Novel method of closing a tracheo-oesophageal fistula using a de-epithelialized deltopectoral flap.

The authors describe a novel use of a de-epithelialized deltopectoral flap for the closure of tracheo-oesophageal fistulae, which have been resistant to other methods of closure.

Management of chondrodermatitis helicis by protective padding: a series of 12 cases and a review of the literature.

There are numerous theories concerning the aetiology of chondrodermatitis, and many authors have suggested that pressure is a significant factor. We prospectively gathered information from 14 patients with a clinical diagnosis of this condition. Many of the patients had a physical condition that forced them to lie on the side of the affected ear. Patients were advised to use protective padding of the ear at night. Most patients were rapidly relieved of their symptoms, although healing was frequently prolonged. This positive response rate and the high recurrence rate after surgery suggest that this condition should be primarily treated conservatively; they also support the theory that pressure on the ear is the main aetiological factor. Biopsies in two patients who did not respond to conservative treatment led to an altered diagnosis.

Cleft palate congenital alveolar synechiae syndrome: case reports and review.

Five cases of cleft palate with interalveolar synechiae have been previously reported. This is the first report of siblings with this condition, and suggests a genetic aetiology. These patients present with an inability to open the mouth adequately. Initial management is directed towards dividing the intraoral adhesions, which may cause significant problems of airway management. Significantly, the intraoral adhesions resolved spontaneously in one of our patients. This, to our knowledge, has not been reported before.

Skin necrosis following injection of non-steroidal anti-inflammatory drug.

We report two patients who developed skin necrosis following an intramuscular injection of non-steroidal anti-inflammatory drug into the anteriolateral area of their thigh. Both patients required further multiple operations and one developed life threatening septicaemia. They were left with disfiguring scars. Skin necrosis, although rare, is a recognized adverse reaction to intramuscular non-steroidal anti-inflammatory injections. It is likely that the injections were, unwittingly, administered subcutaneously. It is important to ensure intra-muscular administration, with an appropriate needle length.

Bath scalds in children in the south-east of Scotland.

Scalds caused by domestic hot tap water constitute a significant but preventable hazard in childhood. We have reviewed some of the factors contributing to such injuries, and the experience of a regional paediatric burn unit in their treatment. There were 91 children with bath water scalds and 667 children with thermal injuries from other sources included in this study. In the former group, scalds were more common on the limbs, including the hands and feet. Scalds involving over 40% of body surface area were more common in children with bath water injuries; however, there was no difference between the groups with regard to hospital stay or requirement for skin grafting. Parents ran the bath responsible for scald production in most cases, but single parenthood did not appear to be a risk factor. First aid application made no significant difference to eventual burn area or hospital stay. It appears from this study that reduction of domestic hot water temperature is necessary. Statutory control is likely to offer the best solution to the problem of domestic hot tap water scalds in childhood.

The role of pharyngoplasty in congenital neurogenic speech disorders.

Children with dysarthria are often seriously handicapped by their inability to communicate. Velopharyngeal incompetence may contribute to their speech difficulties but the indications for pharyngoplasty are poorly defined. The speech of 41 children, thought to have a defect of neurological origin and referred for possible pharyngoplasty, was assessed by a speech therapist, by nasopharyngoscopy and by multiview videofluoroscopy. These investigations revealed that 16 had velopharyngeal incompetence, with a neurological aetiology, and might be expected to benefit from pharyngoplasty. Independent assessment of the intelligibility of these 16 children before and after pharyngoplasty has been related to their preoperative oropharyngeal function. The majority benefited from surgery, some substantially. In particular, good lip and tongue function are shown to be necessary to achieve improved intelligibility. The roles of age, intelligence and aetiology in the success of pharyngoplasty are discussed.

The distally-based dorsal hand flap.

The planning and clinical applications of a series of reverse dorsal hand flaps are described. This new flap is based on a direct cutaneous branch of the dorsal metacarpal artery. It is particularly useful in resurfacing web spaces as well as dorsal metacarpal and phalangeal skin defects. The behaviour of 21 such flaps, all raised in the form of an island, was that of a conventional axial pattern flap.

The properties and uses of non-expanded machine-meshed skin grafts.

Machine-meshing a split skin graft gives it a three-dimensional flexibility that enables it to conform to irregular and concave surfaces without fixation. The drainage of fluid through the slit-like perforations prevents haematoma formation and permits the graft to be applied to an actively bleeding wound. Rapid firm adhesion occurs, allowing early mobilisation. By ensuring that the skin is applied without expansion, excellent cosmetic results can be achieved. This technique has become the method of choice in our unit when grafting awkward sites and for the cover of tangentially-excised burn wounds and we report on 111 consecutive cases.

