Upper extremity deep vein thrombosis with tourniquet use.

INTRODUCTION: Upper extremity deep vein thrombosis is an increasingly important clinical finding with significant morbidity and mortality. The condition may be under-diagnosed in trauma and surgery settings. PRESENTATION OF CASE: We present a case of upper extremity thrombosis with venous congestive symptoms secondary to the use of an operative tourniquet. A literature review and discussion of the causes of upper extremity deep vein thrombosis and the pathophysiological disturbances seen with tourniquet use are presented. DISCUSSION: Upper extremity deep venous thrombosis is uncommon. In this case the likely cause was operative tourniquet use. CONCLUSION: Operative tourniquet may be a risk factor in upper extremity deep vein thrombosis.

Primary breast lymphoma after mastectomy with reconstruction.

Primary breast lymphoma accounts for only 0.05%-1.1% of all breast malignancies, and less than 1% of all cases of non-Hodgkin lymphoma. Although primary breast lymphoma may present clinical similarities to breast carcinoma, the majority of cases lack the typical features of breast malignancy or lymphoma. We describe a case of primary breast lymphoma in a reconstructed breast, 8 years after a mastectomy for breast cancer. To the best of our knowledge, this is the first reported case in the worldwide literature of primary breast lymphoma in a reconstructed breast. We will discuss the diagnostic and treatment strategies involved in the management of primary breast lymphoma, and the effect of breast reconstruction on the detection of recurrent breast cancer.

Nail-gun injuries to the hand.

BACKGROUND: The nail gun is a commonly utilized tool in carpentry and construction. When used properly with appropriate safety precautions, it can facilitate production and boost efficiency; however, this powerful tool also has the potential to cause serious injury. The most common site of nail-gun injuries in both industrial and nonoccupational settings is the hand. MATERIALS AND METHODS: We report on two patients with nail-gun injuries to the hand. A review of the literature and discussion of clinical evaluation and treatment of nail-gun injuries to the hand are presented. RESULTS: Two patients present with soft tissue injuries to the hand with the nail embedded and intact at the injury site. Operative removal of the nail and wound care resulted in successful treatment in both cases. Nail-gun injuries to the hand vary in severity on the basis of the extent of structural damage. Treatment is based on the severity of injury and the presence and location of barbs on the penetrating nail. CONCLUSION: Healthcare providers must understand and educate patients on the prevention mechanics of nail-gun injuries. Nail-gun injuries to the hand necessitate appropriate evaluation techniques, understanding of surgical management versus nonsurgical management, and awareness of potential pitfalls in treatment.

Osteomyelitis of the mandibular symphysis caused by brown recluse spider bite.

BACKGROUND: Brown recluse spider bites cause significant trauma via their tissue toxic venom. Diagnosis of these injuries and envenomation is difficult and many times presumptive. Treatment is varied and dependent upon presentation and course of injury. MATERIALS AND METHODS: We present a case of a previously unreported incidence of osteomyelitis of the mandible as a result of a brown recluse spider bite. A review of the literature and discussion of diagnosis and treatment of brown recluse spider bites are presented. RESULTS: Osteomyelitis of the mandible causing a chronic wound was the presenting finding of a patient with a history of spider bite and exposure to brown recluse spiders. Operative debridement and wound closure resulted in successful treatment. Brown recluse spider envenomation varies in its presentation and treatment is based on the presenting clinical picture. CONCLUSION: Treatment regimens for brown recluse spider bite envenomation should include the basics of wound care. Systemic antibiotics, topical antimicrobials, dapsone, and surgical debridement are valuable adjuncts of treatment, as indicated, based on the clinical course.

Enzymatic debriding agents are safe in wounds with high bacterial bioburdens and stimulate healing.

BACKGROUND: Debridement is essential for successful wound management. Enzymatic debridement is commonly utilized in wound care but has been reported to be unsafe in wounds with significant bacterial bioburden, unless used in conjunction with topical antimicrobials. We examine this hypothesis with 2 commercially available, commonly used preparations of enzymatic debriding agents. MATERIALS AND METHODS: Using a standard rodent model of a chronically infected granulating wound with bacterial levels greater than 1 x 10(5) Colony Forming Units per gram of tissue, commercially available preparations of collagenase and papain-urea were utilized to investigate the response of infected wounds to these preparations, and to evaluate their ability to overcome the inhibition of infection on wound healing. Quantitative bacteriology of tissue biopsies and wound healing trajectories were used to compare the preparations to saline-treated negative controls. RESULTS: Collagenase- and papain-urea-treated wounds demonstrated a reduction in bacterial burden of wounds to < 10(5) colony forming units/gram of tissue (P < .05). This decrease in bacterial bioburden occurred rapidly, allowing wounds to achieve bacterial balance in a short period of time. Wounds treated with enzymatic debriding agents healed significantly faster and to greater extent than saline-treated controls (P < .01); a direct reflection of the decreasing bacterial load of the wound. CONCLUSIONS: Collagenase and papain-urea appear beneficial and safe even in wounds with high bacterial loads, and appear to significantly aid extent and rate of healing, probably by lowering bacterial burden through their positive enzymatic actions on bacteria and necrotic tissue.

