Urokinase in gastrointestinal tract bleeding

Selective urokinase infusion into the superior mesenteric artery allowed the accurate determination of the site of small bowel bleeding in a patient with recurrent lower gastrointestinal bleeding who bled despite resective surgery and who had negative findings on four angiograms. Fibrinolytic agents are useful in rare cases in which the need for successful and accurate diagnosis outweighs the risks of reactivating the bleeding.     

Peribursal fat plane of the shoulder: anatomic study and clinical experience

A comprehensive anatomic and radiographic analysis of the peribursal fat plane in 12 cadavers confirmed that the fat plane seen on radiographs represents extrasynovial fat lining the subacromial bursa and documented the anatomic relations of the bursa. A three-part retrospective clinical evaluation of rotator cuff tears, calcific tendinitis, and rheumatoid arthritis was performed. Two osteoradiologists blindly graded the appearance of the peribursal fat plane with the shoulder in external versus internal rotation in 21 patients with arthrographically intact rotator cuffs and 21 patients with disrupted rotator cuffs. The peribursal fat plane was seen better with disrupted rotator cuffs. The peribursal fat plane was seen better with the shoulder in internal rotation and was seen in 60% of control subjects but only 21% of patients with rotator cuff tears. Partial or complete obliteration of this fat plane is a sensitive (79%) but less specific (60%) indicator of rotator cuff tears. Obliteration of the peribursal fat plane by inflammatory processes in adjacent tissues, including calcific tendinitis and rheumatoid arthritis, occurred with a high frequency.     

Transmyocardial laser revascularization as an adjunct to coronary artery bypass grafting

Many patients with angina related to coronary artery disease respond to medical management or can be completely revascularized using available percutaneous coronary interventions or coronary artery bypass grafting (CABG). There is evidence, however, to indicate that up to 25% of patients are incompletely revascularized following CABG and that incomplete revascularization is a significant independent predictor of early and late mortality and adverse events. Transmyocardial revascularization (TMR) is a surgical option for patients with debilitating angina due to coronary artery disease in areas of the heart not amenable to complete revascularization using conventional treatments. In randomized, 1-year controlled trials with long-term follow-up and in additional clinical experience, TMR performed adjunctively to CABG in patients who would be incompletely revascularized by CABG alone has yielded significantly improved clinical outcomes. Based on these published results, the Society of Thoracic Surgeons has issued a practice guideline recommending adjunctive TMR in this difficult patient group.     

Composite tissue allotransplantation of the hand and face: a new frontier in transplant and reconstructive surgery

Each year an estimated 7-million people in the USA need composite tissue reconstruction because of surgical excision of tumors, accidents and congenital malformations. Limb amputees alone comprise over 1.2 million of these. This figure is more than double the number of solid organs needed for transplantation. Composite tissue allotransplantation in the form of hand and facial tissue transplantation are now a clinical reality. The discovery, in the late 1990s, that the same immunotherapy used routinely in kidney transplantation was also effective in preventing skin rejection made this possible. While these new treatments seem like major advancements most of the surgical, immunological and ethical methods used are not new at all and have been around and routinely used in clinical practice for some time. In this review of composite tissue allotransplantation, we: (i) outline the limitations of conventional reconstructive methods for treating severe facial disfigurement, (ii) review the history of composite tissue allotransplantation, (iii) discuss the chronological scientific advances that have made it possible, (iv) focus on the two unique clinical scenarios of hand and face transplantation, and (v) reflect on the critical issues that must be addressed as we move this new frontier toward becoming a treatment in mainstream medicine.     

