Brachial artery protected by wrapped latissimus dorsi muscle flap in high voltage electrical injury.

High voltage electrical injury can disrupt the vascular system and lead to extremity amputations. It is important to protect main vessels from progressive burn necrosis in order to salvage a limb. The brachial artery should be totally isolated from the burned area by a muscle flap to prevent vessel disruption. In this study, we report the use of a wrap-around latissimus dorsi muscle flap to protect a skeletonized brachial artery in a high voltage electrical injury in order to salvage the upper extremity and restore function. The flap wrapped around the exposed brachial artery segment and luminal status of the artery was assessed using magnetic resonance angiography. No vascular intervention was required. The flap survived completely with good elbow function. Extremity amputation was not encountered. This method using a latissimus dorsi flap allows the surgeon to protect the main upper extremity artery and reconstruct arm defects, which contributes to restoring arm function in high voltage electrical injury.

Les lésions électriques par haut voltage peuvent perturber le système vasculaire et conduire à une amputation distale. Il est important de protéger les vaisseaux principaux d'une nécrose extensive et sauver ainsi un membre. L'artère humérale peut-être totalement séparée de la zone brûlée par un lambeau musculaire pour prévenir toute répercussion vasculaire. Dans cette étude, nous rapportons l'utilisation d'un lambeau de grand dorsal enveloppant pour protéger une artère humérale à nu lors d'une brûlure de haut voltage, afin de sauver le membre supérieur et de récupérer la fonction. Le lambeau enveloppant l'artère humérale exposée et la perméabilité vasculaire ont été contrôlés par une angiographie numérisée. Aucune intervention vasculaire ne fut nécessaire. Le lambeau a survécu complètement avec une bonne fonction du coude. L'amputation distale a été évitée. Cette méthode utilisant un lambeau de grand dorsal permet au chirurgien de protéger la principale artère du membre supérieur et de reconstruire les pertes de substance du bras avec restauration des fonctions dans les brûlures de haut voltage.

Salvage of a free osteocutaneous fibula flap by creating a distal arteriovenous fistula in facial reconstruction.

The case of a 25-year-old male with a facial gunshot wound is reported. A free fibula flap was performed for facial reconstruction. At 48 h after the operation, a thrombotic event was observed in the anastomosis. A distal arteriovenous (AV) fistula was performed to regulate the blood flow in the flap, and a combination of flaps (forehead flap and internal mammary artery perforator (IMAP) flap) was used for the skin defects. After creating the distal AV fistula, the blood flow was regulated and the free flap salvaged. No bone healing problem was observed in the free fibula flap and there were no complications related to the forehead and IMAP flaps. The fistula was patent at 2 years postoperative. Although all high-resistance flap conditions cannot be corrected with a distal AV fistula, the method presented in this case could be used as a last resort procedure for free flap salvage.

A new technique for the surgical repair of double cleft earlobe: modified Millard's rotation-advancement flap.

The double cleft earlobe is a rare earlobe deformation. The most common causes of cleft earlobe are earring or piercing tear injuries and trauma. In this study, the cases of five patients (all women) attending the clinic between 2010 and 2013 suffering from a unilateral traumatic complete double earlobe cleft as a result of an earring injury were evaluated. The principles of Millard's cleft lip repair were applied during the repair of these double cleft earlobe deformities. This adaptation of Millard's technique to repair double earlobe clefts with a non-straight closure appears to give satisfactory results.

A comparison between low-dose (1 microg), standard-dose (250 microg) ACTH stimulation tests and insulin tolerance test in the evaluation of hypothalamo-pituitary-adrenal axis in primary fibromyalgia syndrome.

