Colgajo en cometa como tratamiento de secuelas de quemadura en pulgar / Kite flap for correction of thumb deformities after burn

Introducción. Múltiples técnicas han sido descriptas para la reconstitutición de la función del pulgar quemado, aunque sin relación costo-beneficio. El colgajo en cometa, descripto por Foucher en 1979, aporta cobertura cutánea, sensibilidad y permite mejoría funcional. El objetivo de este trabajo es presentar nuestra experiencia y resultados utilizando el kite flap. Materiales y métodos. Se realiza un estudio restrospectivo, descriptivo, de 4 casos de secuelas de quemaduras en pulgar de la mano atendidas en el Servicio de Cirugía Plástica y Reparadora del Hospital de Quemados de la Ciudad de Buenos Aires en un periodo comprendido desde el año 2016 al 2019. Se realizan colgajos en cometa en isla o tunelizados y posterior rehabilitación kinésica. El seguimiento mínimo de la serie es de 3 meses y se toman registros fotográficos pre-, intra- y posoperatorios. Las variables analizadas incluyen: sufrimiento de colgajos, dehiscencia, congestión venosa, prendimiento de injertos en zona dadora, reintervenciones y mejoría en la función de abducción del pulgar y pinza de la mano. Resultados. Se realizaron 3 colgajos en cometa tunelizados y 1 en isla. La totalidad se presentaron vitales aunque con congestión venosa en las primeras 72 hs. No se registraron complicaciones y no fueron necesarias reintervenciones. La mejoría en la función de pinza y de abducción del pulgar fue objetivable mediante la observación y referida por los pacientes y/o familiares según correspondiera. Conclusiones. Creemos que el colgajo en cometa es la mejor opción de tratamiento para las secuelas de quemadura en pulgar por aportar adecuada cobertura cutánea, ser técnicamente sencillo y poder hallar el pedículo en el 100% de la población. La congestión venosa es la regla, aunque también la supervivencia, siendo la morbilidad de la zona dadora mínima y la mejoría en la función de pinza y abducción del pulgar francamente objetivable.

Introduction. Multiple techniques have been described for repair the burned thumb function, although without cost-benefit ratio. The kite flap described by Foucher in 1979, provides skin coverage, sensitivity and allows functional improvement. The goal of this study it to present our experience and results obtained using the kite flap Materials and methods. A retrospective, descriptive study of 4 cases of burned hand's thumb treated in the Plastic Surgery Unit of the Hospital de Quemados on Buenos Aires in a three year's period from 2016 to 2019. Island or tunneled's kite flaps and subsequent kinesic rehabilitation are performed. The minimum follow-up of the series is 3 months and fotographic records pre, intra and postoperative are taken. The variables analyzed include: suffering from flaps, dehiscence, venous congestion, grafting losts on the donor zone, reinterventions and improvement in the function of thumb abduction and hand clamp . Results. 3 tunelled kite flaps and 1 on island were made. All of them were vital, although with venous congestion in the first 72 hours. No complications were recorded and no reinterventions were necessary. The improvement in hand clamp function and thumb abduction was marked through observation and when it posible, referred by patients. Conclusions. We believe that kite flap is the best option of treatment for sequelae of burns affecting hand's thumb for providing adequate skin coverage, being technically simple and being able to find the pedicle at 100% of the population. Venous congestion is the rule, although survival is also. Donor zone´s morbidity is minimal and the improvement in thumb function is clear

Patterns of adaptation and school performance: a pilot study.

A group of 34 pupils from two school classes (Class 8, M = 13.1 yr., SD=0.5) were administered the Serial Color-Word Test to assess the pattern of adaptation during repeated exposure to the Stroop task (5 massed trials). The typological classification, centered on measures of linear (R) and nonlinear (V) change of reading times, employed norms derived from the medians of the group. The Stabilized primary pattern (low R and low V) corresponded to higher grades, compared with the other 3 primary patterns. Concerning the secondary classification across trials (based on the R and V of the 5 Rs, and on the R and V of the 5 Vs), better school performance was found among subjects with a linear increase of linear changes across trials (high R of the 5 Rs; CR pattern), compared with subjects with a nonlinear increase of linear changes (high V of the 5 Rs; DR and CDR patterns).

