A versatile procedure for the closure of small skin defects

The author describes a method for the primary, direct closure of wide skin lesions, combining the lazy S, crown, and the H-advancement flap techniques. The lazy S edges of the flaps permit the satisfactory use of adjacent surrounding skin with good aesthetic results, when the flaps alone would otherwise be placed under too much strain.     

Absorptiometry and “osteoporosis”: problems

connecting the dots between diverse clinical and other matters and an updated bone physiology reveals relationships that could modify some ideas about the roles and uses of absorptiometry in osteoporosis work. Herein, absorptiometry means that part of clinical densitometry that depends on X-ray absorption by bone and other tissues, thus excluding ultrasound methods and magnetic resonance imaging. The modifications concern, in part, some limitations of bone mineral density data, the kinds of physiological information that absorptiometry can and cannot provide, the relative importance of bone mass and whole-bone strength, how to define and study bone health and osteoporosis, and two kinds of osteoporotic fractures. As those modifications concern important national health care issues, they deserve answers based on hard evidence. Identifying those modifications might help others to evaluate them.     

Reconstruction of the temporal hairline

Reconstruction of the temporal hairline is usually discouraged because of unsuccessful results. A technique using punch hair grafts and micrografts is presented that has shown good cosmetic results.     

33. Der „kalte” Schilddrüsenknoten

Zusammenfassung Der kalte Schilddrüsenknoten gilt als typischer Verdachtsbefund für ein Schilddrüsencarcinom. Seine tatsächliche Dignität ist mit klinischen Mitteln sowie Szintigraphie und Sonographie letztlich nicht zu klären. Das beste abgrenzende Selektionskriterium ist die Feinnadel-Punktionscytologie, wodurch mit Gültigkeit für das Kropfendemiegebiet etwa die Hälfte als suspekte Befunde von dem anderen Teil hochwahrscheinlich gutartiger Veränderungen getrennt und für die Operationsindikation reserviert werden kann.     

Multifactorial genesis of neuroradiological “leucoencehalopathies”

Three cases of neuroradiologically diagnosed leucoencephalopathy are reported. Histopathological examination disclosed Binswanger's encephalopathy in Case 1, congophilic angiopathy with secondary leucoencephalopathy in Case 2, and HIV encephalopathy with secondary white matter changes in Case 3. These three cases demonstrate the unspecificity of neuroradiological findings in leucoencephalopathy.     

219. Ursachen und Behandlungsprobleme der syminetrischen Unterschenkelfraktur

Zusammenfassung Als Ursache der symmetrischen Unterschenkelfrakturengibt es direkte Trauma durch Kantensturz, Fahrzeugkollision oder Stoßstangenanprall. Gehäuft treten die zweizeitigen Kombinationsverletzungen Beine, Kopf, Becken auf. Lokal überwiegen die offenen Trümmerbrüche verschiedener Höhe. Gefäß-Nerven-Verletzung ist relativ selten. Therapeutisch erfordert die Mehrfachverletzung individuelle Indikationsstellung nach vitaler Dringlichkeit. Daher Osteosynthese praktisch nur verzögert primär möglich, und dann eventuell mit zwei Operationsgruppen. Vorbeugend sind verbesserte Sicherheitssysteme zur Unfallverhütung zu fordern.     

Polymeric pyelotomy

A non-toxic, soluble polymeric preparation MAG with controlled period of gelation was synthetized for the extraction of stones from the pyelocalyceal system during surgery for urolithiasis.With respect to toughness the preparation proved superior to the fibrinogenthrombin mixture, used in the so-called fibrin pyelotomy according to Dees. Its biologic testing in animals (rabbits, dogs and pigs) yielded excellent results.By analogy with fibrin pyelotomy we took the liberty to propose the term polymeric pyelotomy.     

The Graf stabilisation system: early results in 50 patients

Summary The results of the first 50 consecutive patients using the Graf stabilisation system are presented. The average age of the patients was 41 years; there were 32 women and 18 men in the group. All patients suffered from intractable symptomatic degenerative disc disease which could be localised to one or more levels. All patients gave a history of chronic back pain, but the mean period of severe disability was 24 months. The mean preoperative disability score (Oswestry questionnaire) was 59%. The average period of follow-up was 24 months (range 19–36 months). At the latest review, the mean disability ability score was 31%. The clinical results were classified as excellent or good in 72% of patients, fair in 10%, the same in 16% and worse in 2%. All but three patients felt that surgery was worthwhile. The results have not deteriorated over the period of follow-up.     

