Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture).

The types of midfacial fractures and their complexity were evaluated in admissions to the Maryland Institute of Emergency Medical Service Systems (MIEMSS) during the years of 1984 to 1988. Two hundred and sixty-eight LeFort fractures were treated and followed (3.2 percent of admissions). One half (50 percent) had skull fractures and 40 patients (15 percent) had LeFort, skull and mandibular fractures. Isolated nasoethmoidal fractures were observed in 176 patients and in 107 patients (39 percent) of patients with LeFort fractures. Isolated mandibular fractures were observed in 321 patients and in 104 patients with LeFort fractures (39 percent). Eleven percent of patients had midfacial, nasoethmoidal and frontal sinus fractures. Six percent of patients had midfacial, frontal bone, frontal sinus and nasoethmoidal fractures (Cranial Base Crush Syndrome). Twenty two percent of patients had LeFort and frontal sinus fractures. Reconstruction of multiple area injuries is simplified by a highly organized treatment sequence that conceptualizes the face in two groups of two units. Each unit is divided into sections, and each section is assembled in three dimensions. Sections are integrated into units and units into a single reconstruction. Conceptually, in each unit, facial width must first be controlled by orientation from cranial base landmarks. Projection is then (and often reciprocally with width) established. Finally, facial length is set both in individual units and in the upper and lower face. Soft tissue is considered the "fourth dimension" of facial reconstruction. Bone reconstruction should be completed as early as possible to minimize soft tissue shrinkage, stiffness and scarring of soft tissues in nonantomic positions.(ABSTRACT TRUNCATED AT 250 WORDS)

Subperiosteal approach as an improved concept for correction of the aging face.

A harmonious facial appearance is determined by a balanced relationship among all tissues of the face. With advancing age, balance is lost among the bone, muscle, fat, and skin as progressive changes occur in their volume, shape, position, and consistency. Study of clinical cases and fresh cadaver dissections has led to better understanding of the superficial musculoaponeurotic system (SMAS) and its relationship with the facial muscles and their bony insertions. From these anatomic studies we have developed an improved concept of rhytidectomy with the subperiosteal detachment of all soft tissues from the orbit, upper maxilla, malar bone, and nose. Following this detachment, the soft tissues of the cheek, forehead, jowls, nasolabial folds, lateral canthus, and eyebrows can be lifted to reestablish their youthful relationship with the underlying skeleton. Our 4-year experience includes 105 patients. Sixty percent of these patients were admitted to the hospital and had their procedure under general anesthesia; forty percent, however, had their procedure in an outpatient setting requiring only local anesthesia (lidocaine hydrochloride 1% plus epinephrine) and intravenous sedation (midazolam, ketamine). Complications have been minimal except for temporary paralysis of the frontal nerve in seven patients; guidelines for prevention have subsequently been developed. The subperiosteal rhytidectomy is excellent and appears more natural for rejuvenation of the upper and central face, eyebrows, periorbita, external canthus, cheeks, and nasolabial fold.

Low residue nutritional supplementation as an adjunct to mechanical preparation for surgical treatment of the colon.

The mechanical and nutritional efficacy of a low residue nutritionally complete liquid diet was evaluated as an adjunct for colonic preparation in patients undergoing large intestinal operations. The complete liquid diet was identical to more traditional clear liquid diets in terms of cleanliness of the intestine and general profile of bacterial flora. This complete diet was well accepted by patients and was superior in its provision of energy, protein, vitamins, minerals and nitrogen. The use of this low residue supplemental diet was associated with a statistically earlier return of intestinal function and a trend toward shorter length of hospitalization. The results of this study indicate that low residue nutritionally complete liquid diets not only offer comparable mechanical cleanliness but also outstanding nutritional advantages not obtained with traditional preparatory diets.

Value of nutritional support in adult cancer patients.

Both the presence of cancer and oncologic therapy cause metabolic alterations that may decrease the ability of the host to maintain anabolism. Nutritional support, properly administered, will replenish lean body mass, visceral proteins, and immunocompetence in human beings and experimental animals with small to modest tumor burdens. To date, stimulation of tumor growth by intravenous hyperalimentation in malnourished patients has not been documented scientifically. The exact role of intravenous hyperalimentation, in combination with chemotherapy or radiation therapy, is controversial, whereas the role of nutritional support for the malnourished surgical patient is more firmly established.

Haemophilus influenzae meningitis and Waterhouse-Friderichsen syndrome in an adult.

