Management of aseptic nonunions and severe bone defects: let us get this thing healed!

Effective nonunion and bone defect management requires consideration of multiple potential contributing factors including biomechanics, biology, metabolic, and patient factors. This article reviews these factors as well as several potential nonunion or bone defect treatments including bone grafts, bone graft substitutes, the induced membrane technique, and distraction osteogenesis. A summary of these concepts and guidelines for an overall approach to management are also provided.

Clinical management of diabetic ulcers.

The presence of neuropathy is the most important factor in the development of a diabetic ulcer, whereas inadequate vascular supply is the most important factor in healing. Diabetic foot ulcers are complex wounds that require a long time to heal. A key element in treating diabetic wounds is to off-load, or remove, pressure from an insensate foot.

Managing peripheral arterial disease and vascular ulcers.

Peripheral vascular disease is common and often undiagnosed. Painful vascular ulcers and intermittent claudication greatly reduce mobility and quality of life. Screening for diagnosis is best accomplished by an ankle brachial index, whereas anatomic visualization of the arterial anatomy may be necessary to plan treatment.

Managing venous stasis disease and ulcers.

Venous leg ulcers are arguably the most common type of venous ulcers seen in clinical practice. Compression therapy is the essential intervention in venous leg ulcer treatment, but coexisting arterial vascular insufficiency must be excluded before compression is initiated. No single topical dressing has been shown to be superior for all wounds.

Clinical management of pressure ulcers.

Pressure ulcers are chronic and difficult to heal. Pressure-reducing devices are clearly superior to a standard hospital mattress in preventing pressure ulcers, but only limited evidence and clinical intuition supports pressure-reducing devices in improving the healing rate of pressure ulcers. Local wound treatment should aim at maintaining a moist wound environment.

Things you never thought of that make a difference: personal goals, common sense, and good behavior in practice.

There are many aspects of your practice that you never think of when you first get into your new practice environment. You have spent the better part of your life training in a rigorous surgical residency and possibly fellowship. You have worked hard to get to this station in life.

Anatomical route of invasion and protective mucosal immunity in Trypanosoma cruzi conjunctival infection.

Trypanosoma cruzi is a protozoan parasite that can initiate mucosal infection after conjunctival exposure. The anatomical route of T. cruzi invasion and spread after conjunctival parasite contamination remains poorly characterized.

Mitochondrial DNA mutations, apoptosis, and the misfolded protein response.

Studies of transgenic mice with accelerated accumulation of mtDNA mutations specifically in the heart lead us to propose that apoptotic signaling and cell death is central to the pathogenesis of mtDNA mutations in aging. It is the cellular response to that apoptotic signaling and the organ?s compensatory response to a loss of cells that specify the phenotype of an accumulation of mtDNA mutations. In the heart, cardiomyocytes induce a vigorous anti-apoptotic, pro-survival response to counteract mitochondrial apoptotic signaling.

Gene expression profile in dilated cardiomyopathy caused by elevated frequencies of mitochondrial DNA mutations in the mouse heart.

Background: Elevated mitochondrial DNA (mtDNA) mutations are associated with aging and age-related diseases, but their pathogenic potential is unclear.

Methods: We performed expression profiling using an Incyte cDNA array of a mouse model of elevated mtDNA mutations wherein random mutations accumulate specifically in the heart. At frequencies of about 1 mutation/10,000 base pairs, these mice show apoptosis of cardiomyocytes and development of four-chamber dilated cardiomyopathy.

Herbals and botanicals in geriatric psychiatry.

There is high prevalence of herbal medicine use among elderly people. Most patients do not reveal their herbal use to their physicians and pharmacists. The authors describe some commonly used herbal remedies in terms of their potential benefits and known adverse effects.

The effects of protein, red blood cells and whole blood on PS valve function.

We tested the performance of low- and medium-pressure PS flow control valves as they were perfused with (1) solutions with varying concentrations of protein, (2) solutions with varying numbers of red blood cells (RBC) or (3) solutions with varying concentrations of whole blood. Perfusion was performed with a peristaltic pump at a constant rate and each trial lasted 2 weeks or until valve failure. Mean valve pressures were measured and recorded electronically, and opening and closing pressures were obtained at baseline and at the end of the perfusion period or upon valve failure.

A procedure for placing pediatric femoral venous catheter tips near the right atrium.

Objective: To find a body measurement that would serve as an index for determining the length of femoral venous catheter to be inserted to achieve a position near the right atrium.

Methods: A candidate index measurement was chosen, and radiographic measurements of routine femoral venous catheter placements were compared with the placement that may have resulted from use of the index in a group of patients. In a subsequent group, the candidate index was used to choose catheter insertion length, the accuracy of which was again evaluated from routine placement radiographs.

Age-related changes in wound healing.

Evidence for age-related effects on wound healing have been derived for the most part from empirical observations without adjustment for confounders other than age. Age-related changes in the structure and function of the skin do occur. Some of these changes result from chronic solar radiation exposure rather than chronological age per se.

Minimally invasive approaches to mediastinal neoplasms.

The goal of minimal-access surgery is to cause the least trauma necessary to gain exposure for an operative procedure. Application of this principle to mediastinal neoplasms involves the use of small incisions with both mediastinoscopy and video-assisted thoracoscopic surgery (VATS). The mediastinum is divided into anterior, middle, and posterior compartments, and this anatomy provides a framework for discussion of diagnostic and therapeutic procedures.

CD30+ anaplastic large-cell lymphoma with aberrant expression of CD13: case report and review of the literature.

