Questioning patient care: when closed mouths must speak.
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Humans↗
Biomedical subjects
E C Smoot
Publications and source records attributed to E C Smoot.
Mechanical leech therapy to relieve venous congestion.
When faced with venous insufficiency following replantation or free-tissue transfer, the surgeons' first choice is surgical repair. When repair is not possible, medicinal leeches may be applied to relieve congestion. However, leeches increase the possibility of infection through their gut contents, and there are times when the available leech supply is short and the need for rapid exsanguination is great. A mechanical device has been developed and tested which could be used as a substitute for the medicinal leech. Using a venous-congested rat epigastric flap, this device was demonstrated to be superior to a medicinal leech in restoring capillary perfusion to the flap during the first hour of exsanguination. The device may offer an alternative to the medicinal leech for the clinical treatment of small areas of tissue with venous congestion.
Animals↗
Effect of the carbon dioxide laser on viability of ear cartilage in a rabbit model.
The carbon dioxide (CO2) laser can be used for rapid, detailed sculpting of cartilage for creation of an ear framework for reconstruction of microtia. Clinical and animal studies of the effect of the CO2 laser have noted good healing with little evidence of a zone of tissue injury adjacent to the laser incisions. The current study has investigated the longer term effect of CO2 on chondrocyte viability in a rabbit ear model in which the laser has been used to incise autogenous cartilage segments for implantation into subcutaneous pockets. Over a 3-month period, the conformational integrity of the segments, when compared to segments incised with a scalpel, was no different. However, radioactive sulfur uptake studies to assess the viability of chondrocytes indicated a decrease in chondrocyte density in those specimens that have been subjected to laser incisions. Although other studies of acute cellular injury indicate that the CO2 laser may be beneficial for cartilage incision and sculpting, the current study indicates that resorption over longer periods of time might be encountered as a consequence of decreased chondrocyte viability in the vicinity of the laser incisions.
Analysis of Variance↗
Delayed development of an ectopic frontal sinus mucocele after pediatric cranial trauma.
We describe the delayed occurrence of a frontal sinus mucocele 14 years after the original trauma. The patient presented with a laterally displaced, enlarging mass that encroached on the dura. The sterile mucocele was removed, and the cranial defect was reconstructed with methyl methacrylate and wire mesh. Our experience confirms the known but rarely observed late development of a mucocele after pediatric facial trauma. To prevent the sequela of mucocele development, the mucosa of the rudimentary frontal sinus in the pediatric patient must be carefully sought and ablated during reconstructive procedures of the forehead when traumatic injury significantly disrupts the normal bony anatomy.
Adult↗
Long arm splinting of the pediatric upper extremity.
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Bandages↗
Effect of motion on digital nerve repair in a fresh cadaver model.
Information in the literature regarding the postoperative management of digital nerve lacerations is vague, and postoperative immobilization for up to 3 weeks is frequently recommended. In order to define more precisely what, if any, postoperative restrictions are necessary, a fresh cadaver model was designed for digital nerve division, resection, repair, and passive motion. Ten digital nerves were divided at the proximal interphalangeal joint and then repaired, mobilized, and inspected. Intact nerve repairs were serially resected in order to determine the limits of resection that would allow motion without repair disruption. All repairs were resistant to disruption even with hyperextension up to a resection length of 2.5 mm, and all repairs were resistant to disruption if splinted in neutral up to a resection length of 5 mm. There was not 100 percent disruption of repairs until a resection length of 1 cm and range of motion including hyperextension. These results give valuable objective data that can be used to guide early motion and splinting protocols after various degrees of digital nerve injury and repair.
Cadaver↗
Toxic epidermal necrolysis: a review and report of the successful use of Biobrane for early wound coverage.
