Non-steroidal anti-inflammatory use in the XV Pan-American Games (2007).

BACKGROUND: non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used in sports medicine to reduce time of incapacity. OBJECTIVE: to describe the frequency of NSAIDs use by athletes in the XV Pan-American Games. METHODS: all athletes who were tested by the anti-doping control filled a form. The voluntarily declared medications were recorded and categorised according to sport modality, sex, region and control situation according to the World Anti-Doping Agency. RESULTS: among the 1261 athletes tested (231 out-competition (OC) and 1030 in-competition (IC); 733 men and 528 women), 63% reported use of drugs, NSAIDs being the most frequently (64% of users) used medications. The use of medications was not significantly different between sexes or among different regions of the world. The number of users of only one type of NSAID was higher than those who used more than one type of NSAIDs or a combination with analgesics (335 vs 168 cases). IC reports presented higher use of NSAIDs than OC. CONCLUSION: athletes tested by the anti-doping control of the XV Pan-American Games reported a high frequency of NSAIDs use. The frequent utilisation in competition suggests that these medications might be used as ergogenic aid.

Effect of recombinant human erythropoietin combined with granulocyte/ macrophage colony-stimulating factor in the treatment of patients with myelodysplastic syndrome. GM/EPO MDS Study Group.

This randomized, placebo-controlled trial was designed to assess the efficacy and safety of therapy with granulocyte-macrophage colony-stimulating factor (GM-CSF) and erythropoietin (epoetin alfa) in anemic, neutropenic patients with myelodysplastic syndrome. Sixty-six patients were enrolled according to the following French-American-British classification: refractory anemia (20), refractory anemia with excess blasts (35), refractory anemia with ringed sideroblasts (9), and refractory anemia with excess blasts in transformation (2). Patients were stratified by their serum erythropoietin levels (less than or equal to 500 mU/mL, n = 37; greater than 500 mU/mL, n = 29) and randomized, in a 2:1 ratio, to either GM-CSF (0.3-5.0 microg/kg.d) + epoetin alfa (150 IU/kg 3 times/wk) or GM-CSF (0.3-5.0 microg/kg.d) + placebo (3 times/wk). The mean neutrophil count rose from 948 to 3831 during treatment with GM-CSF +/- epoetin alfa. Hemoglobin response (increase greater than or equal to 2 g/dL, unrelated to transfusion) occurred in 4 of 45 (9%) patients in the GM-CSF + epoetin alfa group compared with 1 of 21 (5%) patients with GM-CSF + placebo group (P = NS). Percentages of patients in the epoetin alfa and the placebo groups requiring transfusions of red blood cells were 60% and 92%, respectively, for the low-endogenous erythropoietin patients and 95% and 89% for the high-endogenous erythropoietin patients (P = NS). Similarly, the average numbers of units of red blood cells transfused during the 12-week study in the epoetin alfa and the placebo groups were 5.9 and 9.5, respectively, in the low-endogenous erythropoietin patients and 9.7 and 8.6 in the high-endogenous erythropoietin patients (P = NS). GM-CSF +/- epoetin alfa had no effect on mean platelet count. Treatment was well tolerated in most patients, though 10 withdrew from the study for reasons related predominantly to GM-CSF toxicity. (Blood. 2000;95:1175-1179)

The use of the palmaris brevis flap in recurrent carpal tunnel syndrome.

In failed cases of primary carpal tunnel release, the addition of the highly vascular palmaris brevis turnover flap as an adjunct to internal neurolysis discourages scarring and provides a nutrient bed for axonal regeneration. In fact, the palmaris muscle flap actually may suppress the growth of nerve fibers into the overlying scar. Experimentally, classic neuromas do not form when a severed nerve is placed in an innervated muscle, particularly those with minimal excursion, as is the case with the turned over palmaris cushion. Major advantages of the palmaris turnover muscle are (1) proximity of the muscle to the operative field, obviating the need for a distant graft source; (2) negligible functional motor loss as a result of forfeiting this muscle; (3) no separate scar is created in raising this flap; and (4) adequate padding of the subcutaneous fat is still left at the donor site to protect the ulnar neurovascular bundle. Although postoperative healing and rehabilitation time are relatively lengthened by the more extensive dissection, subjective assessments of pain relief and clinical improvements in grip strength, pinch strength, and sensory parameters justify the use of the palmaris brevis turnover flap in recalcitrant carpal tunnel cases.

