Experience with reduction mammaplasty following breast conservation surgery and radiation therapy.

Little is known about the outcome of breast reduction in the previously radiated breast. With the increased popularity of breast conservation in the management of breast cancer, it is inevitable that more women with breast cancer who have had a breast radiated will be seeking breast reduction. Although it would be expected that reduction of the radiated breast would be more challenging and would yield less-pleasing results, it has been unclear whether reduction in the radiated breast could be safely performed without interfering with mammography and cancer surveillance. Our experience using different techniques in three patients demonstrates that such reductions can be effectively and safely done if certain principles are followed. Pedicles should be designed to be broader and shorter than usual, and breast flaps should be undermined or elevated either minimally or not at all.

Closed rupture of the deep transverse metacarpal ligament: diagnosis and management.

Closed rupture of the deep transverse metacarpal ligament (DTML) is an unusual injury. We have managed 2 patients with closed rupture of the DTML between the ring and small fingers resulting from crush injuries to the hand. Both patients presented with painful ulnar deviation of the small finger with extension. The diagnosis was confirmed by exploration through a volar incision. Repair of the ligament with use of the adjacent A1 pulleys to butress the repair was successful in both patients and restored a painless finger flexion-extension arc. Closed rupture of the DTML can be confused with a metacarpophalangeal joint collateral ligament rupture due to the characteristic deviation of the small finger.

Use of multiple views in the echocardiographic assessment of pulmonary artery systolic pressure.

The purpose of this study was to determine which echocardiographic views most reliably demonstrate the maximum velocity of a tricuspid regurgitant jet in the evaluation of pulmonary artery systolic pressure. Consecutive patients seen in three echocardiographic laboratories during a 3-month period were enrolled. A complete Doppler examination was performed on each patient, including a continuous-wave Doppler evaluation of tricuspid regurgitation in each of seven views. All seven views were used to determine the maximum velocity of tricuspid regurgitation. Of the 1163 studies, 866 (75%) had some tricuspid regurgitation by color-flow Doppler and 614 (53%) had a measurable velocity of tricuspid regurgitation in at least one view. No single echocardiographic view consistently yielded the maximum velocity of tricuspid regurgitation. The apical four-chamber view alone was inadequate. All seven views must be used to be certain that the maximum velocity of tricuspid regurgitation has been obtained.

Anterior sacral meningocele and the scimitar sign. Report of a case.

Anterior sacral meningocele is an unusual lesion that usually presents as a presacral mass. This is a case presentation of a young woman who presented with amenorrhea. On physical examination, a large presacral mass was found. Ultrasonography revealed a large cystic structure. Radiography of the pelvis demonstrated a sacral deformity or "scimitar sign" that is pathognomonic for anterior sacral meningocele. The diagnosis was confirmed by computed tomography with myelographic enhancement.

A space-time model of health.

A space-time model of health requires a profound re-thinking of many of our basic tenets. This modern view of man and his world discards the traditional mechanistic paradigm which has been the focus of Western scientific thought and medicine. Stress related disorders are thought to be a result in part of an individual's perception of linear time. Holistic strategies such as biofeedback, relaxation skills, hypnosis, yoga, and imagery, to name a few, ask the individual to step outside linear or objective time by expanding their sense of experiential or subjective time and consciousness. It is suggested that training the time sense is a tool of holistic medicine and a space-time model of health.

Accelerated wound healing with stapled enteric suture lines. An experimental study comparing traditional sewing techniques and a stapling device.

The healing of 3-cm longitudinal colotomies closed with either Czerny-Lembert suture lines (CLSL) or TA-30 staple lines (SSL) were studied in 28 mongrel dogs using bursting strength (BS) measurements. Dogs from each group were sacrificed on postoperative days (POD) 1 through 7. Mean BS for the SSL in all 14 dogs was 165 mmHg +/- 64 and for CLSL 80 mmHg +/- 49 (DF = 13; t = 5.5672; p less than 0.00005 for matched pairs). For POD 2 through 5, BS of the SSL was 154 mmHg +/- 42, three times greater than the BS of the CSLS, which was 54 mmHg +/- 33 (DF = 7; t = 5.6289; p less than 0.0004 for matched pairs). BS of the SSL increased linearly from the first day of surgery: BS (mmHg) = 26 (POD) + 61 (n = 14; r = 0.838; p less than 0.01). BS of the CLSL followed the traditional pattern of wound healing dropping to a nadir after 3 days and then increasing linearly: BS (mmHg) = 32 (POD) - 72 (n = 10; r = 0.834; p less than 0.01). Microscopic examination revealed a greater inflammatory response to the CSLS than the SSL. Differences were most marked from 2 to 4 days following operation. Thus, the SSL healed more rapidly than the CLSL as measured by BS. The SSL healed with a negligible Lag Period of wound healing entering directly into the Period of Fibroplasia.

Cecal volvulus. Low mortality at a city hospital.