Toxic epidermal necrolysis (TEN), is an exfoliative dermatological disorder of unknown cause. A patient with TEN loses epidermis in sheet-like fashion, leaving extensive areas of denuded dermis that must be treated like a large, superficial, partial-thickness burn wound. Methods of coverage described in the English literature over the last decade include the use of several dressings such as fresh-frozen or cryopreserved cadaver allograft, porcine xenograft, and amnionic membrane. Successful use of the biosynthetic dressing, Biobrane, has been described after burn injuries and Stevens-Johnson syndrome; however, its use in TENS has not. We present three patients with TEN treated successfully in our burn center over the past 12 months using Biobrane. The patients were men aged 20, 58, and 77 years, with 58% to 95% total body surface area slough. Diagnosis was confirmed by skin biopsy on admission, and drug ingestion was implicated in each instance. Each patient was thoroughly debrided in the operating room shortly after admission, and denuded areas were covered with Biobrane within 24 to 48 hours of admission. Biobrane demonstrated greater than 90% adherence by 48 hours, and no wound sepsis occurred. Each patient demonstrated epithelialization within 9 days. Patients were ambulatory at 72 hours. Corticosteroids and prophylactic antibiotics were avoided. Enteral nutritional support and aggressive septic surveillance was routine. Hospital stay was between 13 and 30 days without mortality. Early use of Biobrane in patients with TEN appears to provide a reasonable means of wound coverage.
Adult↗
Cautious skin excision of the keyhole pattern for reduction mammaplasty.
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Female↗
Effective teaching in the operating room.
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Clinical Clerkship↗
Assessment of flap perfusion in a porcine model with a heated laser Doppler probe.
Skin and musculocutaneous flaps in a pig model were studied for their response to heating of the laser Doppler probe, both in the perfused state and in conditions of vascular occlusion. Even though heating the probe resulted in an elevation of perfusion of the flaps with no occlusions, it also increased the apparent perfusion of flaps that were occluded. The ability of flows to a augment with heating, therefore, could not be perfectly correlated with impeded vascular flow. The addition of a heated perfusion reading for assessment of vascular occlusion did not improve the accuracy of the laser Doppler for monitoring of capillary-bed perfusion to detect vascular occlusion.
Animals↗
The effect of hyperbaric oxygen on reperfusion of ischemic axial skin flaps: a laser Doppler analysis.
This study evaluates the microvascular reperfusion of ischemic skin flaps with and without acute hyperbaric oxygen (HBO) treatment. Thirty-two axial pattern epigastric skin flaps (3 x 6 cm) in male Wistar rats were subjected to 8 hours of global ischemia by pedicle clamp occlusion. The rats were divided into the following control and two experimental groups: Control (n = 12) with ischemia, no HBO; Group 1 (n = 11) with HBO treatment (three 1.75-hour dives, 2.5 absolute atm, 100% O2) during ischemia; and Group 2 (n = 9) with HBO treatment (two 1.75-hour dives) immediately after ischemia. Laser Doppler flows were recorded in two distal standardized flap locations at 0.5, 2, 4, and 18 hours after reperfusion in control rats and Group 1 rats and at 18 hours only in Group 2 rats, using a Med-Pacific 6000 laser Doppler unit. Mean distal flap laser Doppler flows (mV) were Control: 0.5 hours = 23.2 +/- 11.9, 2 hours = 52.8 +/- 27.3, 4 hours = 53.6 +/- 32.1, 18 hours = 40.2 +/- 36.2; Group 1: 0.5 hours = 71.8 +/- 30.9 (p less than 0.05 vs. control), 2 hours = 74.3 +/- 27.3, 4 hours = 67.4 +/- 20.6, 18 hours = 79.1 +/- 40.3 (p less than 0.05 vs. control); and Group 2: 18 hours = 90.3 +/- 47.9 (p less than 0.05 vs. control). It is concluded that acute HBO treatment of ischemic rat skin flaps improves distal microvascular perfusion as measured by laser Doppler flowmetry. This effect is observed for HBO treatment given either during or immediately after prolonged global ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Operating safely in an underdeveloped country.
The visiting surgical team doing cleft lip and cleft palate repair in an underdeveloped country may find long hours and adverse conditions. Some of the trips are undertaken for resident education. It is the responsibility of the expedition leader to implement safety precautions for protection of both the patients and the volunteers in the operative party as suggested in this article. Equipment maintenance and modified sterilization techniques are also described.
Airway Obstruction↗
Fingernail deformities secondary to ganglions of the distal interphalangeal joint (mucous cysts).