Aesthetic restoration of the severely disfigured face in burn victims: a comprehensive strategy.

Although highly specialized burn centers have significantly reduced mortality rates following extensive total body surface area burns, survivors are often left with grotesque facial disfigurement. The strategy of modern facial restoration emphasizes enhancement of aesthetic appearance as significantly as mitigation of functional impairment. Criteria for success are (1) an undistracted "normal" look at conversational distance, (2) facial balance and symmetry, (3) distinct aesthetic units fused by inconspicuous scars, (4) "doughy" skin texture appropriate for corrective makeup, and (5) dynamic facial expression. Since 1985, the author has successfully restored 17 severely disfigured burned faces by replacement of entire aesthetic units with microvascular "prepatterned" composite flaps blended into the facial canvas by cosmetic camouflage techniques. The series includes hemiface (2), neck/jaw (5), chin/lower lip (3), cheek/malar (5), peri-orbital (2), nose (3), upper lip (4), and ear reconstructions (4). Flaps represented are free preauricular (1), radial forearm (6), ulnar forearm (1), free scapular (6), ilio-osteocutaneous (2), temporoparietal (8), vascularized forehead island (3), supraclavicular (1), and SMAS (1). Important to outcome is extensive initial intraoperative "sculpting" to simulate normal planes and contours. Seams are placed at junctions of facial components. Three-dimensional imaging is used to assess architectural asymmetries, and bone grafts are aided by computer-generated acrylic models. Adjunctive procedures include tensor fasciae latae slings, intraoperative tissue expansion, suction-assisted lipectomy, and scar management. After restoration of facial form and texture, flesh color make-up and/or tattooing of beard, lips, scars, eyebrows, etc., aid to hide scars and pigment the skin to harmonize with the rest of the face. In all cases, facial integrity has been aesthetically restored and, in most instances, with makeup, is near normal in social settings at conversational distances. Facial animation is retained and color matches are excellent. One flap was lost early in the series.

The use of r-HuEpo in the treatment of anaemia related to myelodysplasia (MDS).

One hundred and sixteen (116) anaemic patients with myelodysplastic syndromes (MDS) were treated with recombinant human erythropoietin (r-HuEpo) in an open-label, multicentre, compassionate treatment trial; 100 patients received therapy for > or = 4 weeks and were evaluable for efficacy. The distribution of FAB subtypes was: 44 RA, 40 RARS, eight RAEB, two RAEB-t, one CMML, and five not specified. Mean baseline haematocrit was 24.5%, and the mean prestudy transfusion requirement in the 12 weeks immediately prior to study entry was 6.5 units. r-HuEpo treatment was initiated at a dose of 150 U/kg three times weekly, with dose escalations of 50 U/kg monthly (up to 300 U/kg 3x/week) permitted if the haematocrit failed to rise. Response to therapy was defined as either an increase in haematocrit of > or = 6 percentage points over baseline, unrelated to transfusion, or a > or = 50% decrease in transfusion requirement in the last 3 months of study treatment, compared to the baseline period (12 weeks). By these criteria, 28% (28/100) of patients responded to r-HuEpo treatment. Overall, 86% (24/28) of patients responding to therapy had baseline Epo levels < or = 100 mU/ml. Response rates by FAB subtype were: RA 39% (17/44), RARS 17.5% (7/40) and RAEB 12.5% (1/8). Additionally, a 54% (15/28) response rate was seen in RA patients with baseline Epo levels < or = 100 mU/ml. Responses to therapy were durable and generally occurred at r-HuEpo doses of 150-200 U/kg t.i.w. There were no reports of thrombosis, seizures or therapy-related hypertension. The data show that patients with MDS, especially those with the RA and RARS subtypes, can benefit from treatment with r-HuEpo. Those patients with baseline Epo levels < or = 100 mU/ml were most likely to respond to therapy.

