Necrotizing Soft Tissue Infections of the Hand and Wrist.

Necrotizing soft tissue infections of the upper extremity threaten life and limb. Their presentation is often difficult to recognize and multiple factors contribute to the varied presentation, speed of spread, and morbidity of the disease process. The only treatment to be definitively shown to improve outcomes is prompt surgical treatment. It should be expected to perform multiple debridements as well as reconstructive procedures once the infection and necrosis has been arrested. The use of a multidisciplinary team is mandatory to optimize care for these patients. Despite advances in knowledge and treatment, these infections still have high mortality and morbidity.

Three-dimensional biplanar radiography as a new means of accessing femoral version: a comparitive study of EOS three-dimensional radiography versus computed tomography.

OBJECTIVE: To validate femoral version measurements made from biplanar radiography (BR), three-dimensional (3D) reconstructions (EOS imaging, France) were made in differing rotational positions against the gold standard of computed tomography (CT). MATERIALS AND METHODS: Two cadaveric femurs were scanned with CT and BR in five different femoral versions creating ten total phantoms. The native version was modified by rotating through a mid-diaphyseal hinge twice into increasing anteversion and twice into increased retroversion. For each biplanar scan, the phantom itself was rotated -10, -5, 0, +5 and +10°. Three-dimensional CT reconstructions were designated the true value for femoral version. Two independent observers measured the femoral version on CT axial slices and BR 3D reconstructions twice. The mean error (upper bound of the 95% confidence interval), inter- and intraobserver reliability, and the error compared to the true version were determined for both imaging techniques. RESULTS: Interobserver intraclass correlation for CT axial images ranged from 0.981 to 0.991, and the intraobserver intraclass correlation ranged from 0.994 to 0.996. For the BR 3D reconstructions these values ranged from 0.983 to 0.998 and 0.982 to 0.998, respectively. For the CT measurements the upper bound of error from the true value was 5.4-7.5°, whereas for BR 3D reconstructions it was 4.0-10.1°. There was no statistical difference in the mean error from the true values for any of the measurements done with axial CT or BR 3D reconstructions. CONCLUSION: BR 3D reconstructions accurately and reliably provide clinical data on femoral version compared to CT even with rotation of the patient of up to 10° from neutral.

The role of the scapula in throwing disorders.

Shoulder injuries in the thrower can prove a challenge to diagnose and treat. Overhead throwing is an intricate motion that places considerable torque on the shoulder. The complex interplay of the scapula with the glenohumeral joint and its surrounding musculature allows elite pitchers to achieve speeds >95 miles per hour. An understanding of scapular motion is integral to diagnose and treat shoulder pathology in these athletes. Treatment is aimed at addressing the underlying cause with a physical rehabilitation program. Although nonoperative care is the most predictable and useful treatment, occasionally operative treatment is necessary. This chapter will outline normal scapular motion during throwing, the effects of common shoulder disorders on throwing mechanics, and the prevention, diagnosis, and treatment of these conditions.

Pulmonary resection for multi-drug resistant tuberculosis.

OBJECTIVES: Mycobacterium tuberculosis continues to be a major cause of morbidity and mortality throughout the world. Complacency by the medical profession and by patients has caused a new strain of Mycobacterium tuberculosis to emerge that is highly resistant to current antibiotics. The possibility of a new worldwide epidemic of drug-resistant Mycobacterium tuberculosis is of concern. Optimal therapy for patients infected with multi-drug resistant tuberculosis often requires surgical intervention to eradicate the infection. We report on our experience with pulmonary resection for multi-drug resistant tuberculosis. METHODS: During a 17-year period, 172 patients underwent 180 pulmonary resections. All patients had multi-drug resistant tuberculosis and had a minimum of 3 months of medical therapy before surgery. Muscle flaps were frequently used to avoid residual space and bronchial stump problems. RESULTS: During the study period, 98 lobectomies and 82 pneumonectomies were performed. Eight patients underwent multiple procedures. Operative mortality was 3.3% (6/180). Three patients died of respiratory failure, 2 patients died of a cerebrovascular accident, and 1 patient had a myocardial infarction. Late mortality was 6.8% (11/166). Significant morbidity was 12% (20/166). One half (91) of the patients had positive sputum at the time of surgery. After the operation, the sputum remained positive in only 4 (2%) patients. Mean length of follow-up was 7.6 years (range 4-204 months). CONCLUSIONS: Surgery remains an important adjunct to medical therapy for the treatment of multi-drug resistant Mycobacterium tuberculosis. In the setting of localized disease, persistent sputum positivity, or patient intolerance of medical therapy, pulmonary resection should be undertaken. Pulmonary resection for multi-drug resistant tuberculosis can be performed with acceptable operative morbidity and mortality.