Twenty-six nail deformities secondary to ganglions of the distal interphalangeal joint were retrospectively reviewed to assess the important aspects of their management. The patients' ages ranged from 41 to 79 years. The long and index fingers were most commonly involved. A depression or groove was present in 23 of 26 digits reviewed. Two had gross disruption of the nail. Fifty-eight percent of the cysts had spontaneously drained or had been drained by the patient or a physician preoperatively. Degenerative arthritic changes were seen in 87 percent of those with x-rays or a radiology report available. Most underwent surgical removal of the cyst and debridement of associated osteophytes of the distal interphalangeal joint. The cyst was located above the germinal matrix in all but two digits. Osteophytes were found in all 20 digits in which the joint was explored. No recurrences were seen in those available for postoperative follow-up (22 of 25). Normal nail growth was found in 14 of 22, although follow-up was short in one. All eight postoperative nail deformities were quite mild and of little concern to the patient. There was no correlation between preoperative cyst drainage and aesthetic postoperative nail growth. Nail removal at the time of surgery appeared to be unnecessary unless the nail was grossly disrupted.
Adult↗
In vitro toxicity testing for antibacterials against human keratinocytes.
The use of cultured human keratinocytes in an in vitro comparison of topical antibacterial toxicity for epithelial cells was examined. The complement of three assessments allows testing of epithelial migration, growth, and survival. The three assessments included (1) flow cytometry for determination of cell survival, (2) a comparison of confluent cell culture growth after antibacterial exposures, and (3) an evaluation of cell migration using a technique of dermal explants to study radial migration. A comparative ranking of the toxicities of the various topical antibacterials was determined with the three assessments. This has confirmed anecdotal reports that many of the topical antibacterials are cell-toxic and may inhibit wound healing. This information can be directly extrapolated to the clinical setting, unlike many of the animal data for wound healing that currently exist.
Anti-Bacterial Agents↗
Leech therapy and bleeding wound techniques to relieve venous congestion.
Temporary restoration of capillary skin blood flow can be established by using leeches or by the creation of a dermal wound and the promotion of continued bleeding from the wound site in a flap with venous occlusion. An increasing restoration of capillary flow occurred with initial application of the leech and tended to exceed other techniques of restoring flow. However, all techniques of exsanguination, including leech therapy, restored very low perfusion over a two-hour course of therapy for a volume of tissue simulating a distal finger replant. The temporary increase in flap perfusion with a single leech application was greatest during the feeding activity of the leech and tapered off after the leech was satiated, to approximate flows achieved with local heparin injection and a punch wound.
Animals↗
Dysphagia associated with head and neck trauma: report of a case.
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Accidents, Traffic↗
The effect of acute hyperbaric oxygen therapy on axial pattern skin flap survival when administered during and after total ischemia.
The effect of hyperbaric oxygen (HBO) on axial pattern skin flap survival in male Wistar rats, when administered during and immediately following prolonged total flap ischemia, was evaluated. Eighty-one 3 x 6 cm rectangular epigastric skin flaps were elevated, and the inferior epigastric pedicle of each flap occluded for 8 hr. The animals were divided into a control and three other experimental groups: Control (n = 27) -8 hr flap ischemia, no HBO; Group (n = 21) - HBO therapy (100 percent O2--three 1.75 hr dives at 2.5 atm) during ischemia; Group 2 (n = 21) - HBO therapy (two 1.75 hr dives) following ischemia; Group 3 (n = 12) - HBO treatment during ischemia but with the flap contained in a metal-coated Mylar bag to prevent oxygen diffusion. The percentage of flap necrosis was calculated on postoperative day 6. Mean flap necrosis for controls was 28 percent (+/- 21 S.D.), while HBO treatment during ischemia or during reperfusion significantly reduced this necrosis to 9 percent (+/- 11) and 12 percent (+/- 14), respectively (p less than 0.01). The percentage of necrosis for Group 3, with the local with the local effect of HBO on the flap blocked by the diffusion barrier, was 5 percent (+/- 7), also significantly better than the controls (p less than 0.0005) but no different from the other two experimental groups. HBO treatment increases the percentage of axial pattern skin flap survival when administered during or immediately following total flap ischemia. The improved flap survival appears to be a systemic and not a local effect.
Animals↗
Mauling by pit bull terriers: case report.
A child with extensive soft-tissue defects following an attack by four pit bull terriers is presented. Some future procedures are required and she will have a permanent gait disability. The multidisciplinary management of this patient is described. The escalating problem of dog attacks in the United States is discussed. It is hoped that increased physician and public awareness will expedite the enactment and enforcement of effective vicious-dog legislation.
Animals↗