Patterns of adaptation and directions of aggression.

A group of 85 nonclinical women volunteers were given the Serial Color-Word Test and the Personality Deviance Scale to verify whether different patterns of adaptation to the Stroop task correspond to significant differences in directing aggression. It was predicted that subjects with the Dissociative pattern, i.e., high values of nonlinear changes in reading times, would score lower on Intropunitiveness than subjects with the Cumulative pattern, i.e., high values of linear changes in reading times. The hypothesis was confirmed (p = .005). No other significant intergroup difference was found, aside from a slightly higher mean score of Extrapunitiveness in the Cumulative group, compared with that for the Stabilized one (p = .04).

Patterns of adaptation in asthma and psoriasis.

Patterns of adaptation to a conflict situation were explored by means of the repeated confrontation with the Stroop task (Serial Color-Word Test) in two clinical groups: bronchial asthma (n=40) and psoriasis (n=28). The respective psychosomatic component of each of these syndromes was expected to correspond to peculiar patterns of adaptation. Differences between asthma and psoriasis patients were statistically significant. Asthma was characterized by patterns with high values of nonlinear change, both within each subtest (Primary Types) and across the five subtests (Secondary Types). Psoriatic patients were classified most often as having the C(V) type (high linear increase of nonlinear changes across the subtests) and showed some more ITA+ types, i.e., within the first subtest, longer reading time at the beginning, followed by uniformly faster times.

Self-report of basic symptoms among psychotic and nonpsychotic subjects.

Basic symptoms, as defined and described by the Bonn Scale, were assessed by means of a new self-report inventory, the Rome Basic Disorders Scale. On all the subscales, psychiatric outpatients (n = 105; most frequent diagnoses: Schizophrenia, Anxiety Disorders, and Mood Disorders) scored significantly higher (p < .001) than nonclinical controls (n = 105). Psychiatric patients with at least one diagnosis on the psychotic sets of Foulds' hierarchical inventory (n = 45), compared with the rest of the psychiatric sample (n = 60), had significantly higher scores on nearly all subscales. Two groups of inpatients with Schizophrenia (n = 20) and Mood Disorders (n = 20) were tested on Day 2 and 9 of hospitalization in an emergency ward. Schizophrenic patients had significantly higher scores on most of the subscales, but only on Day 9; on Day 2 depressed and manic patients scored significantly higher on four subscales. Until now basic symptoms had not been studied during the intrapsychotic phase, mainly because of their transformation into first-rank symptoms; present findings suggest that basic symptoms are active also at the height of the psychotic breakdown and that they are more responsive to treatment in Depression and Mania than in Schizophrenia.

Perceptual defense mechanisms in Crohn's disease and panic disorder.

The defense organization of Crohn's disease and Panic Disorder was studied with a well-validated tachistoscopic paradigm, the Defense Mechanism Test. Three sex- and age-matched groups of 34 subjects (Crohn, Panic, and Nonclinical) were compared on the main codings of defense. Crohn patients were characterized by stereotypy and lack of recognition of the threat. The Panic group presented clearly higher frequencies of protocols with repression, isolation, and disappearance of the threat. Especially was the strongest variant of isolation, barrier-isolation, typical of the defensive substructure of panic patients.

Perceptual defenses and self-rated personality disorders: a multivariate analysis.

The relationships between defense mechanisms and personality disorders were explored by means of the Defense Mechanism Test and Millon's Inventory-II in a group of 100 psychiatric nonpsychotic outpatients. Only few significant positive nonparametric correlations were found, concerning barrier isolation, intro-aggression, and lateness of the threat. Also multiple regression analysis evidenced few significant results and mostly in the negative direction. The unpredicted findings may have been partly determined by a general elevation of personality scale scores (due to the emotional distress of psychiatric), leading to a loss of interindividual differences.

