Gene expression of transforming growth factor beta isoforms in interposition nerve grafting.

Scar production and neuroma formation at nerve graft coaptation sites may limit axonal regeneration and impair functional outcome. Transforming growth factor beta (TGF-beta) is a family of growth factors that is involved in scar formation, wound healing, and nerve regeneration. Fifteen adult Sprague-Dawley rats underwent autogenous nerve grafting. The nerve grafts were analyzed by in situ hybridization to determine the temporal and spatial expression of TGF-beta1 and TGF-beta3 messenger RNA (mRNA). The grafted nerves showed increased expression of TGF-beta1 and TGF-beta3 mRNA in the nerve and the surrounding connective tissue during the first postoperative week. These data suggest that modulation of TGF-beta levels in the first postoperative week may be effective in helping to control scar formation and improve nerve regeneration.

Staged closure of complicated bronchopleural fistulas.

Bronchopleural fistulas remain a major complication after thoracic surgery. Despite continued advances in the treatment of this difficult problem, perioperative mortality remains as high as 15%. Multiple treatment strategies have been described with varying degrees of success. Successful treatment of chronic bronchopleural fistulas requires aggressive control of infection, adequate drainage of the chest cavity, closure of the fistula with vascularized tissue, and obliteration of the chest cavity. The authors present their experience with 3 patients who underwent a two-stage closure of their bronchopleural fistulas with pectoralis major muscle flaps followed by omental flap obliteration of the chest cavity. Each patient had previously undergone an Eloesser procedure for chest cavity drainage. The initial muscle flap operation is a small procedure that can be done rapidly with minimal morbidity in chronically ill patients. The intervening period between procedures allows patients to continue aggressive nutritional and physical rehabilitation until they are able to tolerate a second operation for chest cavity obliteration. All bronchopleural fistulas in our series healed, with one minor complication. A staged closure is a safe and effective alternative treatment for chronic and recurrent bronchopleural fistulas.

Community acquired methicillin-resistant Staphylococcus aureus hand infections: case reports and clinical implications.

We report a series of 4 cases of community acquired methicillin-resistant Staphylococcus aureus hand infections in patients without risk factors. Methicillin-resistant S aureus infections commonly involve the skin and soft tissue; therefore, hand infections may become more common as the prevalence of this pathogen increases. Hand surgeons must be aware of this emerging pathogen and obtain appropriate tissue cultures to diagnose and effectively treat this infection.

Use of 20 cm or longer interposition vein grafts in free flap reconstruction of the trunk.

Between January of 1993 and September of 1995, six microsurgical free tissue transplants were performed using saphenous vein grafts ranging from 20 to 39 cm in length. All six free flaps survived. Two wounds were caused by radiation injury and two by tumor resection. The remaining two free flaps were performed for contour deformity and spinal cord coverage. All of the recipient sites were located on the trunk. In each case, an arteriovenous loop was created before the microvascular anastomosis to the free flap. There was one arterial thrombosis requiring thrombectomy and revision of the anastomosis. Three patients developed minor wound complications that responded to local wound care. Each of the flaps successfully provided wound coverage, and in two cases the flaps tolerated further radiation results. Long interposition vein grafts can be used for difficult microsurgical reconstructive procedures with reliable results when no local recipient vessels are available. Versatility is therefore afforded in placement of the flap and the choice of recipient vessels, making this option a useful one in the treatment of complex wounds of the trunk.

Mycobacterium tuberculosis infection of the hand: a case report and review of the literature.

Despite the recent overall increase in cases of tuberculosis and other types of mycobacterial infection, the incidence of tuberculous hand infections remains extremely low in the United States. The rarity of this infection often results in delay in diagnosis and treatment. A case of Mycobacterium tuberculosis infection of the left thumb without pulmonary involvement is presented. The patient's presentation and clinical findings were characteristic of M. tuberculosis infection. Prompt surgical debridement and tissue diagnosis are essential to the diagnosis and treatment of this rare infection.

Lemierre's syndrome: a case of postanginal septicemia and bilateral flank abscesses.

Lemierre's syndrome is characterized by pharyngeal infections in young healthy adults with secondary septic thrombophlebitis and multiple metastatic infections. In the preantibiotic era, Lemierre's syndrome was common and lethal. With the advent of antibiotics, Lemierre's syndrome has become such a rare entity that the diagnosis is often delayed or missed. With prompt recognition, appropriate antibiotic therapy, and surgical drainage of metastatic abscesses, the majority of patients can be cured. A case of Lemierre's syndrome in a 22-year-old previously healthy man treated on a plastic surgery service is presented. Surgeons who can be consulted for deep space infections should be aware of this disease so that the diagnosis and treatment can be initiated promptly to prevent patients from succumbing to this life-threatening but curable disease.