Application of high-tech three-dimensional imaging and computer-generated models in complex facial reconstructions with vascularized bone grafts.

We present a series of six patients with eight flaps in whom computer-generated models were used for fabrication of vascularized bone grafts in complex facial restorations. Preoperative CT data, digitalized on tape, were converted by the CEMAX (Santa Clara, Calif.) 1500 Integrated Hardware and Software System to a three-dimensional visualization of the bone and soft-tissue deficiencies. These data were transmitted by direct computer link to a CNC milling machine that produced full-size slices "stacked" into a three-dimensional template. The acrylic replica aided selection of appropriate donor sites and intraoperative "carving" of bone transfers. Reconstructions included three zygomas, two maxillae, two mandibles, and one frontal bone. Donor sites were iliac crest, scapula, and outer calvarium. Four were free flaps and four island pedicle flaps. All healed without infection. Bone resorption was less than 10 percent. One flap was lost to thrombosis. Other complications included a transient facial palsy in one patient and temporary radial palsy from shoulder traction in another. Computer-generated templates for vascularized grafts are expensive and thus are not indicated or necessary in every patient. The advantages, however, are several. Custom models facilitate preoperative planning, with less guesswork of size, contour, and orientation of the graft, which is especially desirable with vascularized grafts, since the position of the pedicle is critical. Anesthesia time is decreased. Grafts can be fitted exactly, without reshaping and "nibbling." Nuances of depth and tapering are directly carved into the bone. By merging high-tech imaging and microsurgery, the best chance of optimal results can be achieved.

Slip-knot suspension technique: a fail-safe microanastomosis for small-caliber vessels.

The most common technical error associated with microvascular anastomotic failure is accidentally snagging the opposite wall and including it in the stitch, thereby reducing the vessel lumen diameter or occluding it altogether. A simple, safe microsuturing technique is described that combines the use of the slip-knot and the suspension technique in a procedure that allows direct visual inspection of suture placement from first to last stitch. This technique is applicable to end-to-end and end-to-side microvascular anastomoses, for thick-walled ducts such as the vas deferens and the fallopian tube, and in laparoscopic suturing.

[Coronary risk factors in high-rank athletes]. / Fatores de risco coronariano em atletas de alto nível.

PURPOSE: To report the prevalence of coronary risk factors in elite athletes. METHODS: The prevalence of coronary risk factors was determined in 88 athletes (62 men and 26 women) who participate representing Brazil, in the Olympic Games at Seul in 1988, in the Project SEUL/COB/AMIL. The risk factors analyzed were: family history of coronary heart disease, hypercholesterolemia (total-cholesterol and subfractions), hypertension, glucose intolerance, smoking and left ventricle hypertrophy (LVH). We compared the mean values of total-cholesterol/HDL-cholesterol between men and women with unpaired Student's t Test. The distribution of risk factors prevalence by sex was analysed with the chi-square test. RESULTS: Family history of coronary heart disease was detected in 11 (12.5%) athletes. Smoking was found in 12 (13.6%) athletes. There was no one with hypertension or glucose intolerance. LVH was diagnosed with the echocardiogram, in 36 athletes (40.9%). Total-cholesterol mean was 172 +/- 36 mg/dl in men and 187 +/- 34 mg/dl in women. HDL-cholesterol mean was 46 +/- 10 mg/dl in men and 60 +/- 13 mg/dl in women. Total-cholesterol/HDL-cholesterol mean was 4.02 +/- 1.39 mg/dl in men and 3.21 +/- 0.74 mg/dl in women. The difference between total-cholesterol in mean and women was not statistically significant (p less than 0.05). HDL-cholesterol and total-cholesterol/HDL-cholesterol means were statistically different (p less than 0.05). Prevalence distribution of the number of risk factors by sex were not statistically different (p less than 0.05). CONCLUSION: The results shows how important is to look for coronary risk factors in elite athletes.

Nasal spray desmopressin (DDAVP) for mild hemophilia A and von Willebrand disease.