Foulds' hierarchy: validation of predictions in psychiatric and dermatological patients.

Foulds' inclusive non-reflexive law of symptom formation has been hitherto confirmed only on psychiatric or non-clinical persons. Given that respectively a yes-bias and a high frequency of non-classified patients may have inflated the rate of confirming protocols in these groups, a validation study was conducted with the Delusions-Symptoms-States Inventory (DSSI) on 188 psychiatric and 295 dermatological patients. Although non-classified patients were not included in the study (thus lowering the number of conforming patterns), both samples showed percentages of patterns conforming to Foulds' law which were above 85 per cent. No significant intergroup difference was found. The rate of conforming patterns in both groups was lower for members of the two psychotic classes (61-77 per cent). Foulds further hypothesized that the number of pathological sets within a given class grows if there is allocation into a superordinate class. This assumption was confirmed in both groups and for most of the inter-class comparisons. Suggestions were advanced to clarify the issue of the time span to be covered by Foulds' pyramid, to refine the instructions and the response format of the DSSI, and to include into the pyramid further relevant disturbances.

General cognitive abilities and patterns of adaptation: for Serial Color-Word Test norms based on reading times.

In a pool of 859 clinical and nonclinical Serial Color-Word Test protocols, significant positive correlations were observed between reading times on the Stroop task and measures of linear and nonlinear change. Especially nonlinear change, both within and between the five subtests, showed high correlations with reading times. To derive new time-related norms, the sample was divided into five time groups of the same size and stratified medians were calculated for each of the variables of the test. The new classification procedure should permit an assessment of patterns of adaptation less dependent on the general level of perceptual-cognitive functioning.

Symptom profile, Axis II comorbidity and suicidal behaviour in young males with DSM-III-R depressive illnesses.

We assessed the descriptive validity of DSM-III-R major depression (MDD), dysthymia (DD) and adjustment disorder with depressed mood (ADDM) by comparing the clinical profiles of 176 young male patients. The severity of depression increased progressively across the three diagnostic groups (ADDM < DD < MDD). Symptom presentation did not distinguish clearly between the diagnostic groups, even though somatic symptoms were more frequent among MDD patients. The prevalence of personality disorders was much higher (43%) among DD patients than among MDD (22%) and ADDM (15%) patients. The lifetime prevalence of suicide attempts differed in the three diagnostic groups (MDD 27%, DD 17%, ADDM 4%). Assessment of Axis II comorbidity and suicidal behavior can improve the diagnostic distinction between these DSM-III-R depressive illnesses.

Styles of regulation in the bipolar spectrum.

Styles of regulation were assessed with the Serial Color-Word Test in a group of 35 compensated DSM-III--R bipolar patients (Bipolar) and in 3 control groups: Major Depression (n = 35), Schizophrenia (n = 50), and self-rated Personality Disorder (n = 40). On several measures of nonlinear change (V), patients in the Bipolar group had mean scores between those of the Personality Disorder and the Schizophrenic groups, and overlapped with those of the Major Depression group. Patients in the Bipolar group with clearcut temperaments (hyperthymic or depressive) were significantly more dissociative and less stabilized than other patients in the same group. A further group of nonclinical subjects with hyperthymic temperament (n = 20) was significantly more dissociative than the Personality Disorder group.

Personality disorders and psychiatric symptoms in psoriasis.

