Colonic anastomoses: bursting strength after corticosteroid treatment.

PURPOSE: This study was designed to determine the effect of corticosteroids on healing colonic anastomoses. METHODS: Bursting pressure measurements were performed on 108 male albino rats receiving corticosteroid treatment. Twelve animals were sacrificed at time zero to determine the bursting pressure of nonoperated, nonsteroid-treated colon. The remaining 96 animals underwent division and reanastomosis of their midtransverse colon. They were then separated into four groups of 24 each. Twelve animals in each group received steroid treatment while the remaining 12 acted as controls. The groups were sacrificed at 4, 6, 8, and 20 days. The bursting pressures of the anastomoses were then noted. RESULTS: There was no significant difference in bursting strength between treated animals and controls at four days (P = 0.27). A significant difference occurred at 6, 8, and 20 days (P = 0.01, 0.003, 0.009, respectively). The colonic bursting pressure of operated controls returned to that of a normal, nonoperated colon by 20 days. CONCLUSION: This study demonstrates that steroids do have an adverse effect on colonic anastomotic healing.

Ciprostene and indomethacin partially reverse the mechanisms of distal end necrosis in the rat random skin flap.

Survival of random skin flap distal end depends on hemodynamic, cellular, and coagulation mechanisms. This study was designed to evaluate whether administration of ciprostene, a stable prostaglandin I2 analogue, and indomethacin, a cyclooxygenase-hydroperoxydase enzyme inhibitor, would improve the survival rate of random skin flaps. Forty-five male rats were divided into nine groups and injected with sesame oil (control), ciprostene (20 micrograms/kg/day), and/or indomethacin (2 mg/kg/day). Injections were done before (pretreatment for 4 days), after (posttreatment for 6 days), and before/after (pre/posttreatment for 4 and 6 days, respectively) the elevation of random dorsal skin flaps. In the pretreatment and pre/posttreatment studies, the flap survival rate of all drug-injected groups was significantly higher than that of the control group (p less than 0.02). In addition administration of ciprostene alone yielded a trend of better flap survival rate, which, however, was not statistically significant (p less than 0.12). Of interest in the posttreatment study, only the simultaneous administration of ciprostene and indomethacin significantly increased skin flap viability compared with the other groups (p less than 0.02). Therefore, the results demonstrated that administration of ciprostene and indomethacin either alone or together partially reversed the pathophysiological mechanisms that cause necrosis of random skin flap distal end. These pharmacological changes significantly improved random skin flap survival rate.

Transderm scopolamine for the control of perioperative nausea.

A randomized prospective study of 201 patients in two institutions was performed to evaluate the efficacy of a transderm scopolamine patch in the control of postoperative nausea. Of 201 patients, 180 successfully completed the protocol. Demographically, the groups were similar in age, sex, and surgical procedures. Adverse effects were noted in both treatment and control groups. Forty-seven per cent of the placebo and 49 per cent of the transderm scopolamine group did not experience postoperative side effects. The most common adverse reactions were urinary retention, dry mouth, agitation, nausea, and vomiting. There was a reduction in the number of vomiting episodes in the transderm scopolamine treatment group from the control group (21% transderm scopolamine vs. 36% placebo). These differences became more significant among the subgroups in surgery, especially after orthopedic procedures. Thirty-five per cent of the transderm scopolamine group experienced nausea compared with 65 per cent from the placebo, 11 per cent of the transderm scopolamine experienced vomiting compared to 26 per cent. Transderm scopolamine was effective in reducing but not eliminating postoperative nausea.

Malignant clear cell hidradenoma: a case report and literature review.

