Preoperative management of the amputated limb.

Little literature exists on storage and preparation of an amputated limb prior to transfer to a reconstructive plastic surgical unit for possible macroreplantation. This paper describes practical measures used to prolong ischaemia time allowing macroreplantation, tissue harvesting, or fashioning of a useful stump. A simple protocol is used to summarise these points.

Free ulnar artery forearm flap: a modification.

We describe a modification of the free ulnar artery forearm flap that has the benefit of the anastomosis of large-calibre vessels and the reassurance of a reconstructed ulnar artery for perfusion of the donor hand.

Predicting completion of a cognitive-behavioral pain management program by initial measures of a chronic pain patient' s readiness for change.

OBJECTIVE: There is a need to identify pretreatment patient indicators, which are predictive of the successful enrollment and completion of chronic pain treatment programs. Recent evidence suggests the Pain Stages of Change Questionnaire can predict enrollment and completion of a 10-session cognitive-behavioral pain management program. The purpose of this study is to determine whether the pretreatment Stages of Change Questionnaire can predict patients who would complete a cognitive-behavioral pain treatment program. DESIGN: Prospective cohort study using logistic regression analyses. SETTINGS: Patients referred for a 10-session cognitive-behavioral treatment program at a tertiary care multidisciplinary pain clinic or a community-based specialty clinic. SUBJECTS: Three hundred chronic pain patients (151 in the tertiary setting and 149 in the community-based setting) participated, with 147 of the patients (49%) completing and 153 (51%) patients not completing the 10-session program. INTERVENTION: Ten-visit cognitive-behavioral program for chronic pain patients. OUTCOME MEASURE: Completion of program. RESULTS: The Stages of Change Questionnaire scores could predict completion status chi2 (N = 300, 2 df) = 39.7, p <0.001, (goodness-of-fit test chi2 = 5.69, p = 0.68). Those patients completing the program were slightly older and reported higher levels of pain, depression, and disability than did those patients who did not complete. Low "Precontemplation" score remained the best single predictor, as it identified correctly 61% of the cases patients who completed the program and predicted who would drop out in 65% of the cases. CONCLUSION: The Stages of Change Questionnaire is a potentially useful tool; however, the current scoring method is insufficient to recommend its use as an inclusion or exclusion criterion for enrollment in a cognitive-behavioral program.

The mediation of disability by self efficacy in different samples of chronic pain patients.

PURPOSE: A path analytic model conceptualizing self efficacy as a mediator of disability was tested. This model could help explain the circumstances under which disability develops more in some chronic pain patients than in others. METHOD: Questionnaires from 479 chronic pain patients were collected prior to an initial consultative visit with a pain specialist at three pain clinics. These patients represented three separate samples. One sample from a tertiary care hospital (n = 226), one from a community-based clinic (n = 137) and a third sample from combined settings, but excluding patients with a history of depression prior to the onset of their pain (n = 116). Hypothesized and alternative models were tested to identify the model best fitting these data. RESULTS: Regression analysis supported self efficacy as a mediator of the relationship between pain intensity and disability (p < 0.001) in all three groups. This model was best supported in the group with no prior depression (accounting for 47% of the explained variance in disability). The 'no-prior depression' group was different than the other samples in that depression did not contribute to disability in this sample where prior depression was not controlled for. CONCLUSION: Self efficacy in an important variable contributing to the disability of chronic pain patients. Therefore, evaluating and bolstering the patient's belief in their own abilities may be an important component of therapy.

Altered growth regulation and loss of response to retinoic acid accompany tumorigenic transformation of prostatic cells.

