Preliminary experience with cultured epidermal autograft in a community hospital burn unit.

Initial experience with cultured epidermal autograft (CEA) in a community hospital burn unit is described. Five applications of CEA to three patients (mean burn size, 59% total body surface area) were made. Final graft "take" of CEA ranged from 10% to 80%.

The random fasciocutaneous flap for upper extremity coverage.

Rapid and appropriate healing of any upper extremity wound is essential for preservation of normal hand function. If vascularized tissue must be used, local cutaneous flaps nourished by the multiple perforators to the fasciocutaneous plexus avoid the complexity of microsurgical tissue transfers or prolonged immobilization required for distant pedicled flaps. For small or moderate-sized defects, assuming that adequate adjacent deep fascia has remained intact, these simple, rapidly elevated, so-called random fasciocutaneous flaps deserve initial consideration, as demonstrated in all 11 cases in this reported series.

Meta-analysis of the reliability of noninvasive carotid studies.

The author examined those published studies of the consistency (homogeneity) of study outcomes of noninvasive tests that assess the degree of carotid artery disease. Noninvasive tests used to detect carotid artery disease include ocular pneumoplethysmography and duplex ultrasound pulsed Doppler spectral analysis with high-resolution B-mode scan. This meta-analysis showed that all authors had reached essentially the same conclusion: 1) one of these noninvasive tests may be sufficient to determine the clinical management of carotid artery disease, and 2) when two tests are concordant, the test degree of certainty is greatly improved, with anatomic and physiologic information that often matches or surpasses that afforded by the more invasive percutaneous carotid arteriography.

The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with over two-year follow-up evaluation.

Valgus deformity correction poses a major challenge in total knee arthroplasty (TKA). The standard medial approach has many technical limitations and disadvantages that include patellofemoral maltracking and subsequent patellar problems. The lateral approach has been developed and utilized successfully in 79 cases (53 with over two-year follow-up evaluation) since 1980.

Vertebral artery dissection resulting in locked-in syndrome.

A 30 year-old man admitted to the hospital two weeks following a motor vehicle accident developed "locked-in" syndrome resulting from traumatic vertebral artery dissection. Aggressive nursing interventions during the acute and early recovery periods were implemented with the hope that both physical and emotional deficits might be alleviated. Although the prognosis for this type of injury is often poor, this patient has improved steadily over a 16-month period.

Complications of the free-flap donor site from a community hospital perspective.

Techniques for achieving appropriate wound healing with minimal aesthetic or functional deformity of the microsurgical flap donor site are often assumed to be of minor importance or blatantly overlooked. Surprisingly, an analysis of 115 consecutive free-tissue transfers by a single surgeon within a community hospital setting, revealed an overall donor-site complication rate of 31 percent, with significant disability from major complications occurring in 10 percent of cases. Recognition of the projected morbidity of alternative donor sites therefore deserves scrutiny, with the same intensity as does consideration for flap selection, previously done solely to fulfill the requirements of the recipient site.

Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle.

A compound flap implies that more than a single tissue structure has been linked together to achieve a common purpose. In this sense then, a composite flap is the simplest form of a compound flap because by definition it incorporates multiple tissue types, but the latter are restricted in that the vascularization of all contained parts are interdependent and inseparable if total viability of the unit is to be maintained. More complex compound flaps may have components with separate vascular sources but remain physically attached, or may be fabricated by joining disparate flaps together using microsurgical methods.

Assessment of disease activity in a registry of Crohn's disease patients in eastern Pennsylvania.

The objectives of this report are to: 1) compare the Crohn's disease (CD) patient's assessment of their well-being to the physician's assessment of the patient's well-being, 2) use the existing Crohn's disease indices (CDI) in comparing the severity of CD with the patient's self assessment, and 3) compare the CDI with the physician's assessment of patient well-being. The CDI included in this study were the National Cooperative Crohn's Disease Study Index (CDAI), Harvey & Bradshaw Index (HBI), Oxford Index (OXI), Modified-Organisation Mondiale de Gastroenterologie (OMGE), Cape Town Index (CTI), Bristol Index (BRI), St. Marks Index (SMI) and the Van Hees index (VHI).

Complications of 100 consecutive local fasciocutaneous flaps.

A resurgence of interest in the fasciocutaneous flap has been predicated on its simplicity, availability, and versatility. Its dependability in addition is documented in this analysis of complications accrued in 100 consecutive local applications. Major complications that required further surgical intervention occurred in 15 percent of patients, with an additional 11 percent of patients suffering other minor untoward events.

Recontouring of the lateral forehead using the temporalis muscle.

Contour deformities of the lateral forehead are not uncommon after direct injuries or extirpative procedures, or as a sequela to iatrogenic maneuvers for juxtaposed craniomaxillofacial endeavors. Transposition of noncutaneous local vascularized autogenous tissues for augmentation of these defects has minimal inherent risks and little donor site morbidity. Although the temporoparietal fascia has previously been described as a first choice in this regard, if unavailable due to concomitant injury or absence of the superficial temporal vessels, the temporalis muscle itself provides an excellent second option that deserves consideration.

