Flap Related Complications Requiring Secondary Surgery in a Series of 851 Local Flaps Used for Fingertip Reconstruction.

BACKGROUND: Local flaps are widely used to cover fingertip defects. Errors in design or technical execution of the flap may lead to morbidity and additional surgical procedure. The purpose of this study was to review flap related complications requiring unplanned secondary surgery to characterize preventable issues. METHODS: 851 local flaps were used to reconstruct fingertip defects during a 9-year period. Patients requiring unplanned secondary surgery to address flap related complications were subjected to analysis. RESULTS: 31 of 851 flaps (3.6%) required unplanned secondary surgery because of flap related complications. The most reliable flap was VY advancement flap with only one (0.3%) re-operation. The reverse vascular island flap, cross finger flap, and neurovascular island flap were associated with the comparable number of complications (8.0%; 6.3%; and 3.8% respectively). Total or partial necrosis was the cause for re-operation in 6 patients (0.7%). The typical reason for secondary surgery was inadequate soft tissue cover of the tip with homodigital neurovascular island flap and flexion contracture with reverse vascular island flap. Cross finger flaps were revised because of poor graft take at the donor site, bulky flap or flap necrosis. CONCLUSIONS: Local flaps are reliable operations to cover fingertip defects. Each flap has potential pitfalls, which may be avoided if the surgeon is aware of them.

Assessing the association between EFEMP1 rs3791679 polymorphism and risk of glioma in a Chinese Han population.

In this study, we assessed the association between the EFEMP1 rs3791679 polymorphism and glioma risk in a Chinese Han population. A total of 94 glioma patients and 206 healthy controls who conformed to the inclusion and exclusion criteria were recruited from Baogang Hospital between March 2012 and October 2014. The EFEMP1 rs3791679 gene polymorphism was assessed using a polymerase chain reaction-restriction fragment length polymorphism assay and the results were statistically analyzed using SPSS Statistics 17.0. The results of unconditional logistic regression analysis revealed that the GG genotype of EFEMP1 rs3791679 was positively correlated with increased susceptibility to glioma (adjusted OR = 2.09, 95%CI = 1.21-7.81). Moreover, the GG genotype of EFEMP1 rs3791679 was correlated with higher risk of glioma compared to the AA+GA genotype (OR = 2.60, 95%CI = 1.08-6.28) in the regressive model. In conclusion, we report that the EFEMP1 rs3791679 polymorphism influences glioma susceptibility in the Chinese Han population.

Tuberculosis transmission and risk factors in a Chinese antimony mining community.

SETTING: An antimony mine in Jiangxi Province, China. OBJECTIVE: To investigate the incidence of tuberculosis (TB) transmission and associated risk factors in a Chinese antimony mining community. DESIGN: Retrospective cohort study METHODS: The 15-locus mycobacterial interspersed repetitive unit-variable number of tandem repeats (MIRU-VNTR(15-China)) method was used to determine clustering of patients. A region of difference (RD105) deletion-targeted multiplex polymerase chain reaction was adopted to identify Beijing strains. Risk factors for clustering were assessed. RESULTS: Of 263 TB patients, 175 were distributed into 35 clusters. Estimated recent transmission of TB was 53.2% within the community. Patients who failed treatment were more likely to be in clusters (adjusted odds ratio [aOR] 0.03, 95%CI 2.12-6.89). Patients with multiresistant isolates were more likely to have failed treatment and to be in a cluster than those carrying a susceptible strain (aOR 0.001, 95%CI 4.89-29.7). CONCLUSIONS: Individuals who fail treatment are an important source of infection in TB transmission, and multiresistant isolates are mostly responsible for this. TB control plans need to focus on treatment failure cases in the community.

The effect of blocking radial abduction on palmar abduction strength of the thumb.

The measurement of palmar abduction strength of the thumb (PAST) is often used as a research tool to provide an objective assessment of thenar muscle function in patients with carpal tunnel syndrome (CTS). The purpose of this study is to determine the effect of blocking radial abduction on PAST in a normal population. PAST was measured for both hands of 100 healthy volunteers in two positions. In the first position a vertical board was placed perpendicular to the radial border of the hand to block radial abduction, and in the second position PAST was measured without the board. Men had greater PAST. There was no difference in PAST between the dominant and non-dominant hand for both men and women, when a vertical board was used. Without the board, the values were significantly greater in the dominant hand. Radial abduction should be blocked during measurement of PAST.

Effects of L-malate on mitochondrial oxidoreductases in liver of aged rats.

