Removable Rigid Dressings for Postoperative Management of Transtibial Amputations: A Review of Published Evidence

Forty years of clinical experience and peer-reviewed research studies support the use of nonweight-bearing removable rigid dressings (RRDs) as an effective means of postoperative management of transtibial amputations. We reviewed the published medical evidence regarding the use of RRDs as a postoperative management strategy, culminating in an evidence-based practice recommendation. Published peer-reviewed literature on the topic was searched and classified by level of evidence based on the research design using the scale recommended by the PM&R (level I through V). The search uncovered a total of 15 articles, including 5 level I randomized controlled trials, 6 level III retrospective matched controlled trials, and 4 level V case reports.A number of benefits associated with the application of RRDs compared with soft dressings were reported across these 15 studies. These included faster healing times, reduced limb edema, preparatory contouring of the residual limb in anticipation of prosthetic use, the prevention of knee flexion contractures, and reduced external trauma to the limb. Also described were an increased probability of successful prosthetic use and pain reduction. The RRDs studied permitted regular inspection of surgical wounds with greater ease and consistency of application than traditional soft dressing approaches. Rigid dressings provide all the same benefits of RRDs except ease of wound inspection, therefore rendering them impractical for the 82% of patients receiving an amputation for ischemic disease that are at high risk of developing wound dehiscence. Weight-bearing immediate postoperative prostheses are almost exclusively reserved for use on trauma patients who usually do not show evidence of vascular or neurologic impairment. The inherent risks of falls and inconsistent pressure on the surgical wound have further restricted their use in practice to a limited patient type.The benefits of RRDs compared with soft dressings are universally recognized in the published peer-reviewed medical evidence to be superior to soft dressings. Based on the best-available current published evidence, nonweight-bearing removable rigid dressings should be considered the first treatment choice for the postoperative care of transtibial amputees to optimize outcomes with regard to reductions in injury due to falls, knee flexion contractures, edema, healing time, time to prosthetic fitting, and pain.

Sympathetic vasomotor changes induced by manual and electrical acupuncture of the Hoku point visualized by thermography

Considerable evidence implicates sympathetic neural activity in acupuncture analgesia. However, the exact nature of these effects has not been specified in detail, and many experimental findings are contradictory. This study evaluated in normal conditions the specific sympathetic effects of both manual and electrical acupuncture applied to the same hand (Hoku) point. Thermographic measures of superficial skin temperature were used to assess sympathetic vasomotor tone in the face, hand and foot of 19 normal subjects. Baseline assessment, manual acupuncture and electrical acupuncture were performed in 3 separate sessions in a well controlled, 23 degrees C environment. Superficial skin temperature decreased slowly in the control condition. Both manual and electrical acupuncture produced a generalized long-lasting warming effect, indicating reduced sympathetic activity (sympatholytic effect). In addition, electrical acupuncture induced a localized short-term cooling effect, indicating a transient segmental increase in sympathetic activity (sympathomimetic effect).     

Management of pain during debridement: a survey of U.S. burn units

To determine how burn pain is assessed and managed during debridement, questionnaires were sent to 151 U.S. burn facilities. 181 staff members from 93 burn units responded. For a typical adult patient, most respondents preferred a narcotic, but the dosages varied widely without a corresponding variation in assessed pain. The assessed of pain also did not vary with the type of analgesia used or the route of administration (i.v., i.m., p.o. or gas). Half the respondents used psychotropic drugs in conjunction with narcotics, but without a reduction in dosage of the narcotic or a reduction in assessed pain. For a typical burned child, although more respondents recommended using no narcotics or no psychotropics or no analgesics at all, the assessed pain for children and adults was the same, i.e. in the moderate range. Pain during debridement was rated as more severe by those with less job experience and by those who gave higher dosages of analgesics before the procedure. The survey's findings indicate a need to reevaluate current analgesic practices for debridement and to document pain and pain relief.     

Morphologic aberration associated with colonial tenacity of Pseudomonas aeruginosa

A blood isolate of Pseudomonas aeruginosa was encountered which produced, on subculture to Mueller-Hinton agar, markedly adherent, tenacious colonies which were characterized microscopically by the presence of serpentine rows of interlocking bacilli. Factors accounting for the observed morphologic aberration, which was lost upon subculture, remain unknown.     

Effect of some commonly prescribed drugs on certain chemistry tests

Of the 44 commonly prescribed drugs listed only ascorbic acid, at the upper end of its therapeutic range, significantly affected any (glucose, uric acid) of the twenty-three more frequently requested tests measured in the clinical chemistry laboratory. Acetaminophen, acetylsalicylic acid, ascorbic acid, nitrofurantoin, methyldopa and tetracycline at five times the upper end of their therapeutic ranges individually produced consistently significant effects on one or more of the following tests: glucose, bilirubin, carbon dioxide, calcium, cholesterol, uric acid and aspartate aminotransferase. When drugs are added to lyophilized human serum and to fresh human serum in similar concentrations, their effects on clinical chemistry tests performed on these two different sera are not always the same.     