Distended glands or overreplacement of ampullary mucosa at the papilla of Vater

Background/Purpose The role of the ampullary mucosa, especially its distended glands at the papilla of Vater, has not been fully explored.Methods Twenty-nine pancreatoduodenectomized specimens from pancreatobiliary diseases and 44 autopsied cases, as controls, were studied histopathologically and immunohistochemically.Results In 12 out of the 29 pancreatoduodenectomized cases the ampullary mucosa was in contact with the duodenal mucosa just at the outlet of the ampulla. In the remaining 17 cases, the ampullary mucosa overgrew beyond the ostium, replacing a portion of the surrounding duodenal mucosa, termed distended glands, which measured an average of 1532µm in length. The muscularis mucosae of the duodenum and the Oddis sphincter muscle merged in an end-to-end, sharp-angled manner at the ostium in the former, whereas this occurred in an end-to-side, less sharp, rather right-angled manner in the latter. Immunohistochemically, the distended glands in some cases showed negative/weakly positive staining for anti-carbohydrate antigen (CA) 19-9 and a high proliferation index evaluated using Ki67. In the autopsied materials, distended glands were found in 24 out of the 44 cases.Conclusions Distended glands of the ampullary mucosa were frequently found and only grew on the Oddis sphincter muscle extension. They may represent not only malignant change but also an adaptive phenomenon for bile and pancreatic juice flow.     

Methylated β-cyclodextrins are able to improve the nasal absorption of salmon calcitonin

The absorption enhancing effect of methylated -cyclodextrins on the nasal absorption of salmon calcitonin (sCT) was studied in rats and rabbits. The nasal absorption of sCT following administration without additives was low in both species. The absorption in rats could be largely improved by coadministration of cyclodextrins as apparent from the effect on serum calcium concentrations. Trimethyl--cyclodextrin (TMCD), at a concentration of 5% (w/v), was the least potent enhancer. Randomly methylated--cyclodextrin (RMCD) and dimethyl--cyclodextrin (DMCD), all at a concentration of 5% (w/v), were almost equally effective in decreasing serum calcium levels, and the hypocalcemic responses were similar to those of i.v. and s.c. injected sCT. Absorption enhancement was already achieved with 1% DMCD added to the nasal formulations. In rabbits, only the effect of DMCD on the nasal sCT absorption was investigated. A total serum calcium decrement in 4 hours of 9.4±3.9% (mean±SD) was observed following nasal administration of 12.6 IU/kg sCT with 5% DMCD, comparable to that of i.v.-injected sCT. In conclusion, the methylated cyclodextrins DMCD and RMCD are suitable absorption enhancers for nasal sCT administration, which is expected to have a clinical impact on the therapy with calcitonin.     

Urolithiasis,inhibitors and promoters

Summary The aim of this work is to evaluate the role and importance of inhibitors and promoters in urolithiasis. Carrying in mind theoretical considerations, we conclude that in urolithogenic processes, inhibitors and promoters could only play a decisive role in the idiopathic oxalocalcic urolithiasis. We classify the idiopathic oxalocalcic stone-formers into three main groups, considering inhibitory and promoting factors. It is shown that such classification is in good agreement with the clinical results observed in a group of 88 idiopathic oxalocalcic stone-formers.     

Potentiation of transforming growth factor (TGF-β1) by natural coral and fibrin in a rabbit cranioplasty model

The association of a biodegradable material and a growth factor could be of clinical value for treating bone defects. We therefore tested the association of transforming growth factor (TGF-1) in fibrin glue and coral granules to heal skull defects in rabbits. Adult rabbits underwent a double trepanation symmetrically in both parietal bones. Using histomorphometry, we compared bone repair after 1 month in control animals (n=5) and in animals treated with either TGF-1 as a single injection of 1 g in methylcellulose (n=5) or in fibrin glue (n=5), or with coral granules in fibrin glue (n=4) or with coral granules and TGF-1 1 g in fibrin glue (n=5). We measured the diameter of the remaining defect and the surface of the bone growth. TGF-1 without coral in either methyl cellulose or fibrin induced a partial closure of the defect as assessed by a significant decrease in the defect diameter, compared with the control group. However, the association of TGF-1 in fibrin and coral induced an area of the bone growth higher than in any other groups (P<0.05). Two months after surgery, this triple association induced a better healing of the defect than coral alone or control group. In each group treated with TGF-1, the mineralization rate was increased not only at the treated side but also in the contralateral defect which was untreated, suggesting a diffusion of the growth factor. Indeed, when pooled together, the diameter of the defect at the contralateral side of 14 animals that had received TGF-1 was reduced compared with the control group. Significant coral granules resorption occurred between month 1 and 2 and was unchanged by the addition of TGF-1. In conclusion, the triple association of coral granules and TGF-1 in fibrin could be of interest for treating bone defects.     

“Neonatal variant” of Bartter syndrome presenting with acidosis

An infant is reported with the neonatal variant of Bartter syndrome, presenting at 5 weeks of age with metabolic acidosis associated with a life-threatening water and electrolyte depletion. Alkalosis was first shown after 2 weeks of vigorous fluid, sodium, and potassium substitution. We suggest that the extreme fluid and electrolyte losses associated with the neonatal form of Bartter syndrome could lead to acidosis more often than previously suspected, and may cause underdiagnosis of a possibly fatal condition.     