CD13 is commonly expressed in hematopoietic malignancies of myelomonocytic origin and has less commonly been described in lymphoid neoplasms, including acute lymphoblastic leukemia, B-cell lymphoproliferative disorders, and plasma cell malignancies. Aberrant CD13 expression has rarely been described in KP-1 (CD68)-positive large-cell lymphomas. However, CD13 positivity has not previously been described in a case of CD30+ (ALK-1+) anaplastic large-cell lymphoma of presumed null-cell origin without histiocytic differentiation.

Effect of methotrexate on the temporomandibular joint and facial morphology in juvenile rheumatoid arthritis patients.

Juvenile rheumatoid arthritis is a disease characterized by chronic inflammation in one or more joints; it affects children and adolescents up to 18 years of age. This disease may cause significant skeletal joint destruction, and the temporomandibular joint, like other joints, may become severely affected resulting in aberrant mandibular growth, abnormal dentofacial development, and/or altered orofacial muscle function. Methotrexate is the most common remittive agent used in juvenile rheumatoid arthritis to modify the course of inflammatory destruction of peripheral joints.

Expression of the cyclin-dependent kinase inhibitor p27 in keratoacanthoma.

Background: Keratoacanthomas are characterized by initial rapid enlargement followed by clinical regression. A series of cyclin and cyclin-dependent kinase complexes regulate cell cycle progression. p27(kip) inhibits a variety of cyclin-cyclin-dependent kinase complexes in vitro and may act to hold eukaryotic cells in a quiescent state (G0).

The Brugada syndrome: clinical, electrophysiologic and genetic aspects.

This review deals with the clinical, basic and genetic aspects of a recently highlighted form of idiopathic ventricular fibrillation known as the Brugada syndrome. Our primary objective in this review is to identify the full scope of the syndrome and attempt to correlate the electrocardiographic manifestations of the Brugada syndrome with cellular and ionic heterogeneity known to exist within the heart under normal and pathophysiologic conditions so as to identify the cellular basis and thus potential diagnostic and therapeutic approaches. The available data suggest that the Brugada syndrome is a primary electrical disease resulting in abnormal electrophysiologic activity in right ventricular epicardium.

Multiple picrotoxinin effect on glycine channels in rat hippocampal neurons.

The effect of picrotoxinin on glycine-induced chloride currents was studied in dissociated rat hippocampal neuron culture in whole-cell and excised outside-out patches. Picrotoxinin blocked the glycine induced chloride currents. The picrotoxinin effect at 20 microM on glycine dose response relationship suggested a competitive mechanism.

Indirect glutamate neurotoxicity.

Indirect glutamate toxicity can be demonstrated by exposing dissociated rat hippocampal cultures to the media of the same culture transiently exposed (1 min) to glutamate (0.5 mM). The toxicity was maximum when the media was collected 5 min after the glutamate exposure.

Role of neuropeptide Y in cold stress-induced hypertension.

Chronic cold stress (4 degrees C) produced a sustained increase in mean arterial pressure in both normotensive and borderline hypertensive rats (BHR). The high blood pressure in BHRs was significantly reversed by a neuropeptide Y (NPY) Y1 receptor antagonist suggesting that NPY is involved in mediating stress-induced hypertension. Corresponding increases in adrenal NPY messenger RNA and NPY immunoreactivity were found during the stress; furthermore, chronic cold stress also potentiated the pressor response of rats to a subsequent acute stress test in which NPY has been shown to play a role.

Activation of myocardial cAMP-dependent protein kinase by lysoplasmenylcholine.

Plasmalogen-specific, calcium-independent phospholipase A2 (iPLA2) is activated during myocardial ischemia. Accordingly, we have assessed the activation of myocardial protein kinases by the iPLA2 product, lysoplasmenylcholine. Lysoplasmenylcholine-activated protein kinase activity from heart cytosol fractionated on a DE-52 column was identified as cAMP-dependent protein kinase (PKA) based on the following: (1) protein kinase activity stimulated by cAMP and lysoplasmenylcholine co-eluted on sequential chromatographic steps; (2) lysoplasmenylcholine-activated protein kinase activity was inhibited by the PKA inhibitor, PKI; and (3) the unprimed PKA form generated from the primed form of PKA was activated by cAMP and lysoplasmenylcholine.

Early neuroradiologic evidence of degeneration in Menkes' disease.

We report the case of an infant with Menkes' disease who presented with moderately abnormal neurologic findings at birth and with extraaxial bleeding in the posterior fossa. Early cerebellar atrophy and hypomyelination were evident on magnetic resonance imaging at 5 weeks of age. We suggest that neurodegeneration occurs earlier than has been previously reported and may be identifiable even in neonates.

Electrosurgery and cardiac devices.

The increased number of patients with implantable cardiac devices presents a unique challenge to physicians performing office-based electrosurgical procedures. Electrosurgery can be performed safely if the electrosurgical techniques and potential risks from these devices are understood. We present an overview of the most common types of implantable cardiac devices, potential complications associated with them, and recommendations for preoperative evaluation, intraoperative monitoring, and postoperative follow-up.

Apoptosis mediates cell death following traumatic injury in rat hippocampal neurons.

A model of in vitro traumatic injury with dissociated rat hippocampal neurons was studied to explore the mechanism of cell death. The neurotoxicity induced by traumatic injury to the cell culture can be transferred to a naive uninjured culture by media exchange. This toxicity is attenuated by dimethylsulfoxide or superoxide dismutase, suggesting that this toxicity is mediated by a free radical generation.