OBJECTIVE: To evaluate the effect of a nasal spray preparation of desmopressin (DDAVP) on levels of factor VIII activity, ristocetin cofactor activity, and von Willebrand antigen as well as the length of bleeding time in patients with mild hemophilia A and von Willebrand disease; to determine whether effective hemostatic levels can be attained; and to compare the effect of this spray with that of standard intravenous desmopressin treatment. DESIGN: Before-and-after trial in patients known to respond to intravenous desmopressin. SETTING: Regional, comprehensive, hemophilia diagnosis and treatment center. PATIENTS: A total of 22 patients, including 11 patients with von Willebrand disease, 8 patients with mild hemophilia A, and 3 symptomatic hemophilia carriers. INTERVENTIONS: Patients were infused with desmopressin, 0.3 micrograms/kg body weight. At least 1 week later, they were taught to self-administer desmopressin nasal spray, 150 micrograms to each nostril. MEASUREMENTS: In patients with hemophilia, the level of factor VIII activity was measured; in patients with von Willebrand disease, levels of factor VIII activity, ristocetin cofactor activity, and von Willebrand antigen as well as bleeding time were measured before and after each administration of desmopressin. MAIN RESULTS: Desmopressin, when administered intravenously or intranasally, elevated levels of factor VIII, ristocetin cofactor, and von Willebrand antigen in both mildly hemophiliac patients and patients with von Willebrand disease when compared with baseline measures (P less than 0.05). Factor VIII levels adequate for hemostasis were achieved by 82% of the hemophiliac patients. An abnormal bleeding time was corrected in the majority (62%) of patients with von Willebrand disease. CONCLUSION: A nasal spray preparation of desmopressin apparently was effective both in treating bleeding episodes and when used prophylactically for minor surgical procedures in several patients.

Palmaris brevis turnover flap as an adjunct to internal neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome.

Thirteen hands in 11 patients with previous carpal tunnel releases were treated by microscopic internal neurolysis and palmaris brevis "turnover" flaps. All patients in the series had positive electrodiagnostic testing, dysesthetic wrist pain, and numbness in the median nerve distribution before operation. Average age was 41.9 years (range, 27 to 62 years). Ten were male and 3 were female. Range of follow-up after the procedure was from 1 to 1 1/2 years. All hands with abnormal preoperative two-point discriminations or Semmes-Weinstein measurements showed numerical improvement in their sensory parameters. Thenar strength and bulk improved at least one grade in all six cases of thenar atrophy. Mean grip strength was 15.2% greater than before operation. Key pinch increased 5.5% and pulp pinch 31.9%. Subjective assessment of improvement ranged from 25% to 100%. All patients returned to their former jobs or to vocational retaining except the oldest patient who is semiretired.

Metabolic predictors of middle-distance swimming performance.

To evaluate the capacity of different metabolic indices to predict performance in middle distance swimming, 15 competitive swimmers performed a submaximal and a maximal 400 metres freestyle swimming event. Expired gases were collected in Douglas bags immediately after the events for the determination of VO2 max. Arterialized blood samples were collected for the determination of maximal blood lactate concentration and the velocity corresponding to blood lactate concentration of 4 mM. The results demonstrated (means +/- SD): maximal velocity of 1.44 +/- 0.05 m.s-1; velocity at 85 percent of VO2 max of 1.36 +/- 0.04 m.s-1; velocity at 4 mM of 1.32 +/- 0.04 m.s-1; VO2 max of 3.47 +/- 0.5 l.min-1; maximal blood lactate concentration of 11.8 +/- 2.5 mM. Multiple regression analysis relating metabolic indices and maximal velocity demonstrated that only velocity at 85 percent of VO2 max (r2 = 0.81) and velocity at 4 mM (r2 = 0.79) were significant predictors. Thus, 79 percent of the variance in the performance of 400 m freestyle can be accounted for the velocity at 85 percent of VO2 max or the velocity at 4 mM. The success in this event seems to depend on the swimmer's capacity to achieve higher velocities with lower blood lactate levels and/or utilizing a lower percentage of their VO2 max.

Massive foreign body impalement of the shoulder and chest wall.