The effect of epidural morphine on ureteral colic and spasm of the bladder

Twenty-one patients suffering from severe pain associated with ureteric stones and spasm of the bladder which did not respond to repeated systemic injections of pethidine and papaverine received continuous epidural morphine. The morphine, 3-4 mg per dose, was injected into the lumbar-epidural space, and 15-20 min later all patients were pain free for at least 24 h. Administration of morphine was continued for periods ranging from 2 days to 2 weeks according to need. Eleven of the patients with ureterolithiasis passed the stone spontaneously. Epidural morphine analgesia is indicated for persistent ureteral colic and for spasm of the bladder when conventional treatment fails or systemic drugs are contraindicated. It abolishes pain and spasm for prolonged periods of time and does not interfere with the spontaneous elimination of stone.     

Biochemical and exoenzymatic properties of Aeromonas species

One hundred twenty-seven isolates of Aeromonas comprising the three currently recognizable species (A. hydrophila, A. sobria, and A. caviae) were evaluated for biochemical and exoenzymatic properties. Aeromonas species were generally (greater than 90%) characterized as gram-negative fermentative rods that were oxidase-, catalase-, and beta-galactosidase-positive, produced arginine dihydrolase, and failed to decarboxylate ornithine. More than 95% of all isolates tested failed to grow on 6.5% salt or thiosulfate-citrate bile salts agar and were resistant to the vibriostatic agent 0/129. Most Aeromonas species produced acid from hexoses while failing to ferment alcoholic sugars or trisaccharides. In exoenzymatic studies, Aeromonas species were uniformly found to produce several exoenzymes, including amylase, DNase, RNase, esterase, lipase, gelatinase, protease, fibrinolysin, and chitinase. Within the genus, a number of biochemical and enzymatic properties were found to be associated with one or more of the taxonomically recognizable species. These properties included glycoside utilization, Heiberg grouping based upon fermentation of arabinose, sucrose, and mannose, and the elaboration of several extracellular enzymes (elastase, hemolysin, lecithinase, phosphatase). In addition, phenotypic markers previously associated with enterotoxigenic Aeromonas isolates were almost exclusively found among A. hydrophila and A. sobria species, suggesting that these species are the major enteric pathogens.     

Aeromonas species in clinical microbiology: significance, epidemiology, and speciation

Over a one-year period, 32 strains (31 clinical, 1 environmental) of Aeromonas sp. were recovered. Chief sources of isolation were the gastrointestinal tract (48%), wounds (19%), and blood (13%). Gastrointestinal isolates were most often recovered from young (less than 5 yrs) children with diarrhea; wound or blood isolates were recovered more often from an older (avg. 56 yrs) population with one of several underlying disorders. Regardless of body site of isolation, most strains of Aeromonas appeared to be community acquired and not nosocomially transmitted. Over 70% of all isolates recovered during this year period were isolated during summer or fall months, suggesting a seasonal distribution of this microorganism. Speciation of Aeromonas isolates revealed A. hydrophila to be the predominant species isolated from clinical specimens, although significant percentages of other Aeromonas sp. were also recovered from clinical material.     

Fructosamine: A new approach to the estimation of serum glycosylprotein. An index of diabetic control

The development of a novel manual method designed to measure serum glycosylprotein as an index of diabetic control is described. The method relies on the ability of ketoamines (fructosamines) to act as reducing agents in alkaline solution. Conditions are described for a simple colorimetric procedure which permits assay of both a synthetic fructosamine and purified albumin while severely limiting the contribution of interfering substances. Applied to whole sera, the measurement is linear with volume of serum assayed. It allows clear discrimination of normal and diabetic populations (p < 0.001), and is significantly correlated with fasting blood glucose concentration (r = 0.72) and with a thiobarbituric acid procedure for measuring glycosylprotein-derived hydroxymethylfurfural (r = 0.58). The method is rapid (at least 12 samples per hour) and demands only simple equipment.     

Serum immunoglobulins in healthy children and adults. Levels of the five classes, expressed in international units per millilitre.

Serum levels of IgM, IgG, IgA, IgD, and IgE were determined in serum samples of 270 healthy Dutch children (aged 4-13 years) and of 30 healthy Dutch adults, the amounts being expressed in International Units per millilitre. Special attention is given to the IgD and IgE results, since the IgM, IgG, and IgA levels in mg per 100 ml of these sera and their implications have already been reported. In the children's sera the occurrence of relatively high IgD and IgE levels was frequently observed, whereas the adult group did not show excessive variation in this respect. The mean IgD levels found for adult males and females are 21 I.U./ml and 24 I.U./ml, respectively; the mean IgE levels for the same groups are 68 I.U./ml and 88 I.U./ml, respectively. The mean IgD and IgE levels in the children of each year group were usually higher than those of each of the juvenile groups and the mean level of the adult group was not statistically significant. A statistically significant influence of sex and season on the IgD and IgE levels could not be demonstrated in this material either. Three of the 270 children's sera showed an exceptionally low IgA content. In two of these cases the serum was sampled and studied a second time after an interval of four years, when the IgA deficiency proved to be still present. The IgE levels in the sera of these healthy IgA-deficient children were normal, whereas the presence of IgD could not be demonstrated.