History of resectional surgery for tuberculosis and other mycobacterial infections.

Resectional surgery for tuberculosis became increasingly common in the 1940s; however, thoracoplasty remained the most popular treatment of choice until the introduction of effective antituberculosis agents. With the development of rifampin in 1966, surgery was seldom needed except for the occasional massive hemoptysis, bronchial stenosis bronchopleural fistula, or to rule out cancer. With the rise of MDR-TB and the increasing MOTT infections requiring surgery, resectional procedures are again being needed in the treatment of mycobacterial disease.

Creating a hairline.

The hair mass and especially the frontal hairline comprises the largest visible feature of the face and, as such, is prominently featured in the first impression that one person makes in evaluating another. According to proportions proposed by Michelangelo, the hairline should be located at the junction of the middle and upper thirds of the face. The hairline that a hair transplant surgeon creates is the most highly visible feature, and the quality of the work of a surgeon is most often judged by the quality of the hairline. This article discusses modern grafting techniques and hairline design.

Mycobacterium tuberculosis and other mycobacteria.

The immunocompromised post-transplant HIV-positive patient is at increased risk for mycobacterial infection. Early diagnosis and aggressive therapy is critical to successful outcome. Surgical therapy may be required in patients who have complex mycobacterial lung disease, drug resistant tuberculosis, or mycobacterial infections other than tuberculosis.

Improved exercise performance following lung volume reduction surgery for emphysema.

Lung volume reduction surgery (LVRS) for emphysema has been suggested to improve patient lung function and activity. The short-term impact of LVRS on exercise performance was evaluated using maximal and submaximal steady-state exercise testing in 27 patients with severe hypoxemic chronic obstructive pulmonary disease (COPD), along with measurements of patient function, dyspnea, and quality of life. LVRS significantly improved exercise performance, due to ventilatory improvements associated with increased ventilatory reserve, enhanced tidal volume recruitment, and improved alveolar ventilation. Preoperative measurements of ventilatory reserve and dead space ventilation during exercise testing were closely associated with improved exercise performance. Improvements in patient dyspnea, walk distances, and quality of life also occurred following LVRS and were associated with improvements in exercise performance. Surgical mortality from LVRS was low (4%), but short-term all-cause mortality was increased (19%). Short-term mortality was associated with reduced expiratory muscle strength and markedly elevated dead space ventilation. We conclude that LVRS produces significant improvements in exercise performance, dyspnea, and quality of life in selected patients with COPD. Physiologic prediction of patients most likely to survive for an extended period and have significant benefit following LVRS may also be possible.

Surgery in the treatment of multidrug-resistant tuberculosis.

Resectional surgery is recommended for patients with localized multidrug-resistant tuberculosis if adequate pulmonary reserve is present. Appropriate drug specific therapy is employed for approximately 3 months preoperatively and for 18 to 24 months postoperatively. Nutrition is emphasized both pre- and postoperatively. Technically, the use of bronchoscopy, double lumen endotracheal tubes, and muscle or omental flaps is stressed. With the above, cure rates should be better than 90%.

Resection of the right middle lobe and lingula for mycobacterial infection.

BACKGROUND: In a series of 229 patients infected with mycobacterial organisms, we noted a specific female phenotype that involves isolated infections of the middle lobe and lingula. METHODS: Thirteen patients were found to have infections of the middle lobe, lingula, or both. All of them were infected with Mycobacterium other then Mycobacterium tuberculosis, all were women, 12 of the 13 were slender, and most had variable combinations of skeletal abnormalities. All underwent resection of the middle lobe, lingula, or both. RESULTS: There were no operative deaths. Only 2 patients have had reactivation requiring additional antibiotic therapy. All patients have had a decreased number of pulmonary infections in the postoperative period. Anatomic findings at operation included a complete major fissure and at least a partially complete minor fissure with middle lobe resections or an elongated lingula. CONCLUSIONS: Mycobacterial infection of the middle lobe and lingula is primarily a disease of asthenic women and is often associated with skeletal abnormalities and complete fissures or an elongated lingula. We recommend that surgical intervention be performed early once the condition is identified.

