Installing systems successfully in managed care organizations.

The installation of a new administrative system is a tremendous undertaking for any organization, affecting every area of the operation. Often, because of time and budget constraints as well as the perception that change is not immediately necessary, many organizations wait until there is no option but to change systems--then make the changes under short time frames. For a large, multisite organization, the issues are the same but the complexity increases tremendously.

Maffucci's syndrome (hemangiomatosis osteolytica): a report of four cases.

Maffucci's syndrome is a congenital nonfamilial syndrome combining dyschondroplasia, (enchondromatosis) and hemangiomatosis. It is a rare disease; only 200 cases have been reported throughout the world in the past 140 years. Over the past 20 years, four patients have been admitted with signs and symptoms consistent with Maffucci's syndrome. Three were children ages 3, 7, and 9 years. The fourth was 23 years old. Two were male and two female. All had hemangiomas at birth, and all had skeletal deformities and enchondromas. All complained of pain and heaviness of the involved extremity. Three patients had the arterial inflow evaluated with arteriograms, and one had magnetic resonance imaging. Two also had venograms. Two patients had excision of their hemangiomas, and one had sclerotherapy and compression therapy. All had bone biopsies performed. None of the enchondromas or the soft tissue lesions had undergone sarcomatous transformation.

Vascular rehabilitation: benefits of a structured exercise/risk modification program.

A vascular rehabilitation program was designed to increase exercise tolerance and reduce the risk of cardiovascular disease in patients with lower extremity arterial occlusive disease. Sixty-eight patients (32 men, 36 women); ages 55 to 85 years (mean, 68 years) with claudication 30 (44%), or recovering from lower extremity revascularization 36 (53%), or endovascular procedures 2 (3%) entered the vascular rehabilitation program. Each underwent a physical examination, risk factor assessment, noninvasive arterial studies, and cardiac evaluation. A history was taken from each patient also. Six patients (9%) were excluded on recognition of silent myocardial ischemia. Sixty-two patients (91%) were accepted for exercise training in a program designed to offer 24 (1-hour) monitored exercise sessions, 12 (1-hour) personalized education lectures, and development of a home maintenance exercise program. No deaths or major morbidity occurred. Seventeen patients (27%) did not finish the program, eight (13%) because of development of significant cardiac, extremity, or cerebrovascular disease and nine for nonmedical reasons. Of the 45 patients (73%) who completed the program, 38 (88%) had documented increases in walking distances of greater than 100% (122% to 450%). All 45 patients designed home exercise programs, and 88% of the smokers quit. Long-term follow-up was available on 100% of the patients. Thirty-eight patients (84%) have been followed for 2 years or more. Thirty-eight (84%) maintained or improved walking distances recorded on exit from the program. Thirty of the 36 patients (83%) who stopped smoking remained nonsmokers. Significant reductions in cholesterol were seen at 1 year, and significant reductions in triglycerides were seen at 12 weeks and 1 year.(ABSTRACT TRUNCATED AT 250 WORDS)

Descending thoracic aneurysm rupture with a known abdominal aortic aneurysm.

The association of abdominal aortic aneurysms with aneurysmal disease of the thoracic aorta is well established. However, rupture of a descending atherosclerotic thoracic aortic aneurysm in association with an infrarenal abdominal aortic aneurysm can present a difficult diagnostic and therapeutic problem to the treating physician. This article presents a case of rupture of an atherosclerotic descending thoracic aortic aneurysm in the face of what clinically appeared to be a leaking or ruptured abdominal aortic aneurysm.

Lower extremity lymphocele development after saphenous vein harvesting.

Damage to the lymphatic vessels may occur after surgery on the greater saphenous vein. We describe the development of a lymphocele in a patient after saphenous vein harvesting for a coronary artery bypass graft. Treatment of these lymphoceles should initially be conservative, but if this approach fails, surgical excision should be performed and special attention paid to identifying and ligating the feeding lymphatic vessel.

A technique for correction of carotid kinks and coils following endarterectomy.

