Use of higher dose extended interval aminoglycosides in a neonatal intensive care unit.

The objective of this study is to determine the safety and efficacy of an extended interval aminoglycoside dosing guideline implemented in our neonatal intensive care unit (NICU). A retrospective review of pharmacokinetic data on 44 patients led to the development of an extended interval aminoglycoside guideline utilizing a 5-mg/kg dose given at an interval based on postconceptional age and risk factors that may alter aminoglycoside clearance. After implementation of the new clinical guideline, a retrospective review of patient records was performed. Thirty-six of 43 peak levels were within the goal range. Trough levels were <1 microg/mL in 41 of 46 patients, with no trough >2 microg/mL. Thirty-three patients had clinical or culture proven sepsis and were successfully treated with the new regimen. No difference between pre- and post-treatment blood urea nitrogen (BUN) and serum creatinine values was observed. Hearing evaluations were performed in 32 patients with one failure. The patient who failed the hearing screen, passed a follow-up hearing test. Three deaths, none attributed to infection or the drug, occurred during the evaluation period. The dosing guidelines developed for our NICU patients are safe and effective, although evaluation of the longterm potential for ototoxicity should be performed.

[Successful ear replantation without venous anastomosis by using leeches]. / Erfolgreiche Ohrreplantation ohne Venenanastomose durch Applikation von Blutegeln.

Replantation of the ear is a challenging problem for the reconstructive surgeon. Avulsion injury and intima tears of these small vessels often make back cuts and venous interposition necessary. Furthermore, identification and differentiation of the vessels are difficult. The volume of the ear is large in relation to the wound surface and the absence of axial venous outflow makes replantation prone to venous congestion. On the basis of a case report we present the problems, the specific management and final outcome of a successful ear replantation and we discuss the alternative possibilities of reconstruction.

Flap salvage in a "flow-through" flap by manual thrombectomy plus thrombolytic therapy.

A delay in identifying incipient flap failure may inevitably lead to complete pedicle thrombosis and the no-reflow phenomenon. The authors report a clinical case of a lateral arm free flap that suffered complete pedicle thrombosis. They successfully salvaged this flap, a type C fasciocutaneous "flow-through" flap, by manually moving the thrombus from proximal to distal in the main flap artery. This freed the septofasciocutaneous upward-perforating branches, by smoothing and applying firm pressure to the vessel, combined with thrombolytic therapy. Their technique is offered as an alternative procedure for salvaging a failing flow-through flap.

Inhalation injury treated with extracorporeal CO2 elimination.

A 38-year-old male was admitted to the intensive care unit with a full-thickness burn involving 30 per cent of his total body surface area (TBSA) and severe inhalation injury. Respiratory failure developed within 54 h and CO2 could not be eliminated, even by very invasive mechanical ventilation. Because of the patient's age and the minor extent of the burned TBSA, we started extracorporeal CO2 elimination (ECCO2-R) and continued ECCO2-R for 30 days, when the patient was weaned from ECC. The clinical course during ECCO2-R was complicated by major bleeding from a thoracotomy tube, from the site of tangential excision and by four septic episodes. Lung biopsy was performed twice on day 29 (during ECCO2-R) and day 58 (after ECCO2-R) after admission and revealed bronchiolitis obliterans without tendency to recovery. The patient died of sepsis with multiorgan failure on day 81 after trauma.

[Indications and concepts for plastic surgery therapy in chronic varicose ulcer]. / Indikation und Konzepte zur plastisch-chirurgischen Therapie bei chronisch-venösen Ulcera cruris.

In the treatment of extensive leg ulcers, surgical therapy is superior to conservative methods in many respects. Radical resection of sclerotic tissue around the ulcer and its causing veins is essential, followed by defect cover with mesh-skin grafts. Surgery leads to prompt healing with a shortened hospitalization and therefore decreases costs; it leads to a prompt relief of pain and a low rate of recurrence. Especially in the aged patient the indication for operation must be well-considered and discussed interdisciplinarily. Even though operative technique seems to be simple, it should be reserved for the plastic surgeon experienced in the treatment of these lesions.

Emergency free tissue transfer for severe upper extremity injuries.

29 patients with severe upper extremity injury were treated with 27 emergency free flap and three emergency toe-to-hand transfers, after radical débridement and primary reconstruction of all injured structures. There was no flap failure, and no infections or wound-healing complication were seen. Follow-up ranged from 3 months to 6.6 years with a mean of 3.2 years. 19 patients returned to work (14 to their original jobs), three were retired and another seven had no employment before injury. Operation time ranged from 2 hours 45 minutes to 18 hours 20 minutes with an average of 7 hours 45 minutes, depending upon the size of the defect and mechanism of injury. Long-term follow-up revealed successful functional and aesthetic results, decreased morbidity and invalidity, and reduced rates of free flap failure, post-operative infection, secondary operative procedures, hospital stay and medical expense.

[Effect of heading in soccer on the head--a quantifying EEG study of soccer players]. / Balleinwirkung auf den Kopf--eine quantifizierende EEG-Untersuchung bei Fussballern.

We observed a patient with epileptic seizures as a consequence of an occipital contre coup injury, due to heading in football. We decided to investigate the EEGs of ten healthy football players by computerized EEG analysis during their "header training". One player's EEG showed focal slowing, there were no clinical symptoms. The EEG of the other players showed only signs of relaxation after training. These results lead us to the following conclusions: - Cerebral damage due to heading in football cannot be assumed in general. - In predisposed persons, however, the microtrauma caused by heading can lead to clinical manifestation. - Subclinical cerebral disfunction due to heading is possible. However, long term studies should be performed to prove that there might be a risk of permanent cerebral damage in football players, as has already been established in boxing.