Biomedical subjects
Publications and source records attributed to L S Nichter.
A small segment of universally available and inexpensive rubber catheter can be easily fitted to insulate electrocautery tips. This technique can prevent numerous thermal injuries and potential litigation arising from accidently burning adjacent tissues. The routine use of this modification in the operating room can save time, anxiety, and potential litigation by preventing misplaced cauterization.
Treatment of tinea capitis consists of a 5-week course of griseofulvin. A 1-week course of a systemic corticosteroid may be considered in addition to griseofulvin therapy to accelerate the subsidence of inflammation in kerion lesions. Kerion is an inflammatory form of tinea capitis which may progress rapidly into a fulminant infection if untreated. This case report underscores the need for prompt recognition and appropriate treatment of this disorder.
The use of the omentum as a source for vessel grafts is recommended when long or multiple vessel conduits are needed and when a combination of vessel grafts and soft tissue are needed. It is particularly suitable in reconstructing the superficial palmar arch but may also provide an immense graft reserve for the imaginative and careful surgeon.
Pseudofolliculitis barbae is a common cutaneous infection occurring in the bearded area of the face of black men. The infection is caused by ingrown hairs that produce an inflammatory foreign body reaction characterized by papules and pustules at the point of hair penetration that may result in permanent scarring, usually in grooved patterns, and occasionally in keloids. The purpose of this article is to describe the successful treatment of a patient with pseudofolliculitis with keloids that was based on the pathophysiology of the disease and the biology of wound repair.
Much research effort has attempted to identify pharmacological agents that will augment random skin flap survival. Unfortunately, the vast majority of these agents have been administered preoperatively, and as such their routine use is not often justified. Ibuprofen administered in the postoperative period significantly augments random skin flap survival in the rat.
Many congenital cranial vault deformities are only incompletely corrected by currently available surgical techniques. The supplementary use of external cranial vault molding devices after these surgical techniques, however, has resulted in consistently improved cranial vault from over what could be achieved by operation alone. These devices are inexpensive, easily individualized to abnormal skull shapes, and well tolerated by young patients.
Selective external cranial vault remodeling has been practiced since antiquity. The variations, methods, and desired results of external cranioplasty are as pervasive as the practice is old.
This article is a collective review of all the prospective clinical studies that assessed the therapeutic value of antibiotics in minor soft tissue lacerations. This review critically evaluates each study that tests the hypothesis that antibiotic treatment reduces the incidence of infection. Even though the design of each of the studies was scientifically inadequate, important factors were identified that influenced the incidence of infection. On the basis of this collective review as well as other studies, indications for antibiotic therapy of minor soft tissue lacerations have been identified. Future clinical studies must be designed to test more precisely the validity of these recommendations.
Toxic epidermal necrolysis (TEN) is a symptom complex characterized by a devastating skin disorder, erosive involvement of two or more mucous membranes, and severe constitutional symptoms. The disorder shares features with erythema multiforme and is thought to be an expression of the syndrome. Although a wide range of etiologic factors have been incriminated in TEN, only a few cases have provided convincing evidence of a direct causal link. Most cases of TEN have been associated with drug administration.
New guidelines on tetanus prophylaxis in wound management have been prepared by the American College of Surgeons and are available in a poster format or in bulletins. The purpose of this study was to determine the impact of these educational brochures on tetanus prophylaxis in a hospital setting. The results of this study indicate that these informational brochures and posters had insignificant impact on the quality of prophylaxis against tetanus in our hospital. Innovative programs of information exchange and quality assurance are urgently needed to improve the delivery of health care.
A simple, inexpensive, reproducible, and reliable model for digital replantation is described utilizing the rabbit ear. When compared to the human digit, it provides benefits over previous models. It is of similar tissue type and characteristics. The vessels closely approximate the digit in size and number. Results are easily quantified and the opportunity for a paired control in the same animal exists. Therefore, experimental design and statistical calculations may be simplified. The model can function for either replantation or revascularization with only slight changes in its preparation. Survival rates have been over 90%. In addition, the model provides an excellent forum for the development of technical expertise in the aspiring microvascular surgeon.
The results of our experiment prove that arterialized venous perfusion is a viable means of nourishing complex composite tissue without using the arterial tree. Previous laboratory findings, coupled with the results of this experiment, demonstrate that as long as proximal arterial inflow is ensured, both the arterial and venous trees need not be intact to keep tissue alive. Rather, it seems that the prerequisites for tissue survival are that at least one of the two systems be intact and that there be sufficient inflow and outflow channels available. Whether these channels are arteries or veins is probably not important. The use of properly placed efferent or afferent arteriovenous fistulas allows one system to provide both physiologic functions. Whether the efferent arterial anastomosis stays open over the long term appears to be inconsequential. Survival is ensured by either direct perfusion with oxygen delivery through the venous tree or through the eventual ingrowth of recipient vessels into the flap by way of the delay phenomena. This perfusion technique is ideally suited for tissue with an inadequate arterial tree but with an intact venous system devoid of venous valves (most veins less than 1.5 mm in diameter). A well-vascularized recipient bed capable of providing vessel ingrowth into transferred tissue may be important in the case of delayed arteriovenous fistula occlusion secondary to intimal hyperplasia; therefore, further experimental study of these flaps must be undertaken before arterialized venous flaps can be recommended for placement in recipient sites compromised due to radiation, ischemia, diabetes, or other causes of small vessel disease in the recipient bed. Although efferent arteriovenous fistulas are currently used to provide arterialized venous perfusion in selected cases of end stage arterial occlusive and vasospastic disease, perhaps their greatest role is in the management of tissue transfer with an inadequate arterial tree. Much knowledge must be gained to understand the physiologic principles and requirements for optimal perfusion. Many questions are left unanswered. For example, in those arteriovenous fistulas that narrow or occlude secondary to neointimal hyperplasia or other causes, which channels (veins or arteries?) are used for perfusion during recipient vessel growth? Can intimal hyperplasia be reversed or prevented by drug therapy and would this be advantageous? Can venous valves be made incompetent so that this technique can be used for larger vessels?(ABSTRACT TRUNCATED AT 400 WORDS)
An accurate estimation of burn surface area is needed to correctly calculate initial fluid resuscitation, nutritional requirements, prognosis, and comparisons of treatment protocols among burn centers. The following experiment was conducted to test the accuracy of physicians compared to a computer-assisted method. Twenty-seven physicians were asked to estimate the per cent of burned surface area from an adult patient diagram. Physicians were found to consistently overestimate the percentage of burned surface area. The average physician estimate was 42% compared to 29.6% calculated by a computer-assisted program. The degree of error between physician estimates and actual TBSA burned is significant and may critically affect patient management. Additional benefits of computer assistance include a permanent record of injury, burn wound trend analysis, and meaningful statistics involving morbidity, mortality, and comparative treatment protocols among burn centers.
