Reconstruction of severe hand contractures: An illustrative series.

AIM: An overview of a series of severe burn contractures in 44 hands reconstructed over a 20 month period with an easy to follow algorithm. SETTINGS AND DESIGN: The series was carried out by a single surgeon at Green Pastures Rehabilitation Centre in Pokhara, Nepal. All patients attending with severe burn contractures to the hand were included in the series. MATERIALS AND METHODS: This is a retrospective review of burn contractures in a total of 44 hands. All the contractures involved limitation of movement by 60 degrees in two or more joints or by 80 degrees in one joint. The decision making process is presented as a flow chart indicating when and which flaps were used. RESULTS: Illustrations demonstrate what was achieved, with all hands obtaining an improvement in function. CONCLUSIONS: Although many of these contractures can be dealt with by skin grafting the series clearly illustrates the indications for flap coverage.

Fasciocutaneous flaps based on a doppler detected perforator, an illustrative series as used for burn contracture reconstruction.

Perforator flaps are well established as a versatile option in reconstructive surgery that provide thin, pliable cutaneous or fasciocutaneous tissue. They are particularly useful in the reconstruction of large shallow defects, such as after the release of a burn contracture, however there are situations where the additional time spent islanding these flaps may be unnecessary, and the flap is then essentially a fasciocutaneous flap based, but not islanded, on a perforator artery. This paper documents a series of 22 severe burn contractures in 17 patients reconstructed with fasciocutaneous flaps in this way. The arteries were all located pre-operatively with a hand held Doppler probe, around half at the site of a known perforator and half by systematic scanning of the surrounding skin for an ad hoc perforator. All patients achieved a good functional range of motion. There were three cases of partial superficial flap necrosis treated with split skin grafting. The functional and aesthetic outcomes were far better then those expected with split skin grafting, and published series show that contractures treated with perforator flaps are unlikely to ever need further surgery. Without islanding the flap it becomes a feasible option for reconstructing these patients even in the extremely resource poor environment in which they often present, and is an option for all plastic surgeons to consider in the reconstruction of large superficial defects.

Providing pain relief for laser resurfacing: effectiveness of the CoolAnalgesia device.

Laser resurfacing is a painful procedure, and is therefore usually carried out under general anaesthetic or local anaesthetic with sedation. However, the small but significant risk of adverse events from either of these methods has resulted in an effort to develop other methods of controlling the pain associated with the use of lasers. This trial describes of the use of a cooling device (the CoolAnalgesia device) with a carbon dioxide laser. The only anaesthetic used was a eutectic mixture of lidocaine anaesthetic (EMLA) applied as a cream to the face at least 60 min prior to the procedure. Twenty consecutive patients attending two laser centres for facial resurfacing were recruited. Each patient was asked to assess the level of pain on a visual analogue scale from 1-10 every 2 min during lasering. Only one of the patients had a mean pain score for the duration of the treatment of above five, four patients recorded a pain score of above five at some stage during their treatment, but none requested that the treatment be stopped. It would appear that the CoolAnalgesia device in combination with EMLA cream provides a level of anaesthesia sufficient to allow laser resurfacing without the use of local anaesthetic injections or intra-venous agents.

Compartment syndrome in the hand following an adder bite.

This paper reports a case of an adder bite to the hand and discusses the literature on adder bites.

Metacarpal descent, definition and normal range.

Metacarpal descent, an indication of carpometacarpal (CMC) joint mobility, was measured in 90 normal subjects by assessing the alignment of the metacarpal heads with the hand in a relaxed posture and when making a tight fist. Metacarpal descent was greater in women. Hand dominance was associated with an increase in positional angles but not metacarpal descent.

Floral development in Schotia and Cynometra (Leguminosae: Caesalpinioideae: Detarieae).

Floral development was compared among several relatively unspecialized taxa in caesalpinioid tribe Detarieae: Cynometra webberi, an undescribed species of Cynometra, and three species of Schotia. These share a relatively unspecialized caesalpinioid flower type with no loss of organs, but some organ suppression. They also share the following characters: relatively small bracteoles in early stages, a circular floral apex, helical sepal initiation, and a nonmedian abaxial position of the first sepal initiated. Floral symmetry is radial. Order of initiation is helical among sepals in all. Order of petal initiation varies: helical in Schotia afra, unidirectional in Schotia brachypetala and S. latifolia, and simultaneous in Cynometra. Stamens are initiated unidirectionally in all except in the outer stamen whorl of Schotia afra, which is helical. Overlap of time of initiation between whorls occurs in S. brachypetala, S. latifolia, and Cynometra. The carpel initiates concurrently with the petals or directly thereafter in all. A tetramerous calyx results from fusion of the two upper (adaxial) sepal primordia. The carpel initiates ovules before marginal closure in both genera. Organ suppression includes one or two petals in Schotia and sometimes one in Cynometra.