Accumulation of oxidative damage has been implicated to be a major causative factor in the decline in physiological functions that occur during the aging process. The mitochondrial respiratory chain is a powerful source of reactive oxygen species (ROS), considered as the pathogenic agent of many diseases and aging. L-malate, a tricarboxylic acid cycle intermediate, plays an important role in transporting NADH from cytosol to mitochondria for energy production. Previous studies in our laboratory reported L-malate as a free radical scavenger in aged rats. In the present study we focused on the effect of L-malate on the activities of electron transport chain in young and aged rats. We found that mitochondrial membrane potential (MMP) and the activities of succinate dehydrogenase, NADH-cytochrome c oxidoreductase and cytochrome c oxidase in liver of aged rats were significantly decreased when compared to young control rats. Supplementation of L-malate to aged rats for 30 days slightly increased MMP and improved the activities of NADH-dehydrogenase, NADH-cytochrome c oxidoreductase and cytochrome c oxidase in liver of aged rats when compared with aged control rats. In young rats, L-malate administration increased only the activity of NADH-dehydrogenase. Our result suggested that L-malate could improve the activities of electron transport chain enzymes in aged rats.

Measurement and source characteristics of carbonyl compounds in the atmosphere in Kaohsiung city, Taiwan.

The concentrations of eighteen atmospheric carbonyls species were measured by the LpDNPH-Cartridge and the microcomputer air sampling device at Nan-Chie (northern part) and Hsiung-Kong (southern part) sites in Kaohsiung city, southern Taiwan. These samples were then analyzed using a high performance liquid chromatography (HPLC). Measurements showed that the highest concentrations of carbonyls were formaldehyde (18.33 and 18.74 microg m(-3)) at the Nan-Chie and Hsiung-Kong site, followed by acetaldehyde (14.90 and 15.71 microg m(-3)). The concentrations of total carbonyls were higher at Hsiung-Kong site (66.96 microg m(-3)) than at Nan-Chie site (60.41 microg m(-3)). The concentrations of total carbonyls at Nan-Chie site (or Hsiung-Kong site) were 74.06 microg m(-3) (89.99 microg m(-3)) in summer and 37.14 microg m(-3) (46.50 microg m(-3)) in winter, due to the fact that photochemical activities are stronger in summer than in winter. The results of principal component analysis (PCA)/absolute principal component scores (APCS) suggest that the primary pollution sources at Nan-Chie were vehicle exhausts (gasoline and diesel engines), stationary emissions (petrochemical and food industry) and restaurant emissions, and the primary pollution sources at Hsiung-Kong were vehicle exhausts (gasoline and diesel engines), stationary emissions (metal assembly and petrochemical industry) and restaurant emissions.

Inhibition of the replication of hepatitis B virus in vitro by oxymatrine.

This study investigated the inhibitory capacity of oxymatrine on in vitro hepatitis B virus (HBV) replication. HepG2.2.15 cells were treated with oxymatrine 50, 100, 200, 400, 800 or 1000 mg/l, or with human interferon-alpha2b (IFN-alpha2b 1000 U/l) as a positive control. Levels of hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) and HBV-DNA in cell supernatants were determined by enzyme-linked immunosorbent assay and fluorescent quantitative-polymerase chain reaction, respectively. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, flow cytometric analysis and terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick-end labelling were used to evaluate the cytotoxicity of oxymatrine. The inhibitory effects of oxymatrine gradually increased as the concentration increased from 200 to 1000 mg/l for HBsAg and HBeAg, and from 200 to 400 mg/l for HBV-DNA. There was no inhibitory effect of oxymatrine at concentrations < 200 mg/l. No significant difference was seen between human IFN-alpha2b (positive control) and oxymatrine >or= 200 mg/l. It is concluded that oxymatrine can inhibit in vitro HBV replication and antigen expression at concentrations >or= 200 mg/l.

Severe upper limb complications from parenteral abuse of Subutex.

INTRODUCTION: Subutex is a sublingual formulation of buprenorphine that is used to treat opioid dependency. It may be abused parenterally with disastrous consequences. CLINICAL PRESENTATION: We present 4 cases of parenteral abuse of Subutex resulting in severe upper limb complications. TREATMENT: Two vascular complications were treated with combinations of anticoagulants, vasodilators, brachial plexus bock and iloprostol. One severe hand abscess required surgical debridement, and 1 median nerve injury required neurolysis. OUTCOME: All patients had a poor outcome. Both patients with vascular complications required multiple amputations, the patient with a thenar abscess had severely impaired thumb function, and the patient with median nerve injury has ongoing neuralgic pain, numbness and thenar weakness. CONCLUSION: The incidence of complications of parenteral abuse of Subutex is increasing in Singapore. These complications have a poor outcome despite adequate management, and are best prevented by education or legal means.

