Free flap reconstruction of the lower extremity in the elderly

Summary Over a four year period, thirteen patients over the age of 60 (mean 69 years) underwent reconstruction of lower extremity defects with free tissue transfers. Ten latissimus dorsi, one tensor facia lata, and two rectus abdominus free flaps were used. Despite significant risk factors which included previous tobacco use, hypertension, diabetes mellitus, and angiographic vessel abnormalities, ten of thirteen cases had successful outcomes. There was one acute flap failure secondary to arterial thrombosis. Four flaps had delayed healing, with one patient eventually requiring amputation secondary to persistent pain and wound drainage. This experience demonstrates that free flap reconstruction of lower extremity defects in the elderly patient is a reasonable alternative to amputation when other options are limited.From the Section of Plastic and Reconstructive Surgery at the Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA Requests for reprints: J. Fisher, M.D.     

The role of surgery in abdominal non-Hodgkin's lymphoma: experience from the Childrens Cancer Study Group.

To determine the appropriate role of surgical intervention in non-Hodgkin's lymphoma primary to the abdomen, we analyzed the effect of multiple prognostic determinants on event-free survival for patients entered into the CCG-551 study. Eighty-four patients were identified with abdominal lymphoma and of these adequate data for analysis was available on 68 (81%). Variables of interest included: extent of disease at diagnosis, completeness of resection, use of bowel resection, radiation to the primary site, and sex/age/race. The median age on study was 8 years; 79% of patients were white and 85% were male. Thirty-three patients (49%) presented with localized disease. Laparotomy was performed in 67 children (99%) with complete gross resection in 28 (42%). Of the 10 reported surgical complications, 8 occurred in those with extensive disease who were incompletely resected. Radiation to the primary site was given in 60% of patients with median dose of 2,000 cGy. Analysis was performed both for the overall group and for the subgroup receiving optimal chemotherapy for histopathology. Variables with significant predictive effect on event-free survival in univariate analysis included extent of disease (P less than or equal to .001), complete resection (P less than or equal to .002), and use of bowel resection (P less than or equal to .004). However, in multivariate analysis, only extent of disease was an independent predictor of outcome. The data support a role for complete operative excision of localized lymphomas especially when accomplished with bowel resection. Aggressive attempts at debulking extensive retroperitoneal or mesenteric lymphomas are contraindicated.     

13-cis-retinoic acid (NSC 122758) in the treatment of children with metastatic neuroblastoma unresponsive to conventional chemotherapy: Report from the childrens cancer study group

The Childrens Cancer Study Group evaluated daily oral 13-cis-retinoic acid to determine its therapeutic efficacy in 28 children with advanced neuroblastoma refractory to conventional therapy. Cheilitis and fissured lips were the most common side effects; however, fewer than 50% of the patients experienced any toxicity. Two of twenty-two evaluable children demonstrated positive response to therapy. In one case, a child received the drug for 11 months. Seventeen patients demonstrated progressive disease within 28 days of the start of treatment. Three other patients with stable disease, or removed from study at day 28, were considered nonresponsive. Our data demonstrate that, when given as a single daily oral dose of 100 mg/m², 13-cis-retinoic acid does not have significant activity in children with advanced neuroblastoma. © 1992 Wiley-Liss, Inc.     

Method of single-lung transplantation in the absence of a left atrial cuff.

A method used clinically for anastomosing the pulmonary veins to the left atrium, in the absence of a left atrial cuff, during single-lung transplantation by reconstructing the atrium with pericardium is described. Postoperative ventilation/perfusion scans show normal pulmonary blood flow.     

Nonoperative management of adult blunt hepatic trauma in a municipal trauma center.

While nonoperative management of blunt hepatic trauma has become the standard of care in children, its use in the adult population is not as well accepted. The purpose of this study was for the authors to review their experience with operative and nonoperative management of adults with blunt hepatic trauma at an urban trauma center. During the past 7 years, 56 adults were found on abdominopelvic computerized tomography or at exploratory laparotomy to have sustained blunt hepatic trauma. Nonoperative management was considered in patients who were hemodynamically stable; had no signs of peritoneal irritation; and had no other intra-abdominal injuries that might require surgical repair. Of the 56 patients, 20 were admitted to the surgical intensive care unit for careful observation. One patient required the administration of blood products and a second underwent laparotomy within 12 hours of presentation for progressive abdominal pain. This patient had a 4-cm liver laceration easily controlled with electrocautery. This review supports the judicious application of nonoperative management in the hemodynamically stable adult with blunt hepatic trauma who is without signs of significant peritoneal irritation or other intra-abdominal injuries that would require surgical repair.     

Improved compliance with quality assurance markers during trauma room resuscitation using trauma nurse specialists.