Acquired crateriform hyperkeratotic papules of the lower limbs: an unusual variant of acrokeratoelastoidosis of Costa.

We report a man with a 3-year-history of a striking eruption of small, 2-3 mm diameter keratotic, crateriform papules distributed symmetrically over the lower limbs. Morphologically the individual papules closely resembled those described in acrokeratoelastoidosis (AK) of Costa and in focal acral hyperkeratosis of Dowd (FAH). The case is unusual, however, in that there was dramatic involvement of the legs but the hands and feet were largely spared. Current terms used for these entities are unsatisfactory.

Exogenous topical lactoferrin inhibits allergen-induced Langerhans cell migration and cutaneous inflammation in humans.

BACKGROUND: Lactoferrin (LF), an iron-binding protein found in exocrine secretions, is known to possess antibacterial properties. It has recently been proposed that LF may also influence inflammatory reactions. OBJECTIVES: To characterize in humans the ability of recombinant homologous LF to inhibit the induced migration of epidermal Langerhans cells (LCs) from the skin, a process known to be dependent upon the proinflammatory cytokines tumour necrosis factor (TNF)-alpha and interleukin 1beta and to influence cutaneous inflammatory reactions. METHODS: We investigated the anti-inflammatory properties of LF in human volunteers. RESULTS: Topical exposure to LF 2 h prior to sensitization caused a significant reduction in contact allergen (diphenylcyclopropenone, DPC)-induced LC migration from the epidermis as judged by the altered frequency of cells expressing either HLA-DR or CD1a determinants. That this reduction was secondary to an inhibition of TNF-alpha production was indicated by the fact that LF failed to influence LC migration induced by intradermal injection of this cytokine. In approximately 50% of those volunteers who displayed local inflammation in response to DPC, LF was found to cause a discernible reduction in the clinical severity of the reaction, associated with reduced infiltration of inflammatory cells. CONCLUSIONS: These data demonstrate that LF is able to influence cutaneous immune and inflammatory responses, possibly because of an impaired production of local proinflammatory cytokines.

Circumcision: a refined technique and 5 year review.

The vast majority of circumcisions currently performed in the UK are for phimosis or balanitis and the patients are not looking for the denuded glans appearance of a ritual circumcision. We present a refinement of the sleeve technique of circumcision, which involves Horton's test to define the proximal incision margin, and bipolar electro-dissection. A review of all patients undergoing circumcision at the Wordsley Plastic Surgery Unit, in a 5-year period, has shown this technique to be safe with a haematoma rate of only 1.4%, and an overall complication rate of 3%.

Roles for inositol-phosphoryl ceramide synthase 1 (IPC1) in pathogenesis of C. neoformans.

Cryptococcus neoformans is a leading cause of life-threatening fungal infection in immunocompromised patients. Inositol-phosphoryl ceramide synthase 1 (Ipc1) is a fungus-specific enzyme, encoded by the essential IPC1 gene, that catalyzes the formation of complex sphingolipids and may also regulate the levels of phytoceramide and diacylglycerol. Here, we investigated the functions of this essential gene by modulating its expression in C. neoformans using a galactose-inducible promoter. Down-regulation of IPC1 significantly lowers the expression of certain virulence traits such as melanin pigmentation and, remarkably, impairs pathogenicity of C. neoformans in an established rabbit model. Interestingly, we found that IPC1 down-regulation significantly decreases the intracellular growth of C. neoformans in the J774.16 murine macrophage-like cells. Finally, we studied the effect of IPC1 expression under different stress conditions and found that down-regulation of IPC1 confers a defect on in vitro growth at low pH. Because this environment is similar to that in the phagolysosome of J774.16 macrophage-like cells, our findings indicate that down-regulation of IPC1 confers a growth defect in vivo through a pH-dependent mechanism. In conclusion, our study is the first to define a novel and crucial function of Ipc1 in fungal pathogenesis.

Extracellular phospholipase activity is a virulence factor for Cryptococcus neoformans.