An otherwise healthy 36-year-old man had abdominal pain, vomiting, sepsis, and disseminated intravascular coagulation (DIC). Negative exploratory laparotomy was shortly followed by death. Autopsy showed Haemophilus influenzae (type B) meningitis, multiple organ involvement with DIC, and bilateral adrenal hemorrhagic necrosis (Waterhouse-Friderichsen syndrome). This patient is the fourth reported adult with H influenzae meningitis and hemorrhagic infarction of the adrenals, and the first such patient with an apparent abdominal catastrophe.

Intravenous hyperalimentation as nutritional support for the cancer patient--an update.

Debilitating cancer cachexia is multifactorial, but many of the etiologies and most of the resulting effects are similar to those seen in malnourished patients without cancer. From the work in human beings and experimental animals, nutritional support of the tumor-bearing host can replenish lean body mass, visceral protein components, and immunocompetence. This induction of anabolism, however, depends on time, content, the method of administration of hyperalimentation solutions; the initial and continuing catabolic response of the patient, as well as the degree of initial malnutrition; the energy expenditure of the patient required during oncologic therapy; and the expertise of the physician administering nutritional support. Increased tumor stimulation resulting from intravenous hyperalimentation (IVH) has never been observed in humans; the stimulatory effects of IVH on animal tumor systems have been identified only in previously depleted animals, and then growth rates have not been out of proportion to that of the host or to that of otherwise healthy animals. Animal data suggest that tumor growth characteristics can be affected by nutritional state and the exact substrates administered, ie, amino acids, carbohydrates, or fat. Further evidence suggests that the apparent enhanced tumor growth can be used to increase responsiveness to cell cycle-specific chemotherapeutic agents during nutritional repletion. Current evidence supports the use of intravenous hyperalimentation in malnourished cancer patients who have effective oncologic therapeutic options; such patients should not be denied these options simply on the basis of severe nutritional cachexia.

Self-administered bolus jejunostomy feeding and gastric fluid reinfusion in patients with gastric atony.

Twelve patients with profound gastric atony were taught to administer their own tube jejunostomy bolus feedings and, when necessary, to manage their gastric secretions by connecting their gastrostomy and jejunostomy tubes. These techniques allowed 11 of 12 patients to obtain reasonable nutrient intake and eight of the 12 to successfully reinfuse retained gastric secretions; alleviating the need for intravenous fluid replacement and expediting hospital discharge. Seven patients were able to resume some oral intake at home after resolution of their gastric atony. In the sufficiently motivated patient with gastric atony from multiple causes, these techniques provide alternatives to indefinite hospitalization with cumbersome and expensive intravenous hyperalimentation or constant infusion enteral alimentation.

Pancreatic cancer: unreliability of frozen section in diagnosis.

Thirty-two patients with a resectable mass in the head of the pancreas had pancreaticoduodenectomy for suspected or proven cancer. Twenty-eight proved to have cancer (15 periampullary and 13 pancreatic), and four had pancreatitis. The five-year survival for periampullary and pancreatic cancer was 25% and 0%, respectively. The operative mortality was 19%. There were no false-positive frozen section diagnoses. Seventy-five percent with negative frozen section proved to have cancer, of which 17% were five-year survivors. Surgical judgment based on clinical findings may be more reliable than a negative frozen section in the diagnosis of suspected malignancy. Pancreaticoduodenectomy can be done on the basis of clinical judgment when no tumor is seen on frozen section of a mass in the head of the pancreas.

Neutrophil delivery to wounds of the upper and lower extremities.

Clinical observations and experimental evidence indicate that wounds of the lower extremity are more susceptible to infection than are wounds located elsewhere on the body. The details of this regional relative immunoincompetence are not described. In this initial study of regional inflammatory response, neutrophil delivery to standard wounds of the upper and lower extremities was measured in 15 human volunteer subjects using a quantitative skin-window technique. Neutrophil delivery proved to be relatively deficient in the lower extremity. Neutrophil delivery (mean +/- SEM) was significantly lower to the lower-extremity wounds (5,890 +/- 590 cells per cubic millimeter) than to the upper-extremity wounds (16,600 +/- 1,680 cells per cubic millimeter). This lower neutrophil response may be a part of the lower extremity's increased susceptibility to infection. Further functional study of regionally collected neutrophils may provide more details of differences in regional inflammatory response. The mechanisms underlying these differences remain undescribed.

Topical antimicrobial toxicity.

