Faculty Bibliography

OBJECTIVES: This study examined the prevalence, social correlates, and clustering of cardiovascular disease risk factors in a predominantly Black, poor, urban community. METHODS: Associations of risk factor prevalences with sociodemographic variables were examined in a population-based sample of 695 men and women aged 18 to 65 years living in Central Harlem. RESULTS: One third of the men and women were hypertensive, 48% of the men and 41% of the women were smokers, 25% of the men and 49% of the women were overweight, and 23% of the men and 35% of the women reported no leisure-time physical activity over the past month. More than 80% of the men and women had at least 1 of these risk factors, and 9% of the men and 19% of the women had 3 or more risk factors. Income and education were inversely related to hypertension, smoking, and physical inactivity. Having 3 or more risk factors was associated with low income and low education (extreme odds ratio [OR] = 10.2, 95% confidence interval [CI] = 3.0, 34.5 for education; OR = 3.7, CI = 1.6, 8.9 for income) and with a history of unstable work or of homelessness. CONCLUSIONS: Disadvantaged, urban communities are at high risk for cardiovascular disease. These results highlight the importance of socioenvironmental factors in shaping cardiovascular risk.

Modulation of biological pathways governing osteogenesis may accelerate osseous regeneration and reduce the incidence of complications associated with fracture healing. Transforming growth factor beta1 (TGF-beta1) is a potent growth factor implicated in the regulation of osteogenesis and fracture repair. The use of recombinant proteins, however, has significant disadvantages and has limited the clinical utility of these molecules. Targeted gene therapy using adenovirus vectors is a technique that may circumvent difficulties associated with growth factor delivery. In this study, we investigate the efficacy of replication-deficient adenoviruses containing the human TGF-beta1 and the bacterial lacZ genes in transfecting osteoblasts in vitro and osseous tissues in vivo. We demonstrate that adenovirus-mediated gene therapy efficiently transfects osteoblasts in vitro with the TGF-beta1 virus causing a marked up-regulation in TGF-beta1 mRNA expression even 7 days after transfection. Increased TGF-beta1 mRNA expression was efficiently translated into protein production and resulted in approximately a 46-fold increase in TGF-beta1 synthesis as compared with control cells (vehicle- or B-galactosidase-transfected). Moreover, virally produced TGF-beta1 was functionally active and regulated the expression of collagen IalphaI (5-fold increase) and the vascular endothelial growth factor (2.5-fold increase). Using an adenovirus vector encoding the Escherichia coli LacZ gene, we demonstrated that adenovirus-mediated gene transfer efficiently transfects osteoblasts and osteocytes in vivo and that transfection can be performed by a simple percutaneous injection. Finally, we show that delivery of the hTGF-beta1 gene to osseous tissues in vivo results in significant changes in the epiphyseal plate primarily as a result of increased thickness of the provisional calcification zone

Cephalic molding at birth has been traditionally felt to be benign, resulting in only a transient and self-correcting cranial deformity. However, we report a 6-month-old infant who presented with extensive cephalic molding at birth in combination with persistent brachyturricephaly from unilateral coronal synostosis and occipital deformation. Helmet therapy over a 3-month period failed despite patient compliance and numerous adjustments. Intracranial hypertension developed, as documented by multiple occipital bony erosions on computed tomographic scan and by an elevated direct intracranial pressure reading. The cranial vault asymmetry was corrected in two surgical stages: (1) occipital bar advancement, temporoparietal bone remodeling, and midline sagittal strip compression to reduce vertical height, followed in 3 months by (2) fronto-orbital advancement and remodeling