The human pathogenic fungus Cryptococcus neoformans secretes a phospholipase enzyme that demonstrates phospholipase B (PLB), lysophospholipase hydrolase and lysophospholipase transacylase activities. This enzyme has been postulated to be a cryptococcal virulence factor. We cloned a phospholipase-encoding gene (PLB1) from C. neoformans and constructed plb1 mutants using targeted gene disruption. All three enzyme activities were markedly reduced in the mutants compared with the wild-type parent. The plb1 strains did not have any defects in the known cryptococcal virulence phenotypes of growth at 37 degrees C, capsule formation, laccase activity and urease activity. The plb1 strains were reconstituted using the wild-type locus and this resulted in restoration of all extracellular PLB activities. In vivo testing demonstrated that the plb1 strain was significantly less virulent than the control strains in both the mouse inhalational model and the rabbit meningitis model. We also found that the plb1 strain exhibited a growth defect in a macrophage-like cell line. These data demonstrate that secretory phospholipase is a virulence factor for C. neoformans.

Floral ontogeny, pattern formation, and evolution in Hibbertia and Adrastaea (Dilleniaceae).

Floral development was compared with scanning electron microscopy in 12 Australian species of Hibbertia representing most of its morphological variation, and in the related Adrastaea (Dilleniaceae). Calyx and corolla arise in quincuncial helices in radially symmetrical species, while the petals initiate unidirectionally from one side in zygomorphic species. Stamen number (3-200+) proliferates by centrifugal addition of individual primordia or by innovations of common primordia and ring meristems. Common primordia arise in single-stamen positions alternately with petals, and each produces one to several stamens centrifugally that remain attached to a shared base and form a stamen fascicle. A ring meristem in Adrastaea initiates a whorl of five stamens, alternate with the first stamens but outside their whorl. In radially symmetrical species of Hibbertia, a first ring of stamens is supplemented centrifugally by additional stamens on a meristem ring. The first stamens in zygomorphic species of Hibbertia initiate as a terminal ridge on the floral apex, with subsequent stamens added centrifugally on one side and two carpels initiated on the opposite side. The carpels arise as a simultaneous ring in radially symmetrical flowers, or as a simultaneous pair in zygomorphic species. Staminodial presence is viewed as of minor significance. Four pollinator syndromes are proposed for Hibbertia, related to differing floral architecture.

Objective assessment of post-traumatic nerve repairs and neuromas.

The assessment of a nerve repair usually focuses on the level of sensory and motor recovery distal to the site of the repair. However, the development of a painful neuroma or nerve junction, particularly in a digit, can be just as disabling to the patient as an area of anaesthesia. An instrument has been developed to assess objectively the severity of neuroma formation at nerve-repair sites by measuring the threshold percussive force required to elicit a Tinel's sign using standard weights dropped from a uniform height in a tube.

Floral development in Tribe Detarieae (Leguminosae: Caesalpinioideae): Amherstia, Brownea, and Tamarindus.

Floral development was compared among three taxa in caesalpinioid tribe Detarieae sensu lato: Amherstia nobilis and Tamarindus indica have racemose, helically arranged inflorescences, while Brownea latifolia has cauliflorous capitate flower clusters that arise as racemes. All have acropetal flower order; initiation and development are sequential in all except Brownea, which is synchronous. All have paired persistent showy bracteoles. Floral symmetry is dorsiventral (zygomorphic) in all except Brownea, with radial symmetry at anthesis. Sepals initiate helically on a circular floral apex, starting with a median abaxial sepal, in all. Petals are initiated helically in Brownea, and unidirectionally in Amherstia and Tamarindus. Stamens are initiated unidirectionally in each stamen whorl in all except Amherstia, in which the outer whorl is bidirectional. The carpel initiates concurrently with the petals in Brownea, and with the outer stamens in the other taxa. The two upper (adaxial) sepal primordia become fused during development in all, so that the calyx appears tetramerous. Some reduced petals occur in Amherstia and Tamarindus, and some reduced stamens occur in all. All produce a hypanthium by zonal growth, and all except Tamarindus have the gynoecium attached adaxially to the hypanthial rim.

Evolutionary loss of sepals and/or petals in detarioid legume taxa Aphanocalyx, Brachystegia, and Monopetalanthus (Leguminosae: Caesalpinioideae).

Floral development using scanning electron microscopy is compared in several taxa of the Brachystegia subtribal group of caesalpinioid tribe Detariae. This group is characterized by missing sepals and/or petals. In Aphanocalyx djumaensis, Monopetalanthus durandii, and two Brachystegia species, one sepal is initiated in median abaxial position. In the first two, one or two additional sepal rudiments may initiate late. Brachystegia species have all five sepals, which remain scalelike. In Aphanocalyx and Monopetalanthus, one petal initiates adaxially and medianly (a position atypical for the first initiated petal in the family); additional petal rudiments may form in lateral sites. In Brachystegia, five petals are initiated unidirectionally on a meristem ring, but all are suppressed after initiation. In all taxa, ten stamens are initiated on a ring meristem: unidirectionally in Monopetalanthus, bidirectionally in Brachystegia, vs. in erratic order in Aphanocalyx. Carpel and petal initiation are concurrent. Different organ whorls overlap in time in Monopetalanthus and Brachystegia. In all, the floral apex characteristically is elongate radially and narrow tangentially after bracteole initiation. Two ontogenetic features, the meristem ring and the radially elongate post-bracteole floral apex, appear to be possible synapomorphies for the Brachystegia group.