The muscle twitch monitor: a rapid unequivocal method of monitoring free muscle transfers.

A free latissimus dorsi muscle transfer, which required anastomotic revision on two occasions within twenty-four hours of operation, illustrates how the change in response of electrically induced muscle contraction to ischaemia can be used as a rapid and sensitive method of monitoring free muscle transfers. It is a response that has the great merit of being easily recognised by untrained observers because it relies on an absolute rather than a relative change in the measured modality. Furthermore it is not influenced by the clinical condition of the patient or by changes in the flap's environment. Its potential is discussed.

Prostaglandin I2 is not a major metabolite of arachidonic acid in cultured endothelial cells from human foreskin microvessels.

Prostaglandin I2 (PGI2), a potent vasodilator and inhibitor of platelet aggregation, is a major product of arachidonic acid metabolism in endothelial cells that are derived from large blood vessels (e.g., umbilical veins). We have examined whether PGI2 is also a major product of arachidonic acid metabolism in cultured endothelial cells that are derived from dermal microvessels in human newborn foreskin. Supernatants from confluent monolayers of endothelial cells that had been incubated for 20 min with [3H]arachidonic acid and the calcium ionophore A23187 (10 microM) were assayed for prostaglandin F2 alpha (PGF2 alpha), prostaglandin E2 (PGE2), and 6-keto-prostaglandin F1 alpha (PGF1 alpha) (the stable metabolite of PGI2) by using authentic standards and high performance liquid chromatography. Whereas supernates from stimulated umbilical vein endothelial cells contained 6-keto-PGF 1 alpha much greater than PGF 2 alpha much greater than PGE2, supernates from stimulated foreskin microvessel endothelial cells contained PGF 2 alpha congruent to PGE2 much greater than 6-keto-PGF 1 alpha. Similar results were obtained when supernates from stimulated, unlabeled endothelial cells were analyzed by radioimmunoassay. These data indicate that PGI2 is not a major metabolite of arachidonic acid in cultured endothelial cells from human foreskin microvessels.

Basal lamina formation by cultured microvascular endothelial cells.

The production of a basal lamina by microvascular endothelial cells (MEC) cultured on various substrata was examined. MEC were isolated from human dermis and plated on plastic dishes coated with fibronectin, or cell-free extracellular matrices elaborated by fibroblasts, smooth muscle cells, corneal endothelial cells, or PF HR9 endodermal cells. Examination of cultures by electron microscopy at selected intervals after plating revealed that on most substrates the MEC produced an extracellular matrix at the basal surface that was discontinuous, multilayered, and polymorphous. Immunocytochemical studies demonstrated that the MEC synthesize and deposit both type IV collagen and laminin into the subendothelial matrix. When cultured on matrices produced by the PF HR9 endodermal cells MEC deposit a subendothelial matrix that was present as a uniform sheet which usually exhibited lamina rara- and lamina densa-like regions. The results indicate that under the appropriate conditions, human MEC elaborate a basal lamina-like matrix that is ultrastructurally similar to basal lamina formed in vivo, which suggests that this experimental system may be a useful model for studies of basal lamina formation and metabolism.

Isolation and long-term serial cultivation of endothelial cells from the microvessels of the adult human dermis.

A method to isolate and maintain microvascular endothelial cells from the cutaneous vessels of adult human skin in long-term culture has been developed. Endothelial cells lining the microvessels of the papillary dermis are released from surrounding tissue during a brief trypsin incubation (0.3% trypsin, 1% EDTA). Cells are plated onto a fibronectin substrate and maintained in Leibovitz (L15) culture medium containing pooled human serum (50%) and antibiotics. Proliferation is dependent upon the presence of several additional growth factors, cholera enterotoxin (1 X 10(-9) M), isobutyl methylxanthine (3.3 X 10(-5) M), and medium conditioned by explant culture of the mouse EHS sarcoma. Using this supplemented medium, cells proliferate readily and can be cultivated serially for more than 6 passages (3 months in vitro). These cells retain their characteristic endothelial cell morphology, stain positively for Factor VIII antigen, and contain Weibel-Palade bodies.

Factors controlling the in vitro growth pattern of human microvascular endothelial cells.

Monolayer cultures of endothelial cells of human dermal microvascular origin were exposed to a variety of culture conditions and in vitro differentiation of the cells assessed by light and electron microscopic examination. Restoration of a cytologic and fine structural appearance which resembled most closely that present in vivo was possible by raising the intracellular cAMP level. These cells formed junctional complexes seen in uncontracted microvessels and specialized attachment sites at their basal cell membrane, contained a complex network of bundled micro- and intermediate filaments and numerous Weibel-Palade bodies and accumulated electron-opaque deposits between the cells and the culture dish surface.