Large facial arteriovenous malformations are problematic for patients because of grotesque disfigurement, risk of rapid enlargement, and life-threatening rupture. Successful treatment of these relentless complex lesions is one of the most difficult challenges facing plastic surgeons. From a series of 300 large facial arteriovenous malformations, 85 patients were treated with embolization and excision; six of these cases (representing six separate anatomic regions: labial, auricular, eyelid, cheek, chin, and occipitoparietal) were selected for review. The purpose of this article was to look critically at the management of these six facial arteriovenous malformations, including patient presentation, angiographic procedures, surgical planning and technique, and postoperative long-term follow-up care. Lessons learned from the six representative cases provide clues for the management of large facial arteriovenous malformations and demonstrate the possibilities of recurrence and their occasionally relentless behavior. The cases show that long-term control of these lesions with acceptable aesthetic results can be achieved. The mainstay of treatment includes the following: (1) selective intra-arterial embolization with fine catheters and direct lesional embolization; (2) judicious resection and reconstruction with local or expanded tissue flaps; and (3) careful follow-up with serial examinations, duplex, and arteriography

BACKGROUND: Microvascular anastomosis remains one of the most technically sensitive aspects of free-tissue transfer reconstructions. Despite the availability of various mechanical anastomotic coupling systems for human clinical use during the last 8 years, reported clinical series remain rare. OBJECTIVE: To describe a clinical experience in applying a mechanical microvascular anastomotic coupling device (MACD) to end-to-side anastomotic configurations in head and neck free-flap reconstruction. METHODS: The MACD is a readily available high-density polyethylene ring-stainless steel pin system that has been found to be highly effective in clinical studies of end-to-end arterial and venous anastomosis and in laboratory studies of end-to-side anastomosis of rabbit arteries. RESULTS: Thirty-seven end-to-side venous anastomoses were attempted, of which 33 (89%) were completed. Of these, 9 patients had critical anastomoses (only 1 venous anastomosis per patient). In patients undergoing parallel venous anastomoses, 6 had both anastomoses performed using the MACD; in the remaining 12 patients, 1 of the anastomoses was performed using the MACD. A variety of donor flaps and clinical contexts were encountered. Flap survival in the MACD series was 100%. Four anastomoses were converted to conventional suture technique intraoperatively. CONCLUSIONS: The MACD is well suited to end-to-side venous anastomosis when carefully and selectively used by experienced microvascular surgeons. The most common clinical situation requiring this configuration and technique was the lack of ipsilateral recipient veins for end-to-end anastomosis or a ligated internal jugular vein stump that required this approach for device application. Previous radiation therapy does not appear to be a contraindication to its use

Premature cranial suture fusion, or craniosynostosis, can result in gross aberrations of craniofacial growth. The biology underlying cranial suture fusion remains poorly understood. Previous studies of the Sprague-Dawley rat posterior frontal suture, which fuses at between 12 and 20 days, have suggested that the regional dura mater beneath the cranial suture directs the overlying suture's fusion. To address the dura-suture paracrine signaling that results in osteogenic differentiation and suture fusion, the authors investigated the possible role of insulin-like growth factors (IGF) I and II. The authors studied the temporal and spatial patterns of the expression of IGF-I and IGF-II mRNA and IGF-I peptide and osteocalcin (bone morphogenetic protein-4) protein in fusing posterior frontal rat sutures, and they compared them with patent coronal (control) sutures. Ten Sprague-Dawley rats were studied at the following time points: 16, 18, and 20 days of gestation and 2, 5, 10, 15, 20, 30, 50, and 80 days after birth (n = 110). Posterior frontal and coronal (patent, control) sutures were analyzed for IGF-I and IGF-II mRNA expression by in situ hybridization by using 35S-labeled IGF-I and IGF-II antisense riboprobes. Levels of IGF-I and IGF-II mRNA were quantified by counting the number of autoradiograph signals per cell. IGF-I and osteocalcin immunoreactivity were identified by avidin-biotin peroxidase immunohistochemistry. IGF-I and IGF-II mRNA were expressed in dural cells beneath fusing sutures, and the relative mRNA abundance increased between 2 and 10 days before initiation of fusion. Subsequently, IGF-I and IGF-II mRNA were detected in the suture connective tissue cells at 15 and 20 days during the time of active fusion. In contrast, within large osteoblasts of the osteogenic front, the expression of IGF-I and IGF-II mRNA was minimal. However, IGF-I peptide and osteocalcin protein were intensely immunoreactive within these osteoblasts at 15 days (during the period of suture fusion). These data suggest that the dura-suture interaction may be signaled in a paracrine fashion by dura-derived growth factors, such as IGF-I and IGF-II. These peptides, in turn, stimulate nearby osteoblasts to produce bone-promoting growth factors, such as osteocalcin