Power lawnmower accidents are one of the most frequent causes of mutilating injuries in pediatric patients. Guidelines for the optimal surgical management of children differ from adult patients by several key anatomic, physiologic, and rehabilitative features. Small blood vessels in children less than 2 years old may prohibit microvascular surgery. Older children with larger vessels are often better candidates for microvascular flaps than their adult counterparts. Pediatric patients also resist recurrent ulceration of foot skin grafts, tolerate prolonged immobilization, and are rehabilitated more readily than adults. In considering these facts, we outlined an algorithm for surgical reconstruction. Split-thickness skin grafts are generally the first choice for coverage. The medial gastrocnemius is the workhorse of the knee and upper third leg. The soleus provides coverage for the middle third leg; microvascular flaps are used for large lower third leg defects. Crossleg fasciocutaneous flaps are good alternatives when microsurgery is not feasible. When possible, the weight-bearing surface of the foot should be covered with local vascularized sensate flaps; larger defects may require free flaps, crossleg, or gluteal-thigh flaps. Excellent functional rehabilitation has been achieved in our young patients through the combined efforts of the trauma service, plastic and orthopedic surgery, and physical and occupational therapy services.
Inadequate venous outflow is the factor most responsible in digital replantation failure and is a common cause of tissue loss in general. An experimental replantation model utilizing the rabbit ear was used to study the extreme example of venous congestion: absent venous drainage in the replanted part. Results of this study support the use of single arterial inflow along with an efferent AV fistula for outflow in the management of replants with absent venous drainage. Potential indications for the use of an efferent arteriovenous fistula in digital revascularization include the following: (1) the finding of distal veins too small to reanastomose, as is often the case in children and at distal levels in adults; (2) preferential destruction of distal venous structures, as commonly seen in degloving or other dorsal injuries; and (3) in the management of postreplant venous thrombosis.
The efficacy of topical nitroglycerin in the augmentation of random-pattern skin-flap survival was studied. Our model consisted of a standardized cranially based random skin flap on the dorsum of Sprague-Dawley rats. Nitroglycerin was delivered transdermally through a semipermeable membrane from a constant delivery system. The four study groups included preoperative and postoperative nitroglycerin, postoperative nitroglycerin, semipermeable membrane alone, and a control flap. Surviving flap areas were measured by a computer-assisted system, and groups were statistically analyzed for significance. In the rat model, treatment of a compromised random skin flap by topical nitroglycerin demonstrates no improvement in survival. In light of previous studies, this suggests a fundamental drug response difference between axial- and random-pattern skin flaps. Moreover, the use of a semipermeable membrane dressing alone showed a clear benefit (p less than 0.05) over nitroglycerin-treated and control animals.
A user-friendly computer-assisted method of calculating total body surface area burned (TBSAB) has been developed. This method is more accurate, faster, and subject to less error than conventional methods. For comparison, the ability of 30 physicians to estimate TBSAB was tested. Parameters studied included the effect of prior burn care experience, the influence of burn size, the ability to accurately sketch the size of burns on standard burn charts, and the ability to estimate percent TBSAB from the sketches. Despite the ability for physicians of all levels of training to accurately sketch TBSAB, significant burn size over-estimation (p less than 0.01) and large interrater variability of potential consequence was noted. Direct benefits of a computerized system are many. These include the need for minimal user experience and the ability for wound-trend analysis, permanent record storage, calculation of fluid and caloric requirements, hemodynamic parameters, and the ability to compare meaningfully the different treatment protocols.
Coagulase-positive staphylococci of phage group II produce an epidermolytic toxin that results in a spectrum of diseases that include localized bullous impetigo, generalized scarlatiniform syndrome without exfoliation, and staphylococcal scalded-skin syndrome (SSSS). The mechanism of action of the toxin occurs at the level of the lower stratum granulosum, resulting in intraepidermal cleavage. Generalized exfoliative dermatitis, or SSSS, is one of the most severe infections characterized by generalized epidermolysis with desquamation. Generalized scarlatiniform syndrome is an erythematous rash without exfoliation. A localized infection that results in a bulla larger than 5 mm in diameter is bullous impetigo.