Predicting family functioning after TBI: impact of neurobehavioral factors

OBJECTIVE: To identify risk factors for poor family functioning and neurobehavioral problems after traumatic brain injury (TBI) or orthopedic injuries (OI). DESIGN: Longitudinal analyses of data from an inception cohort. PARTICIPANTS: Seventy-five patients with moderate/severe TBI, 47 patients with mild TBI, and 44 patients with OI at discharge; and 49 patients with moderate/severe TBI, 24 patients with mild TBI, and 33 patients with OI at 1-year follow-up. OUTCOME MEASURES: Measures of family functioning (Family Assessment Device) and Neurobehavioral Functioning Index at hospital discharge and 1-year follow-up. RESULTS: At discharge, patients with moderate/severe TBI had more symptoms of depression, memory/attention problems, and motor impairments than patients with OI and greater communication difficulties than patients with OI or mild TBI. At follow-up, patients with moderate/severe TBI continued to have more problems in memory/attention, depression, and communication. Approximately one third of each group had unhealthy family functioning at each assessment period. Few patients reported both impaired family functioning and clinical depression. Distressed family functioning correlated strongly with increased rates of neurobehavioral symptoms. Family dysfunction at follow-up was best predicted by family dysfunction at discharge and depression or memory/attention deficits at follow-up. CONCLUSIONS: After TBI, patients at the greatest risk for distress at follow-up were those with family dysfunction at discharge and continued neurobehavioral problems. High-risk families need to be identified so that necessary referrals and/or treatment can be offered.     

Retrocecal appendix location and perforation at presentation

Retrocecal appendicitis has been theorized to follow a more insidious course than other anatomic variants. To determine the influence of retrocecal anatomy on clinical course of appendicitis, 200 adult patients treated at a major university medical center with the diagnosis of appendicitis from 2001 to 2004 were retrospectively studied. Computed tomography (CT) scans of adult patients with an ultimate diagnosis of appendicitis were analyzed to determine an association between retrocecal appendix and perforation of the appendix at presentation. A higher perforation rate in the retrocecal group would imply patient delay in presentation from more tolerable symptoms. CT scans were examined for retrocecal location and perforation. No significant association was found between retrocecal anatomy and perforation rates at presentation (chi-square = 2.1, P = 0.15, odds ratio = 1.6, 95% confidence interval [0.8-3.0]). However, the risk of perforation was 60 per cent higher in the retrocecal group. By regression analysis, age and the presence of a fecalith on CT scan were predictors of appendix perforation. Appendix location was not. In this study, we found no significant association between retrocecal appendix anatomy and perforation at presentation.     

Use of the extended V-Y latissimus dorsi myocutaneous flap for chest wall reconstruction in locally advanced breast cancer

The extended V-Y latissimus dorsi myocutaneous flap described by Micali and Carramaschi provides an innovative method of closing large anterior chest defects after resection of breast cancer. The technique provides robust chest wall coverage that is able to withstand immediate postoperative radiotherapy. The aim of this article is to confirm the usefulness of the flap's design and describe modifications to the technique. The modifications to technique include: a curvilinear design that recruited more skin for closure in patients with wounds extending laterally or superiorly, routine transposition of latissimus dorsi insertion inferio-medially onto the chest wall to maximize pedicle reach, and the use of small split skin grafts or delayed primary closure if there was tension in closing. Twelve patients who underwent resection of locally advanced breast cancer had immediate chest wall reconstruction with the extended V-Y latissimus dorsi musculocutaneous flap. The V to Y design of the flap's cutaneous island allowed primary closure of chest wound and donor defect. There were no instances of chest wound dehiscence. The chest wounds healed, allowing patients to undergo adjuvant radiotherapy in a mean time interval of 6 weeks after surgery.     

Interactions of Respiratory and Cardiovascular Adjustments to Behavioral Stressors

The relationships among a variety of cardiovascular and respiratory measures were examined in young college males subjected to a cold pressor task, reaction-time shock avoidance task, and three levels of graded exercise. As expected, the relationships between cardiovascular (e.g., heart rate and cardiac output) and respiratory (e.g., oxygen uptake and minute ventilation) variables were tightly linear when considering rest and exercise values. However, the range of individual cardiopulmonary responses during cold pressor and reaction time was considerable, often leading to disruptions in the cardiovascular/respiratory interactions. Analyses of extreme high and low ventilation reactors during both reaction time and cold pressor revealed that the excessive ventilation responders in cold pressor showed clear signs of hyperventilation. Increases in ventilation by the high reactors during reaction time were of smaller magnitude than during cold pressor, with potential hyperventilation much less clear. Increases in minute ventilation by reactors during the cold pressor task were primarily due to large increases in tidal volume, with only modest increases in respiratory rate. For reaction time, however, the increases in ventilation by reactive individuals stemmed from rate increases with tidal volume remaining essentially unchanged.