OBJECTIVE: Primary fibromyalgia syndrome (PFS) is a nonarticular rheumatological syndrome characterized by disturbances in the hypothalamo-pituitary-adrenal (HPA) axis. The site of the defect in the HPA axis is a matter of debate. Our aim was to evaluate the HPA axis by the insulin-tolerance test (ITT), standard dose (250 microg) ACTH test (SDT) and low dose (1 microg) ACTH test (LDT) in patients with PFS. DESIGN AND PATIENTS: Sixteen patients (13 female, three male) with PFS were included in the study. Sixteen healthy subjects (12 female, four male) served as matched controls. ACTH stimulation tests were carried out by using 1 microg and 250 microg intravenous (i.v.) ACTH as a bolus injection after an overnight fast, and blood samples were drawn at 0, 30 and 60 min. The ITT was performed by using i.v. soluble insulin, and serum glucose and cortisol levels were measured before and after 30, 60, 90 and 120 min. The 1 microg and 250 microg ACTH stimulation tests and the ITT were performed consecutively. RESULTS: Peak cortisol responses to both the low dose test (LDT) and standard dose test (SDT) (589 +/- 100 nmol/l; 777 +/- 119 nmol/l, respectively) were lower in the PFS group than in the control group (1001 +/- 370 nmol/l; 1205 +/- 386 nmol/l, respectively) (P < 0.0001). Peak cortisol responses to ITT (730 +/- 81 nmol/l) in the PFS group were lower than in the control group (1219 +/- 412 nmol/l) (P < 0.0001). Six of the 16 patients with PFS had peak cortisol responses to LDT lower than the lowest peak cortisol response of 555 nmol/l obtained in healthy subjects after LDT. There was a significant difference between the peak cortisol responses to LDT (589 +/- 100 nmol/l) and peak cortisol responses to ITT (730 +/- 81 nmol/l) in the PFS group (P < 0.0001). Peak cortisol responses to SDT (777 +/- 119 nmol/l) were similar to peak cortisol responses to ITT (730 +/- 81 nmol/l) in the PFS group. CONCLUSION: We conclude that the perturbation of the HPA axis in PFS is characterized by underactivation of the HPA axis. Some patients with PFS may have subnormal adrenocortical function. LDT is more sensitive than SDT or ITT in the investigation of the HPA axis to determine the subnormal adrenocortical function in patients with PFS.

The effects of rHuEPO administration on pulmonary functions in haemodialysis patients.

The aim of this study was to investigate the effects of erythropoietin therapy on pulmonary functions in haemodialysis patients. Thirteen patients with chronic renal failure on regular haemodialysis and in need of treatment for anaemia were treated with 45-60 U/kg erythropoietin three times a week. Thirteen haemodialysis patients constituted the control group. Patients receiving erythropoietin were given pulmonary function tests prior to the treatment and after Hb levels had reached 10 g/dl. The interval between first and second pulmonary function tests was similar for both the control group and the erythropoietin group. There was no significant difference between the results of the first and the second pulmonary function tests of the control group. However, in the erythropoietin group, the diffusing capacity, maximal voluntary ventilation, forced vital capacity and peak expiratory flow rate values increased significantly. The existence of a relationship between the diffusing capacity and anaemia is well known. Rises in other parameters following erythropoietin administration might be the result of a gain in respiratory muscle strength consequent to anaemia correction.

Enantioselective gallopamil protein binding.

The protein binding of the enantiomers of gallopamil has been investigated in solutions of human serum albumin, alpha 1-acid glycoprotein and serum. Over the range of concentrations attained after oral gallopamil administration, the binding of both enantiomers to albumin, alpha 1-acid glycoprotein, and serum proteins was independent of gallopamil concentration. The binding to both human serum albumin (40 g/liter) [range of fraction bound (fb) R: 0.624 to 0.699; S: 0.502 to 0.605] and alpha 1-acid glycoprotein (0.5 g/liter) (range of fb R: 0.530 to 0.718; S: 0.502 to 0.620) was stereoselective, favoring the (R)-enantiomer (predialysis gallopamil concentrations 2.5 to 10,000 ng/ml). When the enantiomers (predialysis gallopamil concentration 10 ng/ml) were studied separately in drug-free serum samples from six healthy volunteers the fraction of (S)-gallopamil bound (fb: 0.943 +/- 0.016) was lower (P < 0.05) than that of (R)-gallopamil (fb: 0.960 +/- 0.010). The serum protein binding of both (R)- and (S)-gallopamil was unaffected by their optical antipodes (fb R: 0.963 +/- 0.011; S: 0.948 +/- 0.015) indicating that at therapeutic concentrations a protein binding enantiomer-enantiomer interaction does not occur. The protein binding of (R)- and (S)-gallopamil ex vivo 2 h after single dose oral administration of 50 mg pseudoracemic gallopamil (fb R: 0.960 +/- 0.010: predialysis [R] 6.9 to 35.3 ng/ml; S: 0.943 +/- 0.016: predialysis [S] 9.5 to 30.7 ng/ml) was comparable to that observed in vitro in drug-free serum. Gallopamil metabolites formed during first-pass following oral administration, therefore, do not influence the protein binding of (R)- or (S)-gallopamil.