Three topical antibiotics and four antiseptics (1% povidone-iodine, 0.25% acetic acid, 3% hydrogen peroxide, and 0.5% sodium hypochlorite) were directly applied to cultured human fibroblasts to quantitatively assess their cytotoxicity. The four antiseptics were found to be cytotoxic; all of the cytotoxic agents except hydrogen peroxide were subsequently found to adversely affect wound healing in an animal model. Comparison of bactericidal and cytotoxic effects of serial dilutions of these four topical agents indicated the cellular toxicity of hydrogen peroxide and acetic acid exceeded their bactericidal potency. Bactericidal noncytotoxic dilutions of povidone-iodine and sodium hypochlorite were identified. These experiments provide evidence that 1% povidone-iodine, 3% hydrogen peroxide, 0.5% sodium hypochlorite, and 0.25% acetic acid are unsuitable for use in wound care. This sequence of experiments could be used to identify bactericidal, noncytotoxic agents prior to their clinical use.

PIPIDA scan diagnosis of traumatic rupture of the gallbladder.

Eighteen days after injury, a patient was evaluated for bilious ascites with a 99mTc-PIPIDA (paraisopropyliminodiacetic acid) scan. A ruptured gallbladder was shown, and this finding was confirmed at exploration. Radionuclide scanning offers a sensitive, non-invasive approach for delineating disruption of the biliary tract, and should be considered when such a defect is suspected.

Squamous carcinoma arising in a pilonidal sinus.

A patient with squamous cell carcinoma arising from an extensive pilonidal sinus was treated with wide local excision, resulting in an apparent cure over a 1-year follow-up period. Review of the literature revealed 32 previously reported cases of this entity. Forty-four percent of these patients developed recurrences or metastases, and 22% died of their disease. The largest historical treatment group with at least 1-year follow-up (19 patients with localized disease) underwent wide excision. Forty-two percent of these patients recurred or developed metastases. Ultimately, 89.5% of these patients were reported cured, but only five survivors were followed for as long as 5 years. Historical experience appears to identify pilonidal tract squamous carcinoma as an aggressive tumor. The reported success of wide local excision is based on a small number of patients followed for short periods of time. Continued experience with this disease should be reported to verify the adequacy of local excision or identify the need for adjunctive therapy.

Intrahepatic arterial aneurysm: treatment by ligation complicated by hepatic necrosis and biliary-cutaneous fistula.

An intrahepatic hepatic artery aneurysm with massive hemobilia was successfully obliterated by intraoperative ligation of a branch of the right hepatic artery. Subsequent CT studies showed a large area of intrahepatic necrosis that was well tolerated, but was eventually manifested as a biliary-cutaneous fistula. Our patient's benign course argues that management of segmental hepatic necrosis can be tailored to the clinical response.

Calcified parathyroid glands detected by computed tomography.

Computed tomographic demonstration of single calcified parathyroid glands in two patients corresponded to operative findings of a calcified carcinoma and a calcified adenoma. The CT demonstration of a calcified parathyroid gland should suggest carcinoma, and the operative approach should be planned to permit an en bloc resection.

Nursing intervention scoring system in management of a surgical intensive care unit.

Hospital cost containment and nursing shortages have diminished resources available in surgical intensive care units (SICU). To provide a more quantitative approach to management of these resources, the nursing intervention scoring system (NISS) devised by Greenburg et al was instituted in the SICU at the VA Medical Center, Gainesville, Fla. The NISS scores for patients in the SICU were calculated without computer support. During a four-month study period, 725 NISS evaluations on 70 patients were collected. Characteristic curves of NISS scores versus postoperative days were generated from the data and were predictive of workloads in the unit. In addition, NISS patient scores provided a basis for day-to-day bed control and provided an effective tool for management of nursing service staffing. The hospital administrators responded positively to quantitative documentation of SICU resource requirements by providing additional personnel, equipment, and intermediate care facilities. We have concluded that the NISS is an effective means of providing optimal day-to-day use of SICU beds. In addition, the NISS also provides the data needed to quantitate unit needs for nursing service and administration.

Hydrops of the gallbladder in children.

Gallbladder disease in children today is being diagnosed increasingly because of better awareness of its existence and of improved diagnostic capability. A case is presented to describe an unusual pathologic variant termed "acute hydrops" of the gallbladder. This entity occurs specifically in children and is characterized by an acute illness with massive distention of the gallbladder in the absence of stones, bacteria, or congenital malformations. Differential diagnoses include appendiceal abscess, intussusception, volvulus, peritonitis, and pyelonephritis. Routine and contrast radiographic techniques may be combined with abdominal ultrasound to aid in the preoperative diagnosis. The etiology of hydrops is not known, but bile stasis and mesenteric lymphadenitis seem to be important factors. Treatment has varied from supportive observation to operative aspiration or cholecystectomy.