Malignant clear cell hidradenoma is an uncommon variant of sweat gland tumors. Histological sections show lobulated masses and anastomising cords of cells which were polygonal to slightly fusiform in appearance. Most of the cells have bland appearing ovoid nuclei with slightly eosinophilic to clear cytoplasm. Focal areas within the lesion may show malignant changes. These areas may demonstrate large pleomorphic hyperchromatic nuclei, numerous mitotic figures, and a tendency toward squamous differentiation with many of the neoplastic cells demonstrating individual keratinization. Treatment is wide local resection. Consideration of regional lymph node dissection should be entertained because of the tendency to angiolymphatic spreads. Radiotherapy has not been shown to be helpful. Various chemotherapeutic regimens have been tried with inconclusive results. An illustrative case report is presented.

Electrical stimulation treatment of dog's denervated orbicularis oculi muscle.

In this investigation, the electrophysiology and pathology of denervated orbicularis oculi muscles have been studied in dogs during chronic electrical stimulation. The orbicularis oculi muscles were unilaterally denervated in 8 dogs, and 4 of these muscles were directly stimulated on a daily basis for 75 days. No difference in minimum stimulus intensities evoking orbicularis oculi muscle twitch contraction appeared between denervated treated and nontreated muscles. A significant reduction of minimum stimulus intensities evoking upper eyelid complete closure (blink), however, was found in the denervated treated muscles between 10 and 30 days (p less than 0.01). At 28 and 75 days, orbicularis oculi muscle biopsies showed no difference in muscle fiber diameter between denervated treated and nontreated muscles. At 75 days, type II muscle fiber distribution, however, was significantly increased in denervated treated muscles compared with denervated nontreated muscles (p less than 0.01). These findings of orbicularis oculi muscle electrophysiology were consistent with a transient reversal of denervation changes by electrical stimulation, partially supported by muscle biopsies.

Blink reflex recovery after electrical stimulation of the reinnervated orbicularis oculi muscle in dogs.

The paralytic lagophthalmos following palpebral nerve neurotmesis and consequent peripheral denervation of the orbicularis oculi muscle is often associated with harmful effects on the exposed cornea. This study investigated how daily electrical stimulation affects the blink reflex recovery of this muscle after its reinnervation. Six dogs underwent unilateral facial nerve neurotmesis with immediate epineurial repair of the palpebral nerve. Three dogs were randomly chosen to receive electrical stimulation of the reinnervated orbicularis oculi muscles for 75 days. The remaining 3 dogs were controls (nonstimulated muscles). During the study, the reinnervated orbicularis oculi muscle electrophysiology and blink reflex recovery were investigated. The Student's t test was used for statistical analysis. The results can be summarized as follows: (1) between 30 and 50 days, the minimum mean stimulus intensities evoking complete up-per palpebral closure of the stimulated muscles were significantly lower than those of the nonstimulated muscles (p less than 0.01) and (2) the stimulated muscles recovered complete closure of the interpalpebral fissure (blink reflex) at 49.6 days, significantly earlier (p less than 0.01) than the nonstimulated muscles (72.6 days). It is concluded that daily electrical stimulation of the orbicularis oculi muscles, if started immediately after epineurial repair of the palpebral nerve neurotmesis, promotes a faster blink reflex recovery in the dog model.

Symptomatic lead toxicity secondary to retained shotgun pellets: case report.

Symptomatic lead toxicity has only rarely been associated with retention of foreign bodies. Recently a patient was seen who had sustained a shotgun wound to the left upper extremity 10 years previously without apparent nerve injury at the time of injury. The patient was asymptomatic for 9 years. During the tenth year, classic symptoms of lead toxicity, as well as increased blood levels, were documented. Removal of the majority of the lead pellets resulted in substantial decrease in the serum lead level and improvement of symptoms.

In vitro adherence of bacteria to prosthetic grafting materials.

