Management of an infected pseudoaneurysm following an aortoventriculoplasty

An 11-year-old child developed prosthetic valve endocarditis with associated infection of the prosthetic and pericardial patches 6 months following an aortoventriculoplasty. Angiography revealed an associated false aneurysm which communicated with both the ascending aorta and the right ventricular outflow tract. This report discusses the surgical management of this patient.     

Graftskin Heals an Ulcer on an Amputation Stump

BACKGROUND: A 51-year-old man presented with a chronic ulcer of 28 years' duration on the amputation stump of his right foot. The prosthesis was aggravating the ulcer, despite multiple therapies. OBJECTIVE: To heal the ulcer and avoid a below-the-knee amputation. Graftskin, a bilayered living skin construct, was applied. METHODS: Graftskin was sutured in place following gentle debridement. Pentoxifylline was given to improve circulation. The dressing was changed 5 days after Graftskin application, then weekly for 7 weeks. RESULTS: Crusting was evident at 3 weeks, with an underlying white coating at 4 weeks. By 7 weeks, full reepithelialization was present under the crust and no ulceration remained. Over succeeding weeks the ulcer bed became flush with the surrounding skin. The patient's pain ceased, and some sensation and warmth returned to the stump. CONCLUSION: Graftskin treatment successfully healed a chronic ulcer, possibly preventing a more extensive amputation.     

Laparoscopic reduction of an ileoileal intussusception and resection of an inverted Meckel's diverticulum in an adult

Intussusception occurs commonly in children, but rarely is observed in adults. Whereas the hydrostatic pressure of a contrast enema often proves diagnostic as well as therapeutic in infants and children, resection usually is required for an underlying bowel pathology in older children and adults. Conventionally, the resection is accomplished at laparotomy. We report the case of a 20-year-old woman who presented with diarrhea and vomiting of 1 week duration. She was found unexpectedly to have intussusception on abdominal ultrasonography. The intussusception was laparoscopically reduced, and a segment of the middle small bowel that harbored an inverted Meckels diverticulum was resected laparoscopically, after which an intracorporeal anastomosis was fashioned. The ileus resolved on postoperative day 4, and the patient was discharged from hospital on postoperative day 5. The role of the laparoscopic approach in the management of intussusception is discussed.     

Infarction of an accessory spleen causing an acute abdomen

A case is presented of a five year old girl in whom an acute surgical abdomen developed due to torsion and infarction of an accessory spleen. Other similar cases in the literature are reviewed. The incidence, location, and embryologic aspects of accessory spleens are discussed. Infarction of an accessory spleen, although rarely the cause of an acute surgical abdomen, should be considered in the differential diagnosis.     

Development of an ankle-foot orthosis with an oil damper

The purpose of the present study was to develop an ankle-foot orthosis (AFO) that satisfies the requirements for an AFO for patients with hemiplegia as determined in a previous study. An oil damper has been introduced as an assistive device. The oil damper provides a resistive moment to plantar flexion of the ankle joint during initial stance on the paretic side. This function improves the insufficient eccentric contraction of the dorsiflexors. The magnitude of the resistive moment generated by this newly developed AFO can be changed easily to adjust its properties in accordance with the requirements of each patient. The mechanical properties of the AFO were measured, and the results showed that the AFO generated a sufficient resistive moment. Hemiplegic gaits with various types of AFOs were assessed, and it was found that the properties of the AFO affected the movements of the ankle, the knee, and the hip joints. The effects of the resistive moment on the alignment of the shank to the floor during initial stance are also discussed. Based on the results of this study, it is concluded that adjustability will be an essential feature for future AFOs.     

Economics of an academic renal division: an approach

Nephrology divisions work within the systems and constraints of a department of medicine in a college of medicine, and in an increasing number of cases, also within a larger health care delivery system. Key to the division's stability are a consistently applied practice pan, how the tenure and clinical track systems function, how teaching funds are distributed, mechanisms of incentive for the division, and its faculty and the ability to establish and maintain reasonable financial reserves, especially for investment in research. Dialysis, transplantation, hypertension, research, and the teaching of medical students, residents, and fellows are the key elements the divisional organization must address. Incentives for faculty performance should be included in all of these areas. The division director must recognize his or her control of earning capacity in the distribution of responsibilities; financial returns as compared with effort involved vary considerably. Three main problems confront the future of our divisions: manpower shortages in nephrology; the effects of managed care systems on nephrology practice; and the future existence and success of departments of internal medicine and academic health centers.     

Continent diversion with an appendix conduit and an ileocecal bladder

Since March 1989, 23 patients have undergone continent urinary diversion with an ileocecal bladder and a reimplanted appendix conduit. In 21 patients this procedure was combined with a radical cystectomy. Of the patients 7 required an endoscopic procedure before satisfactory self-catheterization could be established. This problem was more common early in the series. The continence mechanism is extremely simple and rapid to construct. Continence rates have been most satisfactory, with only 2 patients having secondary incontinence.     

Indikationen zur Osteosynthese an der Hand und an den Fingern

For the osteosynthesis of the distal end of the radius, the wrist and the metacarpus screws and plates are suitable. For the phalanges single screws or 0,5 to 0,6 mm thick wire-pins are used. The microinstruments of the AO have enriched considerably the surgical possibilities on the hand and on the fingers.