Impalement injuries to the upper extremity are rare. A case is described of penetration of a 10 x 3.5-inch fence post into the left shoulder of a 16-year-old boy, pinning the shoulder to the chest wall. Sequelae of potential serious brachioplexus, vascular, and intrathoracic injuries are reviewed. The author presents a systematic treatment approach to the assessment, extrication, and microneurovascular repair of damaged structures, and to soft tissue reconstruction following massive foreign body injuries.

The versatile temporoparietal fascial flap: adaptability to a variety of composite defects.

The unique properties of the temporoparietal fascial flap (TPFF) offer adaptability in reconstruction of a variety of composite defects. The broad, thin sheet of vascularized tissue may be transferred alone or as a carrier of subjacent bone or overlying skin and scalp. As a pedicled flap, it is ideal for defects of the orbital, malar, mandibular, and mastoid regions. As a free-tissue transfer, the large vessels and lack of bulk find broad utility in reconstruction of the extremities. This flap is our choice for reconstruction of the dorsal hand and non-weight-bearing surfaces of the foot. A viscous gliding surface decreases friction for tendon excursion. The thin contour is aesthetically superior to thicker flaps, allowing unmodified footwear or gloves. The pliable fascia convolutes into surface defects (e.g., bone craters) or drapes over skeletal frameworks (e.g., ear cartilage). The rich capillary network offers nutrition to saucerized bone, cartilage or tendon grafts, and overlying skin grafts. The geometry of the skull lends to fabrication of membranous bone for complex facial puzzles. The donor site is well disguised by hair growth. Twelve cases performed over a 2-year period demonstrate the versatility of this flap. These include complex foot reconstruction, ear and scalp avulsion, shotgun wound of the cheek and orbit, posttraumatic jaw recontouring, chronic osteomyelitis of the hand and foot, and acute resurfacing of dorsal hand with tendon reconstruction.

Small flap coverage of hand and digit defects.

Small defects of the hand and digits challenge the surgeon to use innovative methods of composite reconstruction for retention of digital length; aesthetic nail appearance; coverage of joint, implants, and tendons; release of scar contractures; and restoration of sensation in critical tactile surfaces. This article is by no means totally encompassing but an attempt to provide the reader with an insight into the author's select flap choices applying some of the newer microvascular methods. Descriptions include the volar advancement flap, free microvascular pulp transfer from the toe, "kite flap," onycho-osteocutaneous transfer, arterialized toe transposition, wrap-around flap, arterialized island pedicle, venous flow-through flap, and the free temporoparietal fascial flap. Options are influenced by morphological and physiological considerations, specifically in the fingertip, nail complex, volar surface of the digit, and dorsum of the hand.

The "cap" technique: nonmicrosurgical reattachment of fingertip amputations.

With the exception of children, amputations at the level of the lunula survive poorly by direct reattachment. Microsurgical replantation is costly and often fails because of poor venous drainage. In a series of seven adult patients the severed tip was filleted and replaced as a "cap" over the skeletonized distal phalanx of the stump. A 2 mm remnant of germinal matrix was preserved for nail regrowth. The reconstructed digits, although shortened by an average of 6 mm, give the "illusion" of a normal finger. All were successful with small areas of tip necrosis in two, healing by secondary reepithelialization. Mean static two-point discrimination was 6.5 mm (range, 3 to 10 mm) and pulp pinch was 67% of normal. The "cap" technique of nonmicrosurgical reattachment is a simple, reliable method of functional preservation of pulp tissue, as well as normal esthetic appearance of the nail complex.

The reversed venous arterialized nerve graft in digital nerve reconstruction across scarred beds.