This study presents a technique to correct kinking or coiling of the internal carotid artery using patch angioplasty following endarterectomy, resection, and anastomoses of the vessel. Since 1984, 579 carotid endarterectomies have been performed with 19 patients (3.3%) having arteriosclerotic carotid bulb and internal carotid artery disease associated with a carotid kink or coil. These have been treated successfully using the technique of resection and patch angioplasty. The indications for surgery included seven patients with transient ischemic attacks (36.8%); seven patients who had suffered a cerebrovascular accident (36.8%); amaurosis fugax in two patients (10.5%); and one patient each with Hollenhorst plaque (5.3%), central retinal artery occlusion (5.3%), and an asymptomatic critical stenosis (5.3%). All patients had successful repair of the vessel using saphenous vein or Dacron patch angioplasty. There were no perioperative strokes or deaths. Follow-up ranged from four months to 58 months (mean 25 months). All vessels are patent with no evidence of stenosis. One patient had an ipsilateral cerebrovascular accident but had no evidence of recurrent carotid disease. Surgical correction of the carotid kink or coil can present a difficult surgical problem, and resection, fixation, or transposition can be complicated. The technique of endarterectomy, resection of the redundant vessel with anastomosis of the back wall, and patch angioplasty has been used effectively and safely in this series of patients.

The methodology of liposuction surgery.

The author has attempted to analyze the physical characteristics of liposuction surgery. By categorizing liposuction surgery into various types of procedures, the dermatologic surgeon can describe and elucidate the manner of performing liposuction in each anatomic region. The procedures for fat tunneling and harvesting and cannula manipulation will aid in the teaching and understanding of liposuction surgery.

An easy method for diagnosis of lymphedema.

Lymphoscintigraphy has been very useful in determination of lymphatic abnormalities. However, the radioactive isotopes used have been investigational and difficult obtain. The purpose of this study was to examine patients with extremity edema by lymphoscintigraphy using a radioactive colloid readily available in our nuclear pharmacy, Technetium 99m sulfur minicolloid. Forty limbs in 20 patients were evaluated using Technetium 99m sulfur minicolloid lymphoscintigraphy. All patients had lower extremity edema initially attributed to a venous or lymphatic etiology. There were 12 patients with normal bilateral studies. Seven patients exhibited unilateral obstruction to lymphatic flow, and one had unilateral enhanced flow of lymph. Those with normal studies included five patients with nonspecific edema, four with varicosities, and one patient each with acute deep vein thrombosis, chylous ascites, and excision of the greater saphenous vein for arterial bypass grafting. Five patients with obstructed patterns had previous arterial bypass procedures, one had trauma to the extremity, and one had lymphedema tarda. The one enhanced lymphoscintigraphic pattern was seen in a patient with acute cellulitis. All patients had Doppler venous examinations and other studies included strain gauge phlethysmography, venograms, computed tomography, magnetic resonance imaging, and ultrasound. As with other scintigraphic imaging agents used to study lymphatic flow, Technetium 99m provides clinically useful information in evaluating the swollen extremity noninvasively.

Popliteal artery entrapment: an evolving syndrome.

Popliteal artery entrapment can result in claudication and limb-threatening ischemia in the young adult. The purpose of this study was to evaluate prospectively those patients with popliteal artery entrapment. To define the syndrome, the methods used in diagnosis and the type of anatomic anomaly were established for each patient. From 1977 to 1988, 12 patients were found to have popliteal artery entrapment. The average age was 27 years, with all but three patients under age 40 years. All patients complained of calf claudication, and one had acute ischemia. The ankle pulses decreased with maneuvers in 10 patients; four patients had a resting ankle/brachial index less than one. All had diminished ankle/brachial indexes when a treadmill test was performed at 4.2 mph, 10% grade, for 10 minutes. All patients had biplanar arteriography with passive dorsiflexion and active plantar flexion. All results showed abnormal extrinsic compression or occlusion of the popliteal artery. Twenty limbs were affected; eight of 12 patients (67%) had bilateral entrapment. Type IV (37%) lesions were the most common, with type II (32%) and type III (26%) following closely. One (5%) type I lesion and no type V lesions were found. This is the largest single series of patients with popliteal entrapment in the United States. A treadmill test followed by biplanar arteriography established the diagnosis in all patients. Bilateral involvement was twice that reported in previous studies. Popliteal artery entrapment should be considered in the young adult with claudication and may be seen with greater frequency in an increasingly active population.

Trichloroacetic acid peels revisited.