Attitudes of surgical specialists toward venous thromboembolism prophylaxis in surgical patients.

Venous thromboembolism (VTE) and pulmonary embolism are serious and potentially life-threatening complications in surgical patients; however, the risk can effectively be lessened using appropriate pharmaceutical and mechanical prophylaxis. Due to the variability in opinions and indications for VTE prophylaxis, proposed guidelines for VTE prophylaxis stratified according to patient- and procedure-oriented risk factors were widely circulated. We investigated to what extent these guidelines were accepted by 147 university and community-based surgeons in mid-America and how the recommendations for prophylaxis compared with recent past surgical practice performed on 5285 patients in Kentucky in 2004. Attitudes varied widely with respect to practice sites, modes, and specialty. Actual practices used in the Surgical Care Improvement Project 2004 varied even more widely and were at substantial variance from recommendations and current Centers for Medicare and Medicaid Services quality measures.

Nonvenomous bite injuries of the foot: case reports and review of the literature.

Animal bite injuries to humans are relatively common, however, bite injuries to the lower extremity and more specifically the foot are relatively uncommon. Foot injuries, once infected, may lead to further complications, such as soft tissue loss, bone loss, and the need for amputation. Patients with preexisting medical conditions, such as peripheral vascular disease and diabetes, are especially at risk for such complications. In this article, 2 recent cases are detailed and the literature to examine these injuries of the foot is reviewed.

Wound healing in patients with cancer.

OBJECTIVE: The treatment of patients with cancer has advanced into a complex, multimodal approach incorporating surgery, radiation, and chemotherapy. Managing wounds in this population is complicated by tumor biology, the patient's disease state, and additional comorbidities, some of which may be iatrogenic. Radiation therapy, frequently employed for local-regional control of disease following surgical resection, has quantifiable negative healing effects due to local tissue fibrosis and vascular effects. Chemotherapeutic agents, either administered alone or as combination therapy with surgery and radiation, may have detrimental effects on the rapidly dividing tissues of healing wounds. Overall nutritional status, often diminished in patients with cancer, is an important aspect to the ability of patients to heal after surgical procedures and/or treatment regimens. METHODS: An extensive literature search was performed to gather pertinent information on the topic of wound healing in patients with cancer. The effects that surgical procedures, radiation therapy, chemotherapy, and nutritional deficits play in wound healing in these patients were reviewed and collated. RESULTS: The current knowledge and treatment of these aspects of wound healing in cancer patients are discussed, and observations and recommendations for optimal wound healing results are considered. CONCLUSION: Although wound healing may proceed in a relatively unimpeded manner for many patients with cancer, there is a potential for wound failure due to the nature and effects of the oncologic disease process and its treatments.

Risk acceptance in composite-tissue allotransplantation reconstructive procedures.

Composite-tissue allotransplantation (CTA) is a new therapeutic modality to reconstruct major tissue defects of the face, larynx, and extremities. Unlike most life-saving organ-transplantation procedures, CTA is considered to improve quality of life. Therefore, the question arises, do the risks posed by the immunosuppression drugs that patients must take to prevent rejection justify the benefits of these procedures? The purpose of this study was to assess the relative risk that individuals are willing to accept in order to receive the benefits of CTA procedures. We used a psychometrically reliable and valid instrument to question two primary populations of individuals: those who live with the risks of immunosuppression, and healthy individuals. The level of risk acceptance for the seven transplant procedures tested (foot, single hand, double hand, larynx, kidney, hemiface, and full face) showed significant differences in research participants' risk acceptance for the different transplant procedures, but no significant differences between groups. Based on these findings, we conclude that certain CTA procedures convey benefits to recipients that are perceived by subjects, including individuals who live with the risks of immunosuppression, to warrant the risks of these procedures.

A prospective study of a focused, surgeon-performed ultrasound examination for the detection of occult common femoral vein thrombosis in critically ill patients.

HYPOTHESIS: A focused, surgeon-performed ultrasound examination of the common femoral veins is an accurate screening tool for the detection of common femoral vein thrombosis in high-risk, critically ill patients. DESIGN: A prospective study using a focused ultrasound examination for findings consistent with deep vein thrombosis of the common femoral veins. The results of these examinations were compared with those of duplex imaging or computed tomographic venography studies. SETTING: Surgical intensive care unit. PATIENTS: All critically ill patients who were admitted to the surgical intensive care unit and considered to be at high risk for the development of deep vein thrombosis. MAIN OUTCOME MEASURE: Presence of deep vein thrombosis in the common femoral veins. RESULTS: During a 16-month period, surgeons performed 306 ultrasound examinations on 220 critically ill surgical patients. The results included 295 true negative, 9 true positive, 1 false negative, and 1 false positive, yielding a 90.0% sensitivity, 99.6% specificity, and 99.3% accuracy. CONCLUSION: A focused, surgeon-performed ultrasound examination is a rapid and accurate screening method to detect common femoral vein thrombosis in critically ill patients as well as to examine those patients in whom pulmonary embolism is strongly suspected.