Alzheimer's disease in Down's syndrome with SPECT.

Alzheimer's disease often occurs in patients with Down's syndrome. SPECT scanning with I-123 IMP and Tc-99m HMPAO identifies decreased cerebral perfusion and metabolism in these patients at lower cost. In this case, SPECT scanning revealed changes in Alzheimer's disease in a Down's syndrome patient.

Isle of palm and sole fillet flaps.

Extensive extremity injuries appropriately managed by immediate amputation may be compromised if retained soft tissues are inadequate to permit a simple wound closure. In usual circumstances, if the foot or hand from the soon-to-be-discarded part has not been violated and, by chance, remains viable through a major neurovascular pedicle, then a fillet of the sole or palm fashioned as a local island flap may be used for durable and potentially sensate stump coverage. Function preservation by salvaging maximal amputation stump length could then be achieved in lieu of more complex microsurgical techniques.

Regional fasciocutaneous flaps for the burned axilla.

The conventional approach for secondary correction of unstable axillary scars or contractures with skin grafting commonly risks failure of adherence and early recurrence of the problem, even in highly motivated patients. Potential early mobilization and the avoidance of postoperative splinting may be advantages of reconstruction with vascularized tissues instead. The local fasciocutaneous flap is advocated as a simple, rapidly elevated, single-staged option that preserves function while correcting these deformities.

A private practice model for teaching and research activities.

The majority of neurologists in the United States are in fee for service patient management, dividing their time between hospital and office based practice. Many have had subspecialty training or have had research experience. It is our belief that research should be a component of a neurologist's practice.

Episodic low-amplitude events: an under-recognized phenomenon in clinical electroencephalography.

In a series of 20 EEGs from 15 patients, well-defined brief attenuations occurred interspersed among the background activity. These episodic low-amplitude events (ELAEs) typically lasted 0.5-4 s.

Local fasciocutaneous flap skin coverage for the dorsal foot and ankle.

Recalcitrant wounds of the distal leg and foot are notorious for requiring complex solutions even when deceptively small or benign in appearance. The simplicity of local flap options is always preferable, but is limited about the dorsal foot and ankle region. Inclusion of the well-defined deep fascia with the overlying integument in this area permits creation of local fasciocutaneous flaps that may be an important viable alternative.

Hemorrhoidectomy during pregnancy: risk or relief?

Acute hemorrhoidal crisis can occur in the pregnant female. When medical therapy fails to relieve pain, operative intervention may be necessary. The surgeon, however, may be reluctant to operate due to potential complications to the mother and fetus.

Clostridium difficile--a common and costly colitis.

Clostridium difficile infection manifests as a self-limiting diarrhea, protracted colitis, or toxic pseudomembranous colitis. The incidence of C. difficile in a 514-bed community hospital was studied retrospectively; 155 patients of a total 18,262 admitted during 1988 were identified with C.

Free-tissue transfers for limb salvage utilizing in situ saphenous vein bypass conduit as the inflow.

Using vein grafts to bypass sclerotic and occluded arterial segments is a well-established technique in vascular surgery. For infrapopliteal bypass, autogenous veins have better patency rates than synthetic grafts. Although not resolved, in situ bypasses seem to be better than reversed bypasses, especially for "far away" segments.

Estimation of nitrogen excretion based on abbreviated urinary collections in patients on continuous parenteral nutrition.

The physiologic response to stress can create a net loss of nitrogen, which is indicative of a catabolic state. Nitrogen balance has been demonstrated to be a useful clinical indicator of a patient's catabolic state and the effectiveness of parenteral nutrition, but requires an estimate of total urinary nitrogen excretion. The standard method for determining total urinary nitrogen excretion is 24-hour urinary urea nitrogen excretion.

Local random fasciocutaneous flaps for repair of the burned elbow.

Wound management of the burned elbow is not always possible with a skin graft alone. Rather than resort to distant pedicle flaps or the complexity of microsurgical tissue transfers, local fasciocutaneous flaps may provide a better source for vascularized tissue. "Random" fasciocutaneous flaps do not require isolation of any discrete vessel, but must be designed to parallel the longitudinal axis of perifascial circulation in the upper extremity.

A schema for local flap selection in the upper extremity: a hypothesis.

Whereas any contemplation suggesting routinization in a plastic surgery endeavor may engender abhorrence or bespeak heresy, some generalizations are essential at least as a foundation from which a logical divergence may proceed. Such an approach for the selection of preferable local flaps in wound coverage within the upper extremity can be developed based on available options as will be presented in schematic form to confirm this hypothesis.

Miniplate washers for improving lag screw fixation.

Increased efficiency in using the lag screw principle for rigid fixation of bone, particularly for fragile cortical or soft cancellous grafts, is facilitated by dispersion of screw head compression forces with a biocompatible metallic washer. Although none is commercially available, such washers may be quickly fashioned from the residua of any adaptation miniplate in quantities as required.