Adherence of bacteria to prosthetic grafting material is thought to play an important role in the ultimate development of prosthetic infections. To evaluate the role of bacterial adherence in the initiation and colonization of prosthetic materials, Proplast II, Gore-Tex, and silicone were evaluated for adherence of Escherichia coli and Staphylococcus aureus. Bacteria were radio labeled and incubated with the study material. Adherence was determined by scintillation. Adherence to Proplast II and Gore-Tex reached a maximum at approximately 45 minutes of incubation and demonstrated a detachment phenomenon with E. coli. Similar results were noted with S. aureus, but with a maximal attachment at approximately 30 minutes. Interestingly, bacterial attachment to silicone continued to increase throughout the time of the incubation. In addition, adherence of S. aureus was at a faster rate than E. coli. Attachment of bacteria is a multifactorial process. However, the PTFE graft demonstrates a slower rate of attachment, lower total number of attached bacteria, and faster detachment. The importance of this phenomenon may help explain the foreign body effect of increased susceptibility to infection of foreign materials.

Basal cell burn carcinoma.

Postburn malignant degeneration into squamous cell carcinoma is unusual but well described. Much rarer is malignant degeneration of a burn into basal cell carcinoma. Recently a well-documented case was seen. The cause was postulated to be injury to the more superficial hair follicles and sweat glands. A brief report is given.

Electrophysiological study of the denervated orbicularis oculi muscle in dogs.

This study investigated the electrophysiology of the denervated orbicularis oculi muscle and its clinical application. Orbicularis oculi muscle denervation was achieved by complete transection of the seventh nerve in ten dogs. The parameters studied were the electrical requirements needed to cause a minimal perceptible contraction (twitch) and a complete eyelid closure (blink). Twitch and blink curves were generated. The findings are summarized as follows: (1) Minimum intensities for direct twitch of denervated orbicularis oculi muscle were significantly lower than intensities of normal orbicularis oculi muscle twitch (p less than 0.01) when long stimulus duration (5 to 400 ms) was used. (2) Minimum intensities for direct blink of denervated orbicularis oculi muscle were not significantly different from stimulus intensities for blink of normal orbicularis oculi muscle if long stimulus duration (5 to 400 ms) was used. Twitch and blink curves could be used to clinically follow the orbicularis oculi muscle movement return after operations performed in patients affected by lagophthalmos.

The pleural osteomuscular flap in oropharyngeal reconstruction.

The addition of a pleural segment to the osteomyocutaneous flap used in head and neck reconstruction can be efficacious in selected cases. The pleura underlying the rib segment has been shown to remain viable and provide good healing and oral lining. The extent of pleura that can be transferred is unknown and currently being investigated, but pleura can be safely taken to the edges of the superior and inferior ribs. The pleura offers a thin, pliable, reconstructed surface to the oral cavity that alleviates bulky flaps or difficulty with intraoral skin grafts. This adaptation is a valuable addition to the surgeon in head and neck reconstruction.

Anisocoria following reduction of bilateral orbital floor fractures.

Anisocoria following orbital floor fractures or their repair has been infrequently reported. A case is presented of transient anisocoria following repair of bilateral orbital floor blowout fracture. This was present for less than two hours and resolved spontaneously. The cause is presumed to be a brief neuropraxia to the parasympathetic postganglionic fibers that follow the inferior oblique muscle, which may be entrapped in the fracture. Review of the pathophysiology is presented.

Effects of electrical currents on wound contraction.

A prospective randomized evaluation of the potential beneficial effects of electrical currents has been studied in 13 wounds in 7 pigs. The effect of electrical current was assessed by evaluation of wound contraction and residual open wound area. A 35 mA unipolar square wave stimulation for one-half hour stimulation periods twice a day showed consistent results in 13 wounds in 7 pigs. Application of negative currents shows no stimulation of wound contracture. In fact, negative currents seemed to retard wound contracture. After two weeks of treatment, the control wound had decreased to 58% of its original size, whereas wounds treated with negative currents were 93% of their original size. On the other hand, negative currents alternating with positive currents increased the rate of wound contraction for the first two to three weeks of treatment. At two weeks these wounds were 18% of their original size and continued to decrease to 5% by three weeks. Wound contraction may be increased by electrical currents. The concept of alternating negative and positive currents has not been previously described and seems to offer some promise in this early study. Further work is underway to define the exact values required for the maximum effects on wound contraction.