High affinity polyethylene oxide for improved biocompatibility.

Albumin passivation methods are based on the premise that a confluent layer of conformationally intact albumin will provide a biocompatible surface. However, albumin in contact with foreign surfaces tends to denature, and other proteins will adsorb to the surface, making the albumin passivation theory difficult to test. To overcome these two limitations, it was necessary to have a nondenaturing ligand specific for albumin attached to the surface by a long chain polyethylene oxide (PEO), which is known to have low protein binding. Clinical reports suggest no denaturation of albumin upon binding with warfarin, a drug known to have high albumin affinity. Thus, we tethered warfarin to glass.

Effect of serum amyloid A, HDL-apolipoprotein, on endothelial cell proliferation. Implication of an enigmatic protein to atherosclerosis.

The possible contribution of apo-HDL serum amyloid A (SAA) to the protective effect of HDL against atherosclerosis was studied by evaluating its effect on bovine aortic endothelial cell (BAEC) proliferation. Our results suggest that human SAA, both purified and recombinant, in concentrations relevant to mild acute phase events, significantly inhibit endothelial cell proliferation in a dose-dependent manner (e.g., 50 micrograms/ml causes approximately 88% inhibition; p < 0.001). This inhibition was attenuated by addition of fibroblast growth factor (FGF), which antagonized the SAA-mediated effect. As levels of TNF may be highly elevated during the acute phase response, its effect on BAEC proliferation was evaluated and found, at concentrations of > 1 pg/ml, to be substantially inhibitory Co-incubation of cells with both SAA and TNF was inhibitory, albeit neither additive nor synergistic. FGF antagonized the effect of both proteins. Amyloidic deposit (AA, i.e. SAA 1-76), derived from pathological proteolysis of SAA, practically retains the inhibitory activity (e.g. 50 micrograms/ml causes approximately 66% inhibition; p < 0.001) but apparently lacks the regulatory site towards FGF. In contrast to the above inhibitory effect, synthetic SAA-related peptide corresponding to the sequence 29-33 of SAA enhances BAEC proliferation (50 micrograms/ml causes approximately 64% increase; p < 0.001). The present data, coupled with our previous observations in which SAA was found to induce endothelial PGI2 formation and to inhibit overproduction of PGI2 by TNF and LPS as well as platelet aggregation, may suggest that SAA contributes to the protective effect of HDL against atherosclerosis. This, by means of its modulatory effect on endothelial cell and platelet activation, primarily in the presence of other regulatory proteins. SAA-derived peptides may, potentially, be used as therapeutic agents in the treatment of atherosclerosis and cardiovascular diseases.

Extrapleural pneumonectomy for tuberculosis.

Tuberculosis has infected the human race for thousands of years. The best medical therapy in this country failed to eradicate the disease. In its current most virulent form it is drug resistant and will affect the practice of thoracic surgery once again. The most common indications for resection in patients with tuberculosis are drug resistance and localized disease. Pneumonectomy for tuberculosis, now necessary in more than 50% of operative cases, represents the highest risk operation. The risk is related directly to patient debilitation, the preoperative presence of positive sputum, and intraoperative contamination of the pleural space. Complications can be minimized and an acceptable mortality rate can be achieved with an extrapleural approach supplemented by muscle flap or omentum for reinforcement of the bronchial stump.

The surgical management of tuberculosis.

Due to unpredicted factors, the incidence of tuberculosis is increasing in the United States. Despite excellent anti-tuberculous medication, some patients will require surgical management. The majority of these patients present with multi-drug-resistant tuberculosis (MDRTB). Surgery is indicated, but only after the best possible anti-tuberculous regime has been instituted. In those patients who become sputum-negative and have a destructive pulmonary process, or in those patients with persistent positive sputum and destroyed pulmonary parenchyma, operative management may be beneficial. Surgery can be done with a low mortality and morbidity incidence. Muscle flaps are useful in minimizing postoperative complications. Continued postoperative medical therapy combined with surgery offers a cure in more than 90% of patients. In patients with MDRTB and localized parenchyma disease, surgery combined with continued medical therapy is the treatment of choice in the majority of patients.

Persistence of a normal pregnancy after an early luteectomy. A report of two cases.