The case records of 12 patients with cecal volvulus over a 20-year period were reviewed. The patients averaged 46.7 years old; 75 per cent were white and 67 per cent were male. Patients presented with signs and symptoms of intestinal obstruction. Pain and distention were present in more than half of the patients. X-rays assisted in making the diagnosis of cecal volvulus in only five of the patients. Diagnosis was made in the remainder at the time of surgical exploration. At operation, one cecum was necrotic and required resection. Five patients underwent cecostomy, two cecopexy, and four simple detorsion. Post-operatively, one patient developed a wound infection. There were no deaths. Follow-up for seven patients averaged 75 months each. One patient who had undergone simple detorsion developed another cecal volvulus. All who were contacted were alive and well. At St. Luke's Hospital, cecal volvulus generally occurs in middle-aged white males. Cecostomy or cecopexy adequately treats cecal volvulus when the cecum remains viable. This study demonstrates that prompt surgical intervention, before strangulation of the colon occurs, results in low mortality even in city hospital patients.

Synergistic management: the task of the flight nurse.

In general, it is an accepted fact that the task of management is to design and maintain an environment for the effective and efficient performance of individuals working together in groups toward the accomplishment of preselected missions and objectives. The creation of a synergistic environment is considered as one conductive for meeting this goal of management. The barriers to creating such an atmosphere are many, but the benefits of such efforts are greater in terms of creating the climate for superior performance. According to Doctoroff, a synergistic organization is characterized by a sense of internal harmony which enables people to work with a feeling of fulfillment. It enables them to enjoy what they do, cope with change more easily, and expend less energy to achieve meaningful work. The key prerequisites for synergy are trust, effective communication, rapid feedback, and creativity. An analysis of how this concept may be useful to Aerovac Nursing will be explored. Aware of the contributions of support systems, the task of managing a successful client-provider environment rests with the medical crew director--the flight nurse. Establishing trust, controlling for random communication, and facilitating feedback are some of the facets of this task. With this framework in mind, alternatives to traditional methods of management become possible, for "new" ways are being sought to aid those in managerial positions in meeting the challenges of their roles.

Gastric ulceration associated with larval nematodes (Anisakis sp. type I) in pen reared green turtles (Chelonia mydas) from Torres Strait.

During turtle farming operations in Torres Strait, green turtles (Chelonia mydas) penned on Murray Island became infected with a larval nematode (Anisakis sp. Type I). The larvae were found associated with haemorrhagic ulcers in the pyloroduodenal junction of the alimentary tract. The apparent source of infection was a locally abundant sardine (Harengula ovalis), on which the Murray Island turtles were fed. Turtles held on other islands in the region were not fed sardines and remained uninfected. Recommendations were made to prevent further infection.

Field interactions in aerovac nursing.

The purpose of this paper is to analyze the mutual, reciprocal action or influence between man and his environment. More specifically, an attempt will be made to view aeromedical evacuation as an airborne environmental field interacting with the human field, the patient. The aeromedical evacuation aircraft is the environmental field in which the medical crew members apply and adapt the principles of aerospace medicine to the inflight care of patients, the human field. Thus, an aim of aeromedical evacuation nursing is to promote the synergistic interaction between man and his environment. The conceptual background of this paper is based on the work of a nurse theoretician, Dr. Martha E. Rogers. Her assumptions about man, her principles of homeodynamics, and her goals of nursing service and practice seek to promote the synergistic interaction between man and environment; to strengthen the coherence and integrity of the human field; and to direct and redirect patterning the human and environmental fields for the realization of maximum health potential. By looking at some of the stresses of flight--altitude physiology and sensory alterations--within this conceptual framework, it is hoped an elementary analysis will generate testable hypotheses regarding patient care. Strategies for improving the quality of care given by the medical crew to aeromedical patients are continually sought.

The nursing explosion-technology, knowledge, and practice: its implications for leadership in aerospace nursing.

Authorities agree that we are experiencing a tremendous upheavel in numerous fields of endeaveor, health care in particular, resulting from the rapid growth of human information and capabilities since the 1950s. This upgrowth has touched nursing. This nursing explosion, in terms of technological advancement, increased knowledge, and expanded practice, demands the leadership of aerospace nursing to reexamine it posture and direction. A fresh look at its past and present successes and failures is essential to meet the challenges of the future. For "not to decide is to decide". There are two basic assumptions which underlie this challenge for leadership caused by the nursing explosion. First, as a self-directing profession, nursing can define its philosophical base, determine its goals, and identify the means for attaining those goals. Second, as the largest of the health professions, nursing has the right and responsibility to respond to the quantity and quality of global health care delivery systems. The analysis of this challenge for leadership shall be attempted in the light of three perspectives--organizationally, socio-politically, and professionally. The nursing explosion has dramatized the realization that nursing has the knowledge, power, resources in numbers, and dedication to service to move health care systems in the direction necessary. As Prof. Bell of Harvard has noted, the current revolution of rising entitlement to health care will have a marked influence on the nursing effort and vice versa. The call to leadership "a loud call and a clear call and it cannot be denied."

Systems analysis of an aeromedical evacuation mission.

The author applies general systems theory to the analysis of a social system. Through an examination of information processing in an aeromedical evacuation mission, more meaningful levels of coordination evolve. Thus system analysis, as applied here, is an approach used to not only describe an organization but, more importantly, to clearly discern the interrelationships inherent in an activity of major significance such that change or improvement, if needed, may the more readily result.

Cartilage hair hypoplasia.

Six cases of cartilage hair hypoplasia from five kindreds are described. They demonstrate variation in the expression of clinical features such as sparsity of hair, hair calibre, radiological changes, short stature and the extent of the disproportion between sitting height and stature.