Effect of acetylcholine on in vitro IL-2 production and NK cell cytotoxicity of rats.

In the present study, we explored the effect of acetylcholine (ACh) on lymphocyte function and the receptor mechanisms mediating the effect. Concanavalin A (Con A)-induced interleukin-2 (IL-2) production and natural killer (NK) cell cytotoxicity were used to assess function of the T lymphocytes and the NK cells from rat spleens. Muscarinic ACh receptors (mA ChRs) agonist pilocarpine and antagonist atropine, as well as nicotinic ACh receptors (nAChRs) agonist nicotine and antagonist tubocurarine were used to determine the action pathways of ACh on T and NK cells. ACh at the concentrations of 10(-10) to 10(-8) M exerted an enhancing effect on Con A-induced IL-2 production and an inhibitory effect on NK cell cytotoxicity. Both pilocarpine and nicotine at the same doses as ACh could mimic these effects of ACh. The enhancing effect of ACh on IL-2 production could be blocked by either atropine or tubocurarine. But the inhibitory effect of ACh on NK cell cytotoxicity was abolished only by atropine, not by tubocurarine. These results suggest that ACh, which is a neurotransmitter of peripheral parasympathetic nervous system, can regulate function of T and NK cells, and the different regulatory effects of ACh on the two types of lymphocytes may be mediated by the different receptor mechanisms.

Continuous local anaesthesia for post-operative mobilization of injured digits.

We have studied the effects of sustained local anaesthesia on postoperative mobilization of the injured hand. Small epidural catheters were placed adjacent to the peripheral nerves providing sensation to the involved part of the hand under direct vision in the distal forearm. Repeated doses of 0.5% bupivacaine were then administered during mobilization therapy to relieve pain. Fourteen out of 24 digits (60%) recorded 30 degrees or more increases in active range of motion after bupivacaine injection. The cases that failed to improve had suffered severe injuries. Complications were few and were easily managed as the catheters were distal, superficial and accessible. This is an effective, specific and safe method of providing sustained postoperative analgesia for mobilization.

Towards a splint-free repair for flexor tendon injuries.

Flexor tendon injury has long been recognised as a difficult problem to tackle in hand surgery. Loss of active motion in the digits results in significant morbidity. The increased understanding in tendon healing, role of the tendon sheath, and the development of mobilisation and repair techniques have drastically improved results of flexor tendon injuries over the last 50 years. The treatment of flexor tendon injuries is based on evidence-based medicine, where clinical problems and new concepts were first evaluated in the biomechanical and animal laboratories and clinical practice is dictated by long-term outcome results. However, current surgical repairs are not strong enough to withstand active grip during rehabilitation and patients needed a prolonged period of protected rehabilitation until tendon healing is completed. The need for a more robust repair to allow a splint-free unprotected use of the hand should be the next step forward in the approach to flexor tendon injuries.

Digital replantations including fingertip and ring avulsion.

To reduce ischemic time and yet achieve a high-quality repair, the replantation team should be well organized. The team should be conversant with microvascular techniques and employ efficient methods of tendon repair and bone fixation. Developments in instrumentation and technique in recent years have improved success rates and consequently enlarged the indications for replantation surgery. Nevertheless, the economics of care and long-term functional outcome should not be overlooked, and these issues remain unresolved in the replantation versus terminalization question. The authors address topics relevant to replantation, including techniques and complications of digital replantation, ring avulsion injuries, and distal replantation.

Acupuncture for pilocarpine-resistant xerostomia following radiotherapy for head and neck malignancies.

OBJECTIVE: Xerostomia is a frequent and potentially debilitating toxicity of radiotherapy (XRT) for cancers of the head and neck. This report describes the use of acupuncture as palliation for such patients. METHODS AND MATERIALS: Eighteen patients with xerostomia refractory to pilocarpine therapy after XRT for head and neck malignancy were offered acupuncture as palliation. All patients are without evidence of cancer recurrence at the primary site. Acupuncture was provided to three auricular points and one digital point bilaterally, with electrostimulation used variably. The Xerostomia Inventory (XI) was administered retrospectively to provide an objective measure of efficacy. RESULTS: Acupuncture contributed to relief from xerostomia to varying degrees. Palliative effect as measured by the XI varied from nil to robust (pre- minus post- therapy values of over 20 points). Nine patients had benefit of over 10 points on the XI. CONCLUSIONS: Acupuncture reduces xerostomia in some patients who are otherwise refractory to best current management.

Use of an arterialized venous flap for resurfacing a circumferential soft tissue defect of a digit.