Conventional nerve grafts in complex digital injuries often yield poor results, particularly when placed in traumatized or avascular beds. Vascularized nerve grafts offer an option; experimental evidence suggests superior axonal regeneration across scarred beds with vascularized nerve grafts. We previously described a vascularized graft based on the dorsalis pedis artery--deep peroneal nerve "system." Reluctance to sacrifice this major artery, combined with the recent description by Townsend and Taylor and Gu, et al, of "reversed venous" arterialized nerve grafts, spurred us on to investigate the deep peroneal nerve--dorsalis pedis venae comitantes system. Fourteen neurovenous grafts were used in scarred or poorly vascularized beds for digital nerve reconstruction in 10 patients over a 4-year period. Graft length averaged 4.4 cm; interval from injury was 1 to 17 months. Sensory parameters of return included average static two-point discrimination of 8.3 mm, moving two-point discrimination of 5.8 mm, and median Semmes-Weinstein monofilament appreciation of 2.83. Two patients received three vascularized grafts and three conventional grafts for adjacent nerve injuries in the same digit, serving as internal controls. In these patients, the vascularized nerve grafts returned mean static two-point discrimination values of 9.3 mm and moving two-point discrimination values of 6.7 mm. The conventional nerve grafts averaged static two-point discrimination of 14.3 mm and moving two-point discrimination values of 10.3 mm. These differences imply enhanced axonal regeneration through vascularized nerve grafts. These data suggest that the reversed neurovenous graft may be the procedure of choice in secondary reconstruction of digital nerves across scarred beds or following injuries with poor soft-tissue vascularity, especially in those patients with cold intolerance.

Microsurgical management of complex fingertip injuries: comparison to conventional skin grafting.

In selected cases of severe fingertip injuries, an aggressive approach using microvascular and microneural techniques can yield functional results equal or superior to conventional methods of treatment in less severe injuries. A series of 20 patients were treated microsurgically from 1983 to 1986 for severe acute distal finger injuries or their early sequelae--five distal replantations, eight neurovascular free tissue transfers, and nine distal neurorrhaphies/nerve grafts with or without vascular conduit. Concurrently, 33 simpler tip avulsions were treated with full-thickness skin grafts for comparison. In the microsurgical series, one replant and the distal 1 cm of a free toe flap necrosed. Replants averaged two-point discrimination of 9.8 mm and pulp pinch 65 percent of normal; free toe transfers, two-point of 6 mm, pulp pinch 58 percent; distal nerve reconstruction, two-point 6 mm. Operating time per digit averaged 5.0 hours for replants, 4.3 hours for toe flaps, and 1.5 hours for nerve repair/grafts. All patients returned to full pre-injury employment within six months. None required revisional surgery for dysesthetic fingertips. In the conventional skin graft series, greater than six months follow-up is available in 17 patients. Average two-point was 7 mm (range: 3 to greater than 15 mm) and pulp pinch 83 percent of normal. There were seven poor results with cold intolerance, numbness, and paresthesias, three of which required revisional surgery. The data suggest that microsurgical management of fingertip injuries achieves results comparable to skin grafts, despite the greater complexity of the initial injury. This approach has resulted in fewer secondary tip revisions. Operative times are acceptable. Parameters of sensory return are similar, although pulp pinch is slightly less. Disability times are comparable to the average in major pulp losses. Of importance, final permanent partial factors of disability are diminished in rating, due to retained digital length, improved esthetic appearance, and less dysesthesia/cold intolerance.

Unilateral invasive xanthelasma palpebrarum.

We describe an unusual case of an aggressively invasive, recurrent xanthelasma palpebrarum which was unilateral in its occurrence. Despite characteristics that appeared malignantly invasive clinically, the lesion was benign. The surgical treatment consisted of wide excision and resurfacing of the eyelids with full-thickness skin grafts.

The high-tech hand surgery interface.

We have reviewed a potpourri of high-tech advances of interest to the hand surgeon: electronically controlled prostheses, functional neuromuscular stimulation, computer graphics, data base computer programs, 3-D imaging, magnetic resonance imaging, and lasers--fields that point toward new directions in medicine, in general, and in our specialty, in particular, as we enter the twenty-first century. With clearer understanding of the basics, we can overcome the natural tendencies of negativism fostered by the complexities of the new ideas and proceed with optimism and curiosity.

Nipple reconstruction with four-lobe composite auricular graft.

A new method of nipple reconstruction using a four-lobe free composite graft from the inferior pole of the earlobe in the shape of a clover leaf is described. Invagination of the flaps achieves long-term nipple projection without flattening. Donor deformity has been negligible and ear piercing has been preserved when desired. The transposed grafts have retained the pinkish appearance of the vascular donor sites. Color has blended well with the pigmented areolar grafts.