Trauma nurse specialists (TNS) have been shown to reduce the burden on house staff and to facilitate patient care on trauma wards. In the authors' facility, this expertise has been extended to the emergency department where TNS contribute to an improved standard of care by (1) nursing assessment and injury recognition and (2) continuity of care. As specially trained individuals, TNS expand upon the role of the emergency department staff nurse. The TNS could be shown to improve compliance with trauma resuscitation room protocol and quality assurance markers of direct patient management at a statistically significant level.     

Association of decreased myocardial beta-receptors and chronotropic response to isoproterenol and exercise in pigs following chronic dynamic exercise

The effects of chronic dynamic exercise on myocardial beta-adrenergic and muscarinic cholinergic receptors and chronotropic sensitivity to isoproterenol were studied in 5 Yucatan miniswine. Right atrial and left ventricular biopsies, heart rate responses to isoproterenol, and maximal exercise treadmill testing were obtained before and after 10-19 weeks of treadmill running. Radioligand studies using 125I-iodocyanopindolol (ICYP) and 3H-quinuclidinyl benzilate (QNB) were used to determine the number of beta-adrenergic and muscarinic cholinergic receptors. Maximal oxygen consumption increased from 52 +/- 5 to 65 +/- 7 ml/kg/min (mean +/- SD; p less than 0.02), maximal workload from 530 +/- 111 to 1,074 +/- 179 KPM/min (p less than 0.01), resting heart rate decreased from 91 +/- 13 to 62 +/- 4 beats/min (p less than 0.01), heart rate at 75% of pretraining maximal workload decreased from 253 +/- 15 to 196 +/- 12 beats/min (p less than 0.01), and maximal exercise heart rate decreased from 273 +/- 6 to 254 +/- 9 beats/min (p less than 0.01). Decreased heart rate responsiveness to adrenergic stimulation was observed following chronic exercise. Maximal isoproterenol-stimulated heart rate decreased from 225 +/- 13 to 185 +/- 28 beats/min (p less than 0.05) and the slope of the isoproterenol dose-response relation decreased from 63 +/- 16 to 40 +/- 16 (p less than 0.05). Radioligand studies revealed a decrease in beta-receptor number in the right atrium following chronic exercise (61 +/- 9 vs. 34 +/- 8 fmol/mg; p less than 0.02), but receptor number in membranes from the left ventricle did not change (60 +/- 9 vs. 62 +/- 4 fmol/mg).(ABSTRACT TRUNCATED AT 250 WORDS)     

Everyday memory following traumatic brain injury

Residual memory deficits may represent a problem to the everyday functioning of a large number of people, including those who have sustained traumatic brain injury (TBI). The present exploratory study sought to investigate the interrelationships between subjective memory reports, performance on traditional memory tests, and performance on tests of prospective memory. These interrelationships were contrasted between a group of 24 adults who had sustained TBI and a group of 24 matched control subjects. Prospective memory was hypothesized to be indicative of everyday memory functioning. The results provided preliminary evidence that prospective memory tests are sensitive to TBIrelated neurological impairment and, in comparison to traditional tests, may be better indicators of functional memory capacity. This pattern was particularly true for control subjects, possibly because TBI subjects had difficulties in evaluating their memory functioning.     

Lipopolysaccharide induces DNA-synthesis in a sub-population of hemocytes from the swimming crab, Liocarcinus depurator.

The swimming crab, Liocarinus depurator, contains a small proportion of circulating blood cells which enter S-phase in vitro, as revealed by BrdU assay. These cells are enriched within the semigranular cell band produced by density gradient centrifugation on Percoll and their proportion is significantly higher in blood samples taken from crabs injected 3h previously with lipopolysaccharide (LPS). The occurrence of these cells does not persist as blood samples taken 12h post-injection show similar numbers of these cells to those from saline-treated and untreated controls. However, their appearance appears to be dose related; hemolymph from animals given 15 microg LPS per animal contains greater numbers than that from animals given LPS doses of 0.15 or 0.015 microg per animal. Estimation of the probable number of these cells per ml of the hemolymph, taking into account cell viability and changes in the size of the semigranular cell pool, indicates that they are very rare, comprising merely ca 0.06% of the total cell count. Notwithstanding, this still represents a baseline population in the region of 1.25 x 10(4) ml-1. More importantly, their number rises, approximately 11-fold to ca 14 x 10(4) ml-1 of hemolymph by 3h of injection of LPS. These results show that certain hemocytes from a brachyuran crab can synthesise DNA in vitro, and offers evidence that these cells constitute a rare but distinct sub-population of hemocytes that co-migrate with the semigranular cells during density gradient centrifugation. Since the cells received the stimulus to enter S-phase in vivo, the response must represent one of the mechanisms used by decapods to restore the hemocyte number in the circulation after non-self challenge.