Influence of cross-education training in postoperative hand therapy.

Early studies have shown an effect of cross-education training in normal volunteers and in patients with neuromuscular disorders. In this prospective study, I evaluated application of this principle after upper extremity surgery and immobilization. A detailed therapy program to the contralateral unoperated extremity was initiated in one half of the patients. The other half of the patients had only routine postoperative instructions for rest, elevation, and protective splinting. Range of motion and strength measurements were done preoperatively and at intervals up to three months after operation. Analysis of results shows little difference in range of motion measurements in either group. However, return of strength in the extremity operated on was significantly augmented, up to 150% of the control group, in the patients who received cross-education training. Application of this principle to rehabilitation after injury to specific functional units may increase recovery.

The surgical marking pen: a comparative study.

A study has been undertaken to objectively evaluate the available surgical marking pens. Representative samples were requested from manufacturers of marking pens. Standardized skin preparations were utilized in accordance with the recommendation of the manufacturer of the skin-preparation substance (Betadine, pHisoHex, Hibiclens). Evaluation of the marking pens was done by the ability to make an easily discernible mark and maintain this ability over a 1-year storage interval. Objective evaluation demonstrated a marked variation in effectiveness of the marking pens. Consideration of skin-preparation solutions and types of marking pens are discussed.

Contralateral therapy in upper extremity rehabilitation.

Evaluation of upper extremity function after an elective surgery with emphasis on the possible effect of contralateral therapy was done in 20 patients. This study was designed to test the postulate that range of motion exercises and work to muscle groups of one upper extremity has a beneficial effect on the analogous muscle groups in an immobilized, post-surgical contralateral extremity. Analysis of results show a small, but consistent, effect on range of motion measurements. However, strength measurements were shown to be markedly increased in the group receiving contralateral therapy to the normal extremity, as compared to the normal control group. Significant indirect training occurs by a cross-over phenomenon. Rehabilitation programs can be individually designed to enhance recovery of specific motor groups by utilizing contralateral therapy and cross-education principles. Further work is now underway to further elucidate specific clinical applications.

Comparative clinical study of Sulbactam and ampicillin and clindamycin and tobramycin in infections of soft tissues.

A prospective, randomized, double-blinded study was undertaken to evaluate the effectiveness of Sulbactam (a new semisynthetic, injectable penicillanic acid sulfone) to inhibit beta-lactamase activity of bacteria in infections of the soft tissue. Sixty patients with documented soft tissue infections were prospectively randomized. One-half received 1 gram of Sulbactam per 2 grams of ampicillin every six hours. The other half received 600.0 milligrams of clindamycin every six hours and 1.5 milligrams per kilogram of tobramycin every eight hours. Patient groups were similar in age, sex, associated medical problems and bacteriologic flora of wounds. Sulbactam and ampicillin showed a 93 per cent cure rate or improvement as compared with 81 per cent in the clindamycin and tobramycin group. Eradication of organisms was better in the Sulbactam and ampicillin group (67 versus 35 per cent). Antibiotic activity of ampicillin was significantly augmented by the addition of Sulbactam. Of the 223 total bacteriologic isolates, 38 per cent were sensitive to ampicillin alone. Addition of Sulbactam improved sensitivity to 70 per cent. The Sulbactam and ampicillin combination is an effective combination for the treatment of soft tissue infections.

Traumatic hemipelvectomy.

This is a report of a patient who sustained a traumatic avulsion of the hemipelvis and survived this catastrophic challenge. Survival of the patient is dependent on multiple factors of associated injuries, early management, and general health of the patient. Early involvement of the plastic surgical team offers a coordinating influence that can provide the maximum of efficiency for early care and subsequent reconstruction.