Complex function for SicA, a Salmonella enterica serovar typhimurium type III secretion-associated chaperone.

Salmonella enterica encodes a type III secretion system within a pathogenicity island located at centisome 63 that is essential for virulence. All type III secretion systems require the function of a family of low-molecular-weight proteins that aid the secretion process by acting as partitioning factors and/or secretion pilots. One such protein is SicA, which is encoded immediately upstream of the type III secreted proteins SipB and SipC. We found that the absence of SicA results in the degradation of both SipB and SipC. Interestingly, in the absence of SipC, SipB was not only stable but also secreted at wild-type levels in a sicA mutant background, indicating that SicA is not required for SipB secretion. We also found that SicA is capable of binding both SipB and SipC. These results are consistent with a SicA role as a partitioning factor for SipB and SipC, thereby preventing their premature association and degradation. We also found that introduction of a sicA null mutation results in the lack of expression of SopE, another type III-secreted protein. Such an effect was shown to be transcriptional. Introduction of a loss-of-function sipC mutation into the sicA mutant background rescued sopE expression. These results indicate that the effect of sicA on sopE expression is indirect and most likely exerted through a regulatory factor(s) partitioned by SicA from SipC. These studies therefore describe a surprisingly complex function for the Salmonella enterica type III secretion-associated chaperone SicA.

Site-specific heterodimerization by paired class homeodomain proteins mediates selective transcriptional responses.

Alx4 is a paired class homeodomain protein involved in defining anterior/posterior polarity in the developing limb bud. The paired class of homeodomain proteins cooperatively bind palindromic DNA elements as homodimers or as heterodimers with other paired homeodomain proteins. Previous characterization demonstrates that the strength of the cooperativity as well as the preference for targets is dictated largely by the identity of amino acid 50 of the homeodomain. Here we compare and contrast the DNA binding properties of a glutamine 50 paired homeodomain protein, Alx4, and a lysine 50 paired homeodomain protein, Goosecoid. We demonstrate that Alx4 homodimers, Gsc homodimers, and Alx4/Gsc heterodimers each have distinct DNA binding properties, and each can discriminate between highly related palindromic elements. Using reporter gene assays, we show that Alx4 activates transcription in a site-specific manner, and that Gsc is capable of antagonizing Alx4-mediated activation only from promoter elements that support heterodimer formation. These data demonstrate that paired homeodomain proteins with different DNA binding properties are able to form heterodimeric complexes with unique DNA binding and transcriptional activities. Thus, heterodimerization regulates the DNA binding specificity of these transcription factors and may partially explain how paired homeodomain proteins direct specific developmental functions.

Tumour necrosis factor-alpha induces Langerhans cell migration in humans.

The role of tumour necrosis factor (TNF)-alpha in the mobilization and migration of human epidermal Langerhans cells (LC) has been investigated. Intradermal injection of normal human volunteers with homologous recombinant TNF-alpha was found to cause a dose-dependent reduction in the frequency of LC within epidermal sheets 2 h later. Equivalent results were obtained when epidermal LC were identified on the basis of either CD1a or HLA-DR expression. At the dose of TNF-alpha used routinely (500 U), treatment resulted in an average reduction in LC density of approximately 24%. Treatment with TNF-alpha was associated with a perivascular polymorphonuclear infiltration at 2 h, but the epidermis appeared normal with neither fibrinoid necrosis nor vasculitis, and LC morphology was not affected significantly. These results demonstrate that TNF-alpha provides an important signal for LC migration in humans and is likely therefore to play a crucial part in the induction of cutaneous immune responses.

Lichen planus is not associated with hepatitis C virus infection in patients from north west England.

It has been suggested that infection with hepatitis C virus may be associated with the development of lichen planus and that geographical area may be an important factor affecting the relative risk. The present 2-centre, prospective, epidemiological study investigates this possible association in north west England. A total of 45 patients with classical and/or erosive mucous membrane lichen planus and 32 controls were tested for seropositivity to hepatitis C virus. None of the patients with lichen planus and only 1 of the control patients had serological evidence of infection with hepatitis C. Whilst there may be an important association between these 2 diseases in other countries, this study suggests that this does not appear to be the case in north west England and, furthermore, provides no evidence to advise routine investigation to exclude hepatitis C in patients with lichen planus in this region.