Circumferential defects of digit are uncommon but present a challenging problem to the clinician. The use of simple skin grafts tends to cause tendon adhesions and can limit digital range of motion. The use of local skin flaps, such as a cross-finger flap, is limited by the considerable skin loss in a defect that is circumferential in nature. Other options have included the use of reversed forearm flap or some free tissue transfer. We report a case in which the circumferential defect of an index finger, measuring 6 cm around the digit and 3 cm long, is resurfaced by the use of a free arterialized venous flap raised from the volar forearm skin.

[Changes of catecholamine content in the brain and thymus of rats during antibody response].

AIM: The kinetic changes of catecholamine content in the brain and lymphoid organ of rats during the antibody response were investigated in order to know the effect of immune condition on the activity of catecholaminergic nerve in central and peripheral nervous system. METHODS: Rats were immunized with sheep red blood cells (SRBC). During the days 2-7 after immunization, the content of noradrenaline (NA), adrenaline (A), dopamine (DA) and homovanilic acid (HVA) in the hypothalamus, hippocampus, brainstem and thymus of rats was determined by means of the high-performance liquid chromatography with electrochemical detection. RESULTS: 1. NA content in the hypothalamus and hippocampus significantly increased, but was strikingly decreased in the thymus during the antibody response compared with the saline control. 2. The content in the hypothalamus, hippocampus and thymus markedly augmented in the period of antibody response. 3. DA content in the hypothalamus significantly increased, but in the hippocampus, DA content markedly descended after immunization. HVA, DA metabolite, dramatically rose in the hypothalamus and hippocampus. 4. There were not significant alterations of catecholamine content in the brainstem during the antibody response compared with the saline control. CONCLUSION: The antibody response may enhance the activity of catecholaminergic nerve in the hypothalamus and hippocampus, and may exert different impact on various catecholaminergic nerve in the thymus, but does not markedly affect the activity of catecholaminergic nerve in the brainstem.

Comparison of first carpometacarpal joint arthrodesis with contralateral excision arthroplasty in a patient with bilateral saddle joint arthritis: a case report.

A post-menopausal patient with bilateral primary osteoarthritis of the first carpometacarpal joint (CMCJ) was treated by 2 different surgical techniques. The non-dominant left CMCJ was arthrodesed in 1992 while excision of trapezium and tendon suspensionplasty was done for the dominant right side in 1997. She reported good pain relief with both procedures and she was able to fully oppose both thumbs at 6 years after arthrodesis and 1 year after arthroplasty. The grip and pinch strength was stronger on the arthrodesed side while hand function tests revealed the arthroplasty side to be more dexterous. Subjectively, she preferred the right thumb. Radiographs showed no peritrapezial arthritis in the arthrodesed CMCJ and no proximal migration of the metacarpal on the reconstructed side. Both procedures offered excellent relief of symptoms and she was able to return to work as a machine operator.

[Time effect of restraint stress-induced suppression of lymphocyte transformation].

In the present study, restraint, which caused no direct tissue damage, was selected as a method of stress to investigate time effect of stress-induced suppression of lymphocyte transformation in rats. The lymph node and spleen extract or the serum from rats restrained for 3, 6, 12, 18 h or 12, 24, 48, 72, 96 h after restraint, with concanavalin A (Con A), was added to the lymphocyte suspension of rat mesenteric lymph node and was incubated for 72 h. The optical density (OD) value indicating the level of lymphocyte transformation was determined by colorimetric assay of methylthiazol tetrazolium bromide (MTT). The results are as follows. (1) The lymph node and spleen extract or the serum from the rats restrained for 3 or 6 h did not markedly affect the lymphocyte transformation. (2) The lymph node and spleen extract or the serum from the rats restrained for 12 h or 18 h significantly inhibited the lymphocyte transformation and stronger inhibition occurred at 18 h. (3) Up to 96 h after restraint, the suppressive effect of the lymph node or spleen extract on the lymphocyte transformation still existed, but the suppression of the serum on the lymphocyte transformation almost disappeared. These results suggest that the restraint of rats may cause lymphoid tissues to produce some immune suppressive protein of stress, which is released into blood leading to a generalized suppression of cellular immunity.

Peer review and performance improvement in a radiation oncology clinic.

A program was implemented in the Radiation Oncology Division at Naval Medical Center San Diego to document baselines for process improvement and fairly assess physician supervisory performance for recredentialing. This program was based on criteria established by the American College of Radiology (ACR). In addition to weekly chart rounds with peer review of films and charts while patients are on treatment, a new mechanism of peer review post-therapy was instituted. All patients completing therapy have this peer review prior to final disposition of their charts. Data are now readily available for physician recredentialing. Further, several points of inconsistent chart documentation have been identified and remedied. This mechanism is a simple and efficient way to ensure continuing patient care within ACR standards.