Risk factors in children having palatoplasty.

Palatoplasty carries a relatively high risk of hypoxaemia. We prospectively evaluated 23 children having elective surgery for cleft palate. Intubation was uneventful in 15 patients and the lowest pulse oximetry levels (mean: 93% (range: 100-57)) were less affected than those at extubation (mean: 83% (range: 100-21)) which was uneventful in 10. Establishing a free airway was associated with increased difficulties in patients with Pierre Robin sequence (n = 4). All children who had had a recent airway infection or a parent who smoked (n = 8) had some degree of difficulty in intubation, or extubation, or in both. Increased attention paid to these latter, avoidable, factors may potentially reduce the anaesthetic hazards in this group of patients, who are at increased risk.

Identification of children at high anaesthetic risk at the time of primary palatoplasty.

Closure of the palate is an operation with a higher risk of postoperative hypoxaemia than other plastic surgical procedures. An increase in anaesthetic complications was noticed among our children with a cleft palate who were operated on with a palatoplasty, and this was further investigated. The records of 154 patients operated on between 1979 and 1996 were eligible for the study. A total of 128 had isolated cleft palate (ICP), 19 had Pierre Robin syndrome (PRS), and seven had other identified syndromes (IS). The results showed that the risk of anaesthetic complications was four times greater when the operation was done when the child was less than 1 year old, and there was a sixfold increase when a more elaborate velopharyngoplasty technique was used. Children with Pierre Robin syndrome were further classified according to the degree of neonatal difficulties. The 12 children with most severe problems were at increased risk. When the diagnostic criteria as well as the type of operation were taken into account the incidence of anaesthetic complications was 7/11, which was the highest risk encountered in the present study. When the first operation on the palate in children with Pierre Robin syndrome is planned, it should be based on a classification of neonatal problems and an investigation of their clinical condition. In children at risk the palatoplasty procedure should be postponed until the age of 12-18 months.

[Clear connection between gun ownership and suicide. 92 per cent of attempts result in death]. / Klart samband vapeninnehav och självmord 92 procent avlider av skottskadan.

In a retrospective study involving 20 police districts in Sweden, 348 completed or attempted suicides with firearms were found to have occurred during the period, 1976-88. Statistics on civilian firearms ownership were obtained from police authorities. Firearm suicide was found to be significantly correlated to gun ownership, through the 25 per cent increase in gun ownership during the period was not accompanied by a corresponding increase in the overall suicide rate. The head was the primary target in suicide attempts, both with longarms (rifles and shotguns) and with handguns (pistols and revolvers). Handgun injuries were more common among the survivors. Only 4.6 per cent of the victims survived and could be discharged from hospital. Nearly 10 per cent of those using shotguns or rifles used a string, a rod or their toes to reach the trigger; all of them died. Apart from such well-known predisposing factors such as psychiatric disorders or alcohol abuse that were present in 43 per cent of cases, 24 per cent of the victims were found to have had somatic problems instead.

Pneumatocele after removal of squamous cell carcinoma in the scalp--a rare complication? Case reports.

Two patients with squamous cell carcinoma of scalp had the outer table of the skull opened with an osteotome and a drill. Split skin grafts were applied to the defect in one and delayed split skin grafts in the other. In both cases the lesions were on the vertex and resulted in leakage of cerebrospinal fluid and formation of intracranial pneumatoceles. In one case there was serious disturbance of the central nervous system. We conclude that deep resection within the vertex region overlying the lateral lacuna in close proximity to the sagittal sinus must be done with care and the residual defect should preferably be covered with local flaps.

Decompression of the axillary vein for oedema of the arm caused by axillary dissection and irradiation.

Twenty women with brachial oedema after treatment for breast cancer were operated on by a standard technique, with decompression of the axillary vein and division of the irradiated portion of pectoralis major. After a mean follow-up of 32.5 months a significant improvement was noted in 14 of them. In 19 the range of movement of the shoulder had improved.

Close range blasts toward the maxillofacial region in attempted suicide.

In Sweden, suicides and attempted suicides with firearms are rare. This retrospective study is based on our experience with 12 consecutive cases of attempted suicide not resulting in death but in facial injuries. The extent of soft and hard tissue injuries is presented for each case. The maxilla was the bone most often fractured. Six patients sustained mandibular fractures, three with major bone defects. Depression was by far the most common emotional state immediately preceding the suicide attempt. At least four patients were under the influence of alcohol at the time of the injury. Initial treatment included sharp, conservative debridement and internal or external fixation of jaws. Bone grafting, local or distant flaps were postponed until all devitalized tissue was recognized. We conclude that these self-inflicted injuries with an initially grotesque appearance respond well to conservative debridement and early reconstruction, leading to satisfactory functional aesthetic, social and psychiatric rehabilitation.

Microsurgical replantation of an amputated penis.

The microneurovascular replantation of a completely amputated penis is described. Fifteen hours after the replantation an arterial reanastomosis was performed due to a secondary thrombosis. The result after 3 months is excellent, with returned capacity of erection.

Granulomatous inflammation of the vulva and penis--a genital counterpart to cheilitis granulomatosa.

3 patients are described, in whom chronic swelling of the external genitals occurred after recurrent infections. The histological findings were identical to those seen in cheilitis granulomatosa, the dermal component of Melkersson-Rosenthal syndrome. The authors suppose that the disease of the 3 patients is a genital counterpart to cheilitis granulomatosa, and the name vulvitis or posthitis granulomatosa is suggested.