In vitro models of human prostatic carcinogenesis are increasingly available and include representatives of normal, immortal, tumorigenic and metastatic phenotypes. In this study, growth regulation of immortal, but non-tumorigenic, human papillomavirus-transformed prostatic epithelial cells was compared to that of their tumorigenic variants. These variants were created either by exposure to a carcinogen or by passage through mice. In all cases, tumorigenic cells retained responsiveness to a potent mitogen, epidermal growth factor, and to a potent growth inhibitory factor, 1,25-dihydroxyvitamin D3. Responses to other growth regulatory factors were altered. One set of transformants, CA-HPV-10 and its tumorigenic variants 5019 and 5019IIc, lost their requirement for insulin-like growth factor. Another set, RWPE-1 and its tumorigenic variant 129Nu5002-1 Tu, became unresponsive to growth inhibition by transforming growth factor-beta. The only alteration uniquely correlated with the tumorigenic phenotype was loss of response to retinoic acid. This factor, which inhibits growth of normal and immortal but non-tumorigenic prostatic epithelial cells, had no effect on tumorigenic 129Nu5002-1 Tu cells. We previously reported that conversion of an SV40-immortalized prostatic epithelial cell line to tumorigenicity by introduction of the ras oncogene also resulted in loss of responsiveness to growth inhibitory activity of retinoic acid. 129Nu5002-1 Tu cells, which do not have an altered ras gene, gained the same phenotype. This suggests that loss of inhibition by retinoic acid may be a critical element in the tumorigenic conversion of prostatic epithelial cells.

A cheap, disposable external fixator for comminuted phalangeal fractures.

Reduction of a severely comminuted fracture of a long bone in the hand can be difficult to hold. An external fixator can be the best method of maintaining satisfactory reduction in such fractures. A small, disposable external fixator is described, made from a syringe barrel and K-wires. It allows accurate reduction with minimal soft tissue trauma and is easy to construct and apply. It allows early mobilization of the digit and is inexpensive.

Use of a vertical rectus abdominis myocutaneous flap in bilateral groin dissection for recurrent carcinoma of the penis.

We present a 42-year-old man requiring bilateral groin dissection for recurrent squamous cell carcinoma of the penis. Tissue cover was obtained using a pedicled vertical rectus abdominis myocutaneous flap. This case is made interesting by the use of a unilateral flap to cover a large bilateral lower abdominal tissue defect, enabling minimal weakening of the abdominal wall, primary skin closure, and allowing early mobilization and hospital discharge.

Meeting the needs of unpartnered elders: a peer training program involving elders with myocardial infarction.

Myocardia infarction (MI) is the leading cause of death in elderly adults. For those elderly who do recover, results are less than optimal when compared to those seen with younger patients. With a shortened length of stay in hospitals for elderly MI patients, and an increase in life expectancy that leads to an estimated 33 million elders in the U.S. population, there is a growing community-based population of elders who are recovering from MI. The use of elders as peer advisors has been demonstrated to be a cost-effective method of promoting health and enhancing recovery, with only a modest investment of the professional healthcare provider's time and money. An innovative, low-cost intervention matches recent MI elders who are unpartnered--and at higher risk for morbidity and mortality than partnered elders--to a peer advisor who has also survived acute MI in the past.

The neuroplastic phenomenon: a physiologic link between chronic pain and learning.

Recent advances in the understanding of how the mind works is the result of painstaking research which has isolated tiny regions of the spinal cord and brain, and singular chemical pathways or responses to sole neurotransmitters. The true nature of the central nervous system has eluded investigators because of its fully integrated, constantly changing structure and a symphony of chemical mediators. Each sensation, thought, feeling, movement and social interaction changes the structure and function of the brain. The mere presence of another living organism can have profound effects on the mind and body through imperceptible olfactory stimuli. Neuroplasticity is a general term referring to the ability of neurons to alter their structure and function in response to internal and external stimuli. Although differences occur with aging, this is a lifelong process. Physical and chemical neuroplastic changes occur with learning, memory and chronic pain. Evidence presented supports the notion that chronic pain is a maladaptive learned phenomenon. Further evidence supports that if severe pain is allowed to persist for more than 24 hours, the neuroplastic changes associated with the development of incurable chronic pain syndromes begin to take place. Even after chronic pain is well established, new thought and behavior patterns can be learned, allowing sufferers to restore more adaptive physiologic, cognitive and behavioral patterns.

Phaeohyphomycosis caused by Exophiala dermatitidis following intra-articular steroid injection.