Diagnostic approach in instability and irritative state of a “lumbar motion segment” following disc surgery—Failed back surgery syndrome

Summary A diagnostic protocol for patients with suspected instability and irritative state of a lumbar motion segment following lumbar disc surgery is presented and the results of internal fixation are analyzed.In this group of patients the clinical picture and physical signs may be quite distinct and suggestive of instability and irritation of a lumbar motion segment, however, in isolation, they do not allow to decide upon surgery. Radiological studies favour a decision for surgery only in cases with an obvious instability of a motion segment. Anaesthethizing the articular nerves permits localization of the irritable segment and non-surgical therapeutic decisions (thermocoagulation) can only be taken in cases of an isolated facet-syndrome when instability has been ruled out. The trial plaster jacket holds the most important position with respect to the indication for internal fixation as demonstrated by the conformity of the results of the plaster jacket and the results of surgery.After internal stabilization excellent, good, satisfactory and moderate results were obtained in 20, 3, 1 and 1 patients, respectively.The German term Bewegungssegment comprises all parts which are involved in the movements of one vertebral segment, i.g. disc, facet joints, ligaments and related muscles.     

116. Neue Anus praeter-Verfahren: Magnetverschluß

Zusammenfassung Seit Mai 1976 wurden 85 Magnetringe bei 81 Patienten implantiert. In 16 Fällen kam es zur Infektion, darunter 5 Spätinfektionen. 24 von 51 befragten Patienten tragen den Magnetdeckel regelmäßig. Größtes Problem ist eine fehlende Dichtigkeit (39 %). Die Ergebnisse ließen sich mit einem Deckel mit beweglichem Mittelstöpsel verbessern. Auf die Frage, ob das Magnetsystem die Colostomiepflege erleichtert, antworteten 37 % der Kranken mit ja, 22 % mit gering und 41 % mit nein. 56 % würden sich erneut einen Magnetring implantieren lassen.     

Selective transposition of the pectoralis major myocutaneous flap: an electromyographic evaluation

Although it has been postulated that the segmental anatomy of the pectoralis major muscle should allow intact motor function to be preserved at the donor site after a myocutaneous island flap has been transposed, the functional outcome of this selective harvesting technique has not been previously investigated. In this study the degree of innervation of the residual pectoralis major muscle on the chest after traditional (10 patients) and selective (10 patients) pectoralis major myocutaneous flap transposition has been evaluated using postoperative electromyography. According to the data obtained, while an intact innervation of the external segment is maintained utilizing both techniques, it is impossible to preserve functional innervation of the remaining sternocostal strip medial to the donor site during a pectoralis major myocutaneous flap transposition, even after its selective harvesting.     

In-vivo and ex-vivo renal preservation

Summary A new renal perfusate of modified intracellular electrolyte composition made hyperosmolar with mannitol and requiring no additional additives was successfully used to preserve canine kidneys ex-vivo for 48 hours by initial perfusion and hypothermic storage. The new perfusate was also successful in protecting totally ischemic canine kidneys from the lethal effect of two-hours of normothermic exposure in-vivo. — The preservation technique is uncomplicated, the materials involved are inexpensive, and the preservation apparatus is readily transportable.Supported by the Max Kade Foundation, New York, New York.     

“Kissing” bilateral large carotid-ophthalmic aneurysms

A case of unruptured bilateral large carotid-ophthalmic aneurysms, which appear to be adjoining and kissing each other when visualized by three-dimensional computed tomographic angiography (3-D CTA), is reported. Although bilateral carotid-ophthalmic aneurysms are not rare, bilateral large ones are quite rare, and direct imaging of kissing aneurysms of this portion has not been reported. Since 3-D CTA is becoming a useful tool for the diagnosis of cerebral aneurysms, we propose that these and similar bilateral large carotid-ophthalmic aneurysms are good candidates for the term kissing aneurysms.     

30. Interdisziplinäre Zusammenarbeit in der Intensivmedizin — Gemeinsamkeiten und Abgrenzung aus der Sicht des Anaesthesisten

Zusammenfassung Der Intensivmedizin liegt das Prinzip zugrunde, gestörte Vitalfunktionen aufrechtzuerhalten oder wiederherzustellen, um Zeit zur Behandlung des Grundleidens zu gewinnen. Ihre Erfordernisse haben zu neuen Formen interdisziplinärer Zusammenarbeit geführt. Mit Hilfe der Begriffe Vitalfunktionen und Grundleiden werden in der Regel zugleich die Behandlungskompetenzen von Anaesthesist und Chirurg abgegrenzt. Beide Bereiche stehen aber trotzdem in einem korrespondierenden Zusammenhang und können nur im Rahmen einer gemeinsamen Tätigkeit gesehen werden, wobei jeder auch stets die Belange des Partners berücksichtigen muß.     

Cerebral reperfusion in brain death of a newborn. Case report

A case of sudden infant death after 15 minutes of successful resusciation of cardiovascular function is presented. While apnoic cranial nerve areflexia and electrocerebral silence persisted, angiography and transcranial Doppler sonography demonstrated nearly normal cerebral perfusion, which even increased day by day inspite of the persistence of other signs of brain death. The phenomenon cerebral reperfusion is concluded to be compatible with the diagnosis of brain death.