In accessory neuropathy electrodiagnosis, upper trapezius compound muscle action potential (CMAP) latencies and amplitudes are commonly measured. The few prior reports describing middle and lower trapezius recording have traditionally emphasized latency value determination. The utility of amplitude measurement with middle and lower trapezius recording has not, to our knowledge, been previously described in individual patients with accessory neuropathy. We report three patients (A-C) who developed unilateral accessory neuropathy following surgical procedures. Accessory nerve conduction studies were performed with surface recording over the upper, middle, and lower trapezius muscles. Latency values were normal except for a prolonged lower trapezius latency value in patient B. Side-side trapezius amplitude comparisons revealed striking asymmetries from all three recording sites in patients A and B (71-95% CMAP amplitude decrements) and in the lower trapezius recording of patient C. Middle and lower trapezius side-side CMAP amplitude comparisons may increase the sensitivity of accessory neuropathy electrodiagnosis

OBJECTIVES: Routine carpal tunnel electrodiagnosis frequently includes median (MPW) and ulnar (UPW) palm-wrist mixed nerve conduction latency determinations over 8 cm. Despite widespread use, normative palmar latency difference (PLD) and UPW values, and the relative utility of onset latency (OL) or peak latency (PL) measurements are controversial. The current study was conducted to determine normative values for these parameters. METHODS: MPW and UPW studies were performed unilaterally in 33 normal controls. The PLD-OL and PLD-PL were calculated. The mean, range, standard deviation, and upper limits of normal were determined. 74 hands (50 patients) with both clinical and electrophysiologic median neuropathy were also studied. RESULTS: The abnormal MPW and UPW cut-offs were both 1.8 ms (OL), and 2.3 ms (PL). The abnormal PLD cut-offs were 0.5 ms (OL and PL). Using either OL or PL, PLD parameters were similar within controls, and also within CTS patients. Using either OL or PL, UPW parameters were similar between controls and CTS patients. CONCLUSIONS: An abnormal PLD cut-off of 0.5 is recommended. This is slightly higher than some prior recommendations, however it should minimize the likelihood of false positive studies. Onset and peak latency measurements are likely to have similar clinical utility

The optimal period of time between peripheral-nerve repair and initiation of limb lengthening procedures has never been precisely determined. In the clinical setting, the surgeon must decide how long the repaired nerves should be allowed to heal before subjecting them to the forces created by the limb-lengthening process. The authors designed a study to quantify and qualify the effects of different recovery periods between initial nerve repair and subsequent limb-lengthening via distraction osteogenesis. Forty-two Sprague-Dawley male rats were randomized in two different categories of nerve repair: end-to-end and nerve grafts. At 4, 8 and 12 weeks after nerve reconstruction, the femur was submitted to limb-lengthening at a rate of 1 mm/day (0.25 mm every 6 hr). Sciatic Function Index (SFI) evaluation indicated that the impact of distraction was detrimental in the grafted nerves, although they maintained their electrical and morphologic properties at comparable levels to the non-distracted nerves. Nerves with direct coaptation presented an overall superior regeneration pattern. The findings in end-to-end repairs distracted at 8 weeks and those of grafted nerves at 12 weeks were comparable to those in distracted normal nerves. The morphology of the distracted nerves appeared to be more organized than that observed in the non-distracted nerves