A patient with long-standing rheumatoid arthritis presented with a painful pigmented chronic nodule on the dorsum of the right hand, at the site of intra-articular steroid injections undertaken 5 years previously. Histology showed pigmented fungal elements consistent with phaeohyphomycosis. Cultures yielded black yeast-like colonies, identified as Exophiala dermatitidis and sensitive to itraconazole and amphotericin. A 1-month course of itraconazole resulted in marked clinical improvement but surgical excision and skin grafting were required for complete resolution. Phaeohyphomycosis has been related to inoculation injury but association with intra-articular steroid injection appears hitherto to be unreported.

Women and heart attacks: prevention, diagnosis, and care.

Despite being viewed as a male health problem, more women die from heart disease than men. The literature and preliminary research data reviewed clearly support that gender differences exist. The higher prevalence of myocardial infarction in older women and those with other known risk factors suggests the etiology, pathophysiology, and treatment is the same as for men. Differences in socioeconomic status, psychosocial profiles, presenting symptoms, disease progression, and a poorer response to treatment suggests that myocardial infarction in women is not fully understood. Women need to know they are at risk and not delay seeking treatment for subtle but important symptoms. Assessment strategies that take into account the woman's body, personal profile, and the female pattern of variant angina, non-Q wave, nonocclusive infarction are reviewed. Considering the literature that links social support with survival, mobilizing support to help the women direct energies to her own recovery becomes a necessary intervention. Implications to health teaching, diagnostic testing, diagnosis, referral, and the effective management of women with myocardial infarction are delineated.

Stepwise immortalization and transformation of adult human prostate epithelial cells by a combination of HPV-18 and v-Ki-ras.

Recent investigations have shown the presence of ras gene mutations and human papillomavirus (HPV) DNA in prostate carcinomas. In the present study, secondary adult human prostatic epithelial cells, upon transfection with a plasmid containing the entire HPV-18 genome, acquired an indefinite life-span in culture but did not undergo malignant conversion. Subsequent infection of these immortalized cells with the Kirsten murine sarcoma virus, which contains an activated Ki-ras oncogene, induced morphological transformation that led to the acquisition of neoplastic properties. These findings demonstrate the malignant transformation of adult human prostate epithelial cells in culture by a combination of viral oncogenes and the successive roles of HPV infection and Ki-ras activation in a multistep process responsible for prostate carcinogenesis.

The risk from radiation exposure during operative X-ray screening in hand surgery.

In response to legislation concerning the use of ionizing radiation, and to a case in which a patient developed multiple skin malignancies as a result of over-exposure to ionizing radiation, we set up an investigation to attempt to quantify the radiation dosage to which theatre personnel are exposed during X-ray fluoroscopy (screening) in hand surgery. It was found that the risk was small if sensible precautions were taken, but increased significantly if they were ignored. From these results specific measures are outlined which, when implemented, reduce the dose of scattered radiation to which theatre personnel and patients are subjected during screening in hand surgery.

Characterization of a human Kaposi's sarcoma cell line that induces angiogenic tumors in animals.

OBJECTIVE: To characterize a Kaposi's sarcoma (KS) cell line established from a tumor biopsy from the oral mucosa of an iatrogenically immunosuppressed HIV-negative man. METHODS: Cells were placed in culture and evaluated by a variety of biologic, serologic, karyotypic, and immunologic procedures. Electron microscopic examination was performed. The ability to produce tumors in nude mice was evaluated, and the nature of the cells within the tumor determined. Assays for urokinase plasminogen activator type (uPA), plasminogen activator inhibitor-1 (PAI-1) and the urokinase receptor (uPAR) were conducted. RESULTS: The SLK cell line has an endothelial cell morphology with very little anaplasia. The karyotype indicates diploid phenotype of human origin. Immunohistochemical and electron microscopic examinations confirmed the endothelial nature of this cell line. No viruses were detected. The tumors induced in nude mice showed hypervascularization, with characteristics of KS. The cell line produces uPA and PAI-1, and also expresses uPAR. CONCLUSIONS: The SLK cell line is of endothelial cell origin and the first human cell line to induce KS-like tumors in recipient animals. The expression of urokinase and its receptor suggests a paracrine and autocrine interaction that may be important for the growth of the tumor. The SLK line should be valuable for studies of KS pathogenesis and therapeutic approaches to this malignancy.