Two groups of psoriatic outpatients (ns = 192 and 119) were given, respectively, the Million Clinical Multiaxial Inventory-II and Foulds' Delusions-Symptoms-States Inventory. They were compared with dental (n = 192) and with general surgical (n = 190) patients. The psoriatic group presented clearly higher mean scores and frequencies on most of the personality disorder scales. On Foulds' inventory, psoriatic patients showed higher frequencies of neurotic and psychotic class allocations. A cluster analysis of personality scores provided evidence for 4 different personality clusters of patients with psoriasis: (a) Avoidant, Dependent, Schizoid, and Self-defeating (32.2%), (b) Compulsive, Narcissistic, and Aggressive (30.7%), (c) no personality disorder (18.2%), (d) Borderline, Paranoid, and Schizotypal, etc. (18.8%).

Effects of fluoxetine on aggressive behavior of adult inpatients with mental retardation and epilepsy.

Nineteen mentally retarded inpatients with epilepsy and a history of current or recent aggressive behavior were treated with 20 mg of fluoxetine daily. All were concurrently taking other psychotropic medications, including carbamazepine and neuroleptics. A standardized rating scale (MOAS) was used to assess the effects of fluoxetine on aggressive behavior. There were wide individual differences in drug response. In nine patients, fluoxetine treatment was associated with increased aggression, while drug withdrawal led to a decrease to below pretreatment levels. Two hypotheses concerning the apparent association between fluoxetine and increased aggression are discussed: 1) adverse effects secondary to either drug interaction or fluoxetine overmedication; and 2) a specific serotonergically mediated effect on the regulation of aggression. This study suggests that the clinician who treats mentally retarded patients with impulsive aggressive behavior should remain aware that fluoxetine may have diverse effects on aggression that vary over time and interindividually.

Melancholia: a Defense Mechanism Test study.

The defensive organization of Melancholia was explored with a tachistoscopic percept-genetic technique, the Defense Mechanism Test. A sample of 20 women inpatients with a DSM-III-R diagnosis of Major Depressive Episode or Major Depression, Melancholic Type was contrasted with a matched group of depressed outpatients and a matched group of nonclinical subjects. Signs of introaggression on the hero, statue-repression, and stereotypy significantly characterized melancholic patients. The latter were discriminated from depressed outpatients as showing more signs of stereotypy and of discontinuity. Mask-disguise defenses were typically endorsed by Bipolar melancholic patients and significantly differentiated them from Unipolar melancholic patients. One type of stereotypy (regarding wrong age attributes of the central figure) successfully predicted a poor response to antidepressive therapy. Relevant modifications of the current Defense Mechanism Test coding criteria for stereotypy are proposed.

The efficacy and safety of tianeptine in the treatment of depressive disorder: results of a controlled double-blind multicentre study vs. amitriptyline.

Three hundred in- and outpatients suffering from depressive disorder, as diagnosed using DSM-III criteria were treated for 6 weeks under double-blind conditions in a multicenter controlled study of tianeptine vs. amitriptyline. Both groups presented steady improvement of depressive syndrome from day 7 up to the end of the treatment, as shown by all evaluation scales: HDRS, SAD, CGI. Furthermore, anxiety linked to the depressive syndrome decreased equally in both groups, as shown by the HARS measurements. In addition to the improvement of mood, the tianeptine-treated patients presented less somatic complaints and side effects when compared to the reference antidepressant. These results confirm previous findings that tianeptine is an effective antidepressant with a lower side effect profile than amitriptyline.

Assessment of depression in Alzheimer's disease: symptoms, syndrome, and computed tomography findings.

The Hamilton Rating Scale for Depression (HAM-D) and DSM-III-R criteria were simultaneously employed to assess the prevalence of depression in 26 outpatients with dementia of the Alzheimer type and 26 age-matched normal control subjects. Both assessment methods evidenced a higher frequency of depression during the severe stages of Alzheimer's disease. Among the Alzheimer patients, the prevalence rate of depression produced by the HAM-D (38%) was higher than the rate produced by DSM-III-R criteria (23%). Such a difference was due to the weight given by the HAM-D to the vegetative symptoms reported by the Alzheimer patients with more severe dementia. In a subgroup of 14 Alzheimer patients who underwent computed tomography, the volumetric measurement of CSF spaces did not reveal any difference between the depressed and nondepressed patients. On the basis of these results, the clinical problems related to the assessment of depression in Alzheimer's disease are discussed.