Trichloroacetic acid (TCA) is a time-honored peeling agent that has no known systemic toxicity. Recent interest in reversing the effects of actinic damage has led to the utilization of combination therapies. Retinoic acid, solid CO2, pyruvic acid, Jessner's formula, and other agents have been used to increase the effectiveness of TCA and enhance peeling results. Repetitive peels with low concentrations of TCA can be effective for areas prone to scarring.

Abnormalities of lymphatic drainage in lower extremities: a lymphoscintigraphic study.

Chronic lower-leg edema in patients with venous disorders was studied by means of lymphoscintigraphy. Lymphatic patterns of flow were evaluated prospectively in 26 patients with technetium 99m antimony trisulfide colloid injected subcutaneously in the interdigital web spaces on the feet. Most patients in this study had postphlebitic syndrome, and all of these patients had abnormal lymphoscintigraphic flow patterns. Nine had evidence of lymphatic obstruction, and one had an enhanced flow pattern. Three patients had veins used for distal arterial bypass, and all these veins showed decreased lymphatic flow. Two patients with Klippel-Trenaunay syndrome (congenital varicose veins associated with limb elongation, a capillary nevus, and an abnormal deep venous system) had obstruction to lymphatic flow, and two others had normal and enhanced patterns. Normal studies were seen in four of five patients who had veins used for coronary artery bypass grafting. The finding of decreased lymphatic flow in patients appears to be the result of the length of time from an episode of deep venous thrombosis, the occurrence and number of episodes of cellulitis and lymphangitis, and mobilization of the vein for use in distal arterial bypass surgery. This study shows that the edema attributed previously to primary venous disorders may have a significant lymphatic component. The degree of lymphatic obstruction can be determined by lymphoscintigraphy with technetium-labeled antimony trisulfide colloid.

Selection and utilization of liposuction cannulas.

The liposuction surgeon can now choose from a wide variety of cannulas. However, the author has found that most procedures can be successfully performed using five or six basic types. Types of cannulas and techniques of liposuctioning are briefly described.

Intra-abdominal vascular injury secondary to penetrating trauma.

There were 85 patients in this series. The overall mortality was 17.6%. Gunshot wounds were responsible for 51 injuries, with a 21% mortality. There were three stabbings and three shotgun blasts, with a mortality of 10% and 33%, respectively. There were 127 intra-abdominal vascular injuries. The majority were to the SMA and its branches: 34. The highest mortality occurred with protal vein and combined aortic and vena caval injuries (80%). Fatalities averaged twice as many vascular injuries as survivors. There were 194 organ injuries. A liver injury predicted the highest mortality as did injuries to the spleen, lung, and pancreas. The presence of shock and the ability to rapidly control the source were the major predictors of survival. Fatalities averaged a Trauma Score of 7.5; survivors averaged a score of 14.0. There were 12 deaths which occurred intra-operatively and three postoperatively, for a total of 15 deaths. Once the patients made their way from surgery, their survival was 96% assured. Early suspicion of an intra-abdominal vascular injury followed by rapid exposure and control of hemorrhage are the keys to successful management.

The chemical peel.

The spectrum of chemical peeling encompasses a diverse group of peeling agents with the ability to produce a wide range of cutaneous burns. The most spectacular peels are produced by the phenol formulas. The physician, however, is restricted in the number of potential candidates as determined by skin color and potential toxicity. While not as impressive, trichloroacetic acid peels are an excellent modality for treatment of actinic keratoses, actinic dermatitis and lentigoes. Improvement of rhytides, skin tone, and texture can be impressive. Utilization of TCA may require repetitive peeling to obtain the desired result. With the alarming increase in the incidence of severe facial solar radiation as manifested by multiple premalignant and in situ malignant lesions, therapeutic chemical peeling has become an increasingly important procedure. The dermatologic surgeon can not only eradicate the multitude of facial lesions present but also markedly diminish the incidence of new lesions.

Control of bleeding during dermabrasion.

Dermabrasion may be complicated by excessive bleeding during the procedure. Adrenosem salicylate has been used to control capillary oozing in various other surgical procedures. In a double-blind stidy of ten patients undergoing dermabrasion, Adrenosem salicylate was found to reduce capillary oozing during the procedure to a worthwhile degree. No untowards effects were encountered.