Two cases occurred of early luteectomy/left cystectomy. In one case it resulted from a hemorrhagic corpus luteum at four weeks' gestation. In the second case it resulted from a left adnexectomy at five weeks from torsion of the adnexa. Histologic analysis defined the lesions as a hemorrhagic corpus luteum and necrotic ovary, respectively. Despite the lack of a corpus luteum and the absence of hormonal replacement therapy, both pregnancies developed normally, in the first case for 7 weeks, until it was terminated on the patient's request, and in the second case until 38 weeks, when a normal infant was delivered by cesarean section.

Rectification of STM Current to Graphite Covered with Phthalocyanine Molecules.

The scanning tunneling microscope (STM) can be used to measure current-voltage characteristics on an atomic scale. The attachment of copper phthalocyanine molecules, in contrast to a variety of other molecules, to graphite changes the electrical characteristics of the STM from relatively symmetric to highly asymmetric or rectifying. Evidence is presented to show that the asymmetry arises because of the electronic energy levels of the copper phthalocyanine. The organic molecules were bonded to the graphite by an acid-base reaction that may have wide applicability.

Surgical management of resistant mycobacterial tuberculosis and other mycobacterial pulmonary infections.

Between August 1983 and October 1990, 42 patients with resistant Mycobacterium tuberculosis underwent 44 pulmonary resections. During the same time, 38 patients with mycobacterial infections other than tuberculosis had 41 pulmonary resections. All patients either were poor candidates for medical therapy alone or had existing complications requiring surgical intervention. There was one operative death in each group, both from adult respiratory distress syndrome (postpneumonectomy pulmonary edema). Complications were high, with bronchopleural fistula most commonly occurring after right pneumonectomy in patients infected with Mycobacterium avium with superimposed infection with nonmycobacterial pathogens. In patients undergoing pneumonectomy for resistant Mycobacterium tuberculosis, the left lung was most often resected. It is recommended that if localized disease is present and medical treatment is likely to fail, pulmonary resection should be performed for resistant Mycobacterium tuberculosis infection after 3 months of drug-specific therapy. Muscle flaps were used frequently to avoid residual space and bronchial stump problems. Earlier resection in patients with indolent nontuberculous mycobacterial pulmonary infections is advocated before extensive polymicrobial contamination and right lung destruction.

A region in the dorsolateral striatum of the rat exhibiting single-unit correlations with specific locomotor limb movements.

1. To examine the activity of single units in the lateral striatum of the awake rat with respect to sensorimotor function, 788 units were recorded during locomotion and passive testing. The focus of this report is on 138 units (18%) that fired in relation to sensorimotor activity of a single limb. The remaining units were related to other body parts (16%), to general body movement (38%), or were unresponsive (28%). 2. Firing rates of limb-related units were near zero during resting behavior but increased markedly during treadmill locomotion. Each of the 138 units exhibited a rhythmic pattern of discharge in phase with the locomotor step cycle. Passive testing revealed that 86/97 units tested (89%) responded to passive manipulation of a single limb, exhibiting increased firing rates. Of these, 77 (90%) were related to contralateral and 9 (10%) to ipsilateral limbs. Sixty-one units (71%) were related to a forelimb and 25 (29%) to a hindlimb. Of the 86 units responding to passive manipulation. 34/48 units tested (71%) also responded to cutaneous stimulation of the same limb but no other part of the body. 3. To study in greater detail the rhythmic unit discharges in phase with the locomotor step cycle, computer-synchronized videotape recordings were used to generate perimovement time histograms constructed around discrete locomotor movements of each limb (n = 17 units). Activity of each unit was shown to be restricted to a specific portion of a particular limb's step cycle. The majority of units discharged throughout (8 units) or during a portion of (3 units) the swing phase, whereas other units fired during a portion of stance (3 units), footfall (2 units), or foot off (1 unit). 1. The specificity of unit firing was further demonstrated by the finding that rhythmic discharges, related to discrete locomotor limb movements in the forward direction, were completely absent during spontaneous deviations such as backward or disrupted locomotion. 5. Units related to limb movement were located in the far lateral, especially the dorsolateral, subregion of the striatum. This subregion extend rostrocaudally from A-P +1.6 to -1.0 mm relative to bregma. No clear somatotopic organization was observed, but this issue requires further study. 6. These results show that functional representations of individual limbs can be demonstrated in the lateral striatum of the rat, within a subregion containing terminals of projections from somatic sensorimotor cortex.(ABSTRACT TRUNCATED AT 400 WORDS)