Mania, loss and defense: a percept-genetic investigation.

The defensive organization of manic states has been investigated with the Defense Mechanism Test-Separation Theme. A black and white stimulus portraying a mother figure who is leaving an infant alone was presented tachistoscopically, at increasing durations of exposure, to 22 inpatients who had had a manic episode and to 22 age- and sex-matched normal controls. The manic group was characterized by the following six major defense codings: (1) the infant is able to walk or run, (2) the mother is a rigid, inanimate being, (3) the mother is veiled or disguised, (4) the mother is protective or inviting, (5) the mother is seen as a male figure, and (6) colors are perceived in the colorless stimulus. Controls were more often coded for the denial of mother's actions (she enters the room, she opens a window, etc). The findings were discussed in the context of the pertinent percept-genetic and psychoanalytic literature.

Alexithymia as related to sex, age, and educational level: results of the Toronto Alexithymia Scale in 417 normal subjects.

The Toronto Alexithymia Scale (TAS) was administered to 417 normal subjects. Total TAS scores and scores of the four TAS factors were correlated with sex, age, and educational level. Age ranged from 21 to 64 years. The sample was subdivided into three groups according to age. TAS scores, both total and on single subfactors, were significantly greater in the higher age groups with respect to lower age groups. Subjects with a lower educational level scored higher on factors 1, 2, and 4 and had higher TAS total scores with respect to subjects with a higher educational level. As for sex, no significant differences in total TAS scores were obtained, but women scored higher at factor 1. Factor analysis of the TAS, performed on both the whole sample and the subgroups according to sex and age, confirmed the fair internal stability of the TAS.

A study of schizophrenic outpatients with the Defense Mechanism Test.

Intrapsychic defensive strategies are allegedly expressed on the Defense Mechanism Test through the presentation, at increasing tachistoscopic exposure times, of a picture in which a central figure is threatened by a peripheral person. Several types of perceptual alterations of the stimulus configuration are coded as defenses in the subjective reports. A number of test variables have already been shown to differentiate significantly between nonclinical controls and nonpsychotic psychiatric patients. In the present study, after a review of the pertinent percept-genetic literature, nonpsychotic patients (n = 57) were compared with a group of schizophrenic outpatients in the active phase (n = 21). As predicted, significantly more schizophrenics than controls were coded for projection and regression and for certain variants of these signs. Four subcodings of repression, three of isolation, the sign of reaction formation, and several variants of identification differentiated in the same direction. Reports in which the central figure was too old and changed from a correct to an incorrect sex attribution were highly characteristic of the schizophrenic sample. No defensive variable was significantly linked with nonpsychotic pathology. Two variants, one of regression and one of identification, allowed a correct diagnostic placement for all schizophrenics and for 82.4% of the nonpsychotic patients. The findings, besides being a further clinical validation of the Defense Mechanism Test, provide a preliminary distinction between high- and low-level defenses. It is suggested that they are congruent with an hierarchical model which implies inclusive nonreflexive relationships between classes of mental disorders.

Negative symptoms and visual behavior in DSM-III-R prognostic subtypes of schizophreniform disorder.

Eighteen male patients with a DSM-III-R diagnosis of schizophreniform disorder were rated on the Scale for the Assessment of Negative Symptoms and their visual behavior during interview was recorded through an ethological technique. Affective flattening, alogia and the global severity of the negative-symptom syndrome were found to be more prominent among poor-prognosis patients. In addition, compared with patients with good prognostic features, poor-prognosis patients showed a pattern of visual behavior (less eye contact and more eye closures) suggesting poor rapport with the interviewer. The results demonstrate that cross-sectional phenomenology of patients with DSM-III-R schizophreniform disorder shows differences in important clinical domains, such as negative symptoms and capacity to establish and maintain social interaction.