Regulation of sterol transport in human microvascular endothelial cells.

In cultured human dermal microvessel endothelial cells, the rate of efflux (about twofold greater than for fibroblasts under equivalent conditions) was coupled to an equivalent high rate of sterol net transport from the cells to the medium. This net transport was linked with esterification via lecithin:cholesterol acyltransferase. Since the use of free sterol by plasma transferase is constant, such increased net transport indicates that endothelial cells are highly efficient, in competition with plasma lipoproteins, in supplying free sterol for esterification. These results indicate the marked ability of endothelial cells to regulate and maintain their sterol balance in the face of high sterol levels to which these cells are uniquely exposed in human plasma.

Human dermal microvascular endothelial cells in vitro: effect of cyclic AMP on cellular morphology and proliferation rate.

Macrovascular endothelial cells isolated from the human umbilical vein and microvessel endothelium from the newborn foreskin dermis differ in their requirements for optimal growth in vitro. In the presence of 5 X 10(-4) M dibutyryl cyclic AMP (Bt2cAMP), human dermal microvessel endothelial cell proliferation rate increased to give a cell number of 203% of controls values by day 10 in culture. The cells retained their characteristic endothelial cell morphology, reached confluence, and could be serially passaged. Cells grown in the absence of Bt2cAMP did not proliferate readily and grew in a disorganized pattern. The effect of Bt2cAMP on microvascular endothelial cell proliferation rate and morphology could be duplicated by cholera toxin (CT) used together with isobutyl methylxanthine (IMX). These agents were found to elevate intracellular levels of cyclic AMP in microvascular endothelium over 40-fold. Human umbilical vein cells in culture failed to respond to either Bt2cAMP or CT together with IMX. The growth-promoting effect of dibutyryl cyclic AMP (Bt2cAMP) on human foreskin dermal microvascular endothelium in vitro is in marked contrast to the lack of response of human umbilical vein cells. These results provide further evidence of differences in the mechanisms that regulate macro and microvessel endothelial cell proliferation in vitro.

Isolation and growth of endothelial cells from the microvessels of the newborn human foreskin in cell culture.

A procedure for the isolation and in vitro cultivation of endothelial cells from the microvessels of the newborn human foreskin dermis is described. The epidermis was removed from foreskin tissue using a Castroviejo keratotome (0.1 mm shim). Endothelial cells were released from the dermal vessels by trypsinization of 5 mm2 sections of dermis at 37 degrees C for 40 min. Cells were expressed into Minimal Essential Medium (MEM) containing 10% pooled human serum, collected by centrifugation and plated onto either a plain plastic or a fibronectin treated culture surface. In primary culture the rate of endothelial cell proliferation was dependent upon serum type and concentration being optimal in 50% pooled human serum. High serum concentration in combination with pretreatment of the culture surface with fibronectin was required for maximal proliferation rate, for the cells to achieve confluence and for subcultivation. Primary and subcultured cells were characterized as endothelial by light microscopic, immunofluorescent (Factor VIII associated protein) and ultrastructural (Weibel-Palade body) criteria.

Growth and morphology of rabbit marginal vessel endothelium in cell culture.

A procedure for the isolation and cultivation of endothelium from the marginal vessels of the rabbit ear is described. Endothelial cells, isolated by slow perfusion with a trypsin solution, are cultured in minimal essential medium supplemented with 10% fresh rabbit serum for up to 6 mo. In primary culture, marginal vessel endothelial cells grow in an expanding circular pattern with closely apposed cell membranes. Weibel-Palade bodies, subcellular organelles unique to endothelial cells in situ, are present in both primary and in serially cultivated cells (12 passages). In intact skin, Weibel-Palade (W-P) bodies are observed in the perinuclear cytoplasm in close proximity to the cell membrane facing the vascular lumen. 8-16 tubules of 200 A diameter are present in each body. In primary and subcultured cells, W-P bodies of identical size are seen in the vicinity of the Golgi apparatus and in close proximity to the outer cell membrane. At the optimum serum concentration (10%), a cell doubling time of 72-96 h is observed. When growth in normal rabbit serum and in platelet-poor serum is compared, a slower growth rate is observed in the absence of platelets, suggesting that factors released by platelets affect endothelial cell proliferation. However, addition of crude platelet factor does not substitute for complete serum. Fibroblast growth factor is not mitogenic for rabbit marginal vessel endothelium in vitro.