dichotomized into high PDA users (> or =3 days in past 7) and low PDA users (< 3 days). Of 43 subjects enrolled, 18 (41.90%) completed the 6-month intervention. Their mean HbA1c decreased 17.50% from 9.70% at baseline to 8.00%, a significant mean HbA1c change of -1.7% (95% CI = -2.60 to -0.90). The mean HbA1c change was higher among reported high PDA users (n = 9, mean difference = -1.90, 95% CI = -3.20 to -0.50) than among reported low PDA users (n = 9, mean difference = -1.50, 95% CI = -2.80 to -0.30). Significant increases were reported for the foot care and general diet subscales of the Summary of Diabetes Self-Care Activities from 3 to 6 months. Enhancing T2DM self-care by adults with a PDA was associated with significant reductions in HbA1c; the reductions were greater among reported high PDA users.

Background: A recently published study from our laboratory demonstrated that morphine sulfate (MS) attenuates microvascular hyperpermeability after hemorrhagic shock in rats. MS binds to the mu receptors located on the surface of endothelial cells. Activation of the endothelial cell mu receptors has been shown by several investigators to stimulate adenylate cyclase. We hypothesize that MS binding to the mu receptor on endothelial cells increases cyclic adenosine monophosphate via adenylate cyclase activation. Cyclic adenosine monophosphate inhibits the phosphoinositide/MAP kinase hyperpermeability pathway via the protein kinase A (PKA)-dependent inhibition of Raf-1., Methods: Studies were conducted in five groups of urethane-anesthetized Sprague-Dawley rats: Group 1--control group, Group 2--a non-receptor-blocking adenylate cyclase inhibitor: SQ22536, at 100 microg/kg (n = 5), Group 3--a PKA inhibitor: H89, at 10 microg/kg, Group 4--a morphine sulfate (10 microg/kg) and PKA inhibitor group, and Group 5--an adenylate cyclase inhibited and morphine (10 microg/kg) group. Intravital microscopy in mesenteric postcapillary venules and rat lung microvascular endothelial cell monolayers were used to measure permeability., Results: Adenylate cyclase and PKA inhibition resulted in vascular hyperpermeability., Conclusion: Our data demonstrated an increase in vascular hyperpermeability after inhibition of adenylate cyclase via SQ22536, a nonreceptor inhibitor. This increase in hyperpermeability was attenuated when treated with MS. Morphine did not attenuate hyperpermeability after blockage following PKA with H89 suggesting the action of MS is upstream of PKA and PKA dependent.

Background: Sestamibi scanning is commonly used for preoperative localization in patients with hyperparathyroidism. However, 12% to 15% of these studies are equivocal or negative. Ultrasound may also be used to identify patients suitable for a minimally invasive parathyroidectomy., Methods: Data from patients treated for hyperparathyroidism between January 2000 and April 2006 were reviewed retrospectively. Sestamibi and ultrasound results were scored as definitive, suggestive, or negative. Patients with suggestive or negative sestamibi scans were included in the analysis., Results: A total of 261 patients underwent operation without a definitively localizing sestamibi scan. Preoperative neck ultrasound was performed in 80 of these patients. Overall, ultrasound was either conclusive or suggestive in 45 of 80 patients (56%) without a definitively localizing sestamibi scan and correctly correlated with the surgical findings in 38 of 45 (84%) of these patients., Conclusion: In patients with nonlocalizing sestamibi scans, neck ultrasound increases the number of patients suitable for minimally invasive parathyroidectomy.

Persistent hiccups have been reported to occur occasionally during rehabilitation hospitalizations. Hiccups can interfere with patient participation and progress, and this can lengthen and complicate the rehabilitation hospitalization. Chlorpromazine, the only Food and Drug Administration-approved agent specifically indicated for hiccups, is often chosen as a first-line treatment. However, chlorpromazine does not always provide favorable results. The intent of this paper is to (1) review hiccups and implications of persistent hiccups in the rehabilitation setting, (2) provide additional evidence that chlorpromazine is often not the best treatment choice for hiccups in rehabilitative patients, (3) report the effectiveness and favorable tolerability of modest doses of gabapentin in a small case series of three patients, and (4) review potentially effective treatment approaches for hiccups.