Three-square-flip-flap reconstruction for post burn syndactyly.

INTRODUCTION: Burns of the hands may result in the formation of web space contractures-post burn syndactyly. We present our experience using the three-square technique originally described by Bandoh for minor syndactyly. METHOD: Tissues of the contracted web are regard as forming three facets of a cube. If elevated and transposed 90 degrees on their base the facets will fall into place and line the interior of the cube creating a deepened web-space. The first flap is based on the web itself either dorsally or volarly. The second flap is based distally on one of the fingers. The third flap is based laterally on the other finger. Surgery is followed by a splinting regimen. RESULTS: The design of the flaps is simple and the operation is easy to perform. This technique has achieved good functional and cosmetic results; there have been no flap losses or significant complications. CONCLUSION: The three-square-flip-flap is a simple reliable and safe method for the treatment of post burn syndactyly.     

Capacity planning for cardiac catheterization: a case study

BACKGROUND: Excessive waiting for procedures such as cardiac catheterization is an important issue for health care systems. Delays are generally attributed to a mismatch between demand and available capacity. Furthermore, due to the dynamic nature of short-term referral rates, procedure times, and patients' medical urgency, all of which are important contributors to the problem of excessive waiting time, it has been difficult to predict capacity needs accurately. The objective of our paper is to demonstrate how such calculations could be performed. METHODS: After constructing a patient flow model and populating it with appropriate data from 16 consecutive months of operations (n=6215 referrals) of a regional cardiac centre in Ontario, we used computer simulation to simulate the operations of catheterization laboratories in several "what-if" scenarios. We divided the patients into three urgency categories: U1--hospitalized patients, U2--urgent outpatients, U3--elective outpatients. We tested the accuracy of the model by comparing a 1-year sample of computer simulation with actual data which resulted in a highly significant correlation of 0.94. RESULTS: We observed from the referral cohort that waiting times were long, both overall and within each urgency category. We observed from the simulation models that: (1) a one-time infusion of capacity to clear the backlog failed to reduce the waiting times; (2) targeting extra capacity to highest urgency categories reduced waiting times overall and also benefited low urgency patients for whom specific increased capacity was not earmarked; (3) there were no significant effects on waiting times if in some cases patients or referring physicians were able to choose their cath physician; and (4) in situations where the arrival rates increased overall or within specific urgency categories, waiting times increased dramatically and failed to return to baseline for several months to years for the low urgency patients. Efficiency of the labs within the existing capacity could be improved by: (1) reducing changeover time between cases (2) externalizing and standardizing many of the pre- and post-procedural management of the patients, and (3) more carefully balancing the booking to reduce both slack and overtime. INTERPRETATION: Capacity determination is a complex and dynamic process. A combination of available clinical and administrative data, along with a computer simulation model, helps predict capacity needs and is the most appropriate strategy to minimize waiting of patients for procedures. This approach is generalizable and can lead to more effective management of waiting lists for a variety of procedures.     

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

Purpose. To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 at Loewenstein Rehabilitation Hospital, Israel.

Method. This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA.

Results. Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay.

Conclusions. Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.     

C-reactive protein and NT-proBNP as surrogate markers for pulmonary hypertension in Gaucher disease

BACKGROUND: N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) values correlate with mild-moderate pulmonary hypertension assessed by tricuspid insufficiency (TI) gradient>or=30 mm Hg in Gaucher disease. The purpose of this study is to ascertain improved risk stratification based on correlation with NT-proBNP and C-reactive protein (CRP), a standard marker of inflammation. METHODS: Patients with type I Gaucher disease were selected to reflect differing degrees of echocardiographically determined TI gradient values. NT-proBNP was performed by immunoassay and CRP by standard methods. FINDINGS: There were 45 patients (18 males; 40%); mean age=42.5 (range: 4-80) years. Median NT-proBNP value=153 (range: 46-6703) pg/ml; median CRP value=0.145 (range: 0.02-2.69) mg/dl. There was a statistically significant correlation between these values (r=0.445, P<0.01). Elevations of CRP and NT-proBNP were risk factors for pulmonary hypertension with odds ratios of 8.47 and 4.9, respectively. The area under the Receiving Operator Characteristic (ROC) curve for diagnosis of pulmonary hypertension was 0.93+/-0.04 for CRP, and 0.7+/-0.1 for NT-proBNP. All patients with pulmonary hypertension had elevation of either CRP or NT-proBNP (100% sensitivity). CONCLUSIONS: Elevated CRP was a better predictor of pulmonary hypertension in Gaucher disease than elevated NT-proBNP values. Elevated CRP (>0.5 mg/dl) or elevated NT-proBNP (>150 pg/ml) reduces the need to perform echocardiography by more than half, even in this group with over-representation of pulmonary hypertension. The role of inflammatory features in pulmonary hypertension in Gaucher disease is discussed. Further studies are required to ascertain if this approach is useful for prognosis of pulmonary hypertension.     

Oxidative stress causes telomere damage in Fanconi anaemia cells - a possible predisposition for malignant transformation

Fanconi anaemia (FA) is an autosomal recessive and X-linked disease characterized by severe genetic instability and increased incidence of cancer. One explanation for this instability may be the cellular hypersensitivity to oxidative stress leading to chromosomal breaks. This study explored the possible oxidative damage to telomeres of FA lymphocyte cell line, HSC536/N, and its possible effect on telomere function. We postulated that combination of oxidative damage with overexpression of telomerase may provide a possible model for malignant transformation in FA. The cells were grown in the presence of telomerase inhibitor and exposed for 1 month to H₂O₂ combined with various antioxidants. This exposure caused shortening of telomere length and damage to the telomere single stranded overhang, which was prevented by several oxidants. This shortening was associated with development of severe telomere dysfunction. Control cells did not exhibit this sensitivity to H₂O₂. Telomere dysfunction did not evoke damage response in FA cells, in contrast to normal P53 upregulation in control cells. Reconstitution of telomerase activity protected FA telomeres from further oxidative damage. These results suggest a scenario in which oxidative stress causes telomere shortening and ensuing telomere dysfunction may form the basis for malignant transformation in FA cells. Upregulation of telomerase activity in sporadic FA cells may perpetuate that process, thus explaining the malignant character of FA cells in vivo .     

Twin Pregnancy in a Patient after the Fontan Operation: Report of a Case

Singleton pregnancy in patients with single ventricle after the Fontan operation has been reported with significant offspring and maternal complications. We report a twin pregnancy and premature delivery, in a patient following the Fontan operation.     

Injectable protease-operated depots of glucagon-like peptide-1 provide extended and tunable glucose control

Peptide drugs are an exciting class of pharmaceuticals increasingly used for the treatment of a variety of diseases; however, their main drawback is a short half-life, which dictates multiple and frequent injections and an undesirable “peak-and-valley” pharmacokinetic profile, which can cause undesirable side-effects. Synthetic prolonged release formulations can provide extended release of biologically active native peptide, but their synthetic nature can be an obstacle to production and utilization. Motivated by these limitations, we have developed a new and entirely genetically encoded peptide delivery system—Protease Operated Depots (PODs)—to provide sustained and tunable release of a peptide drug from an injectable s.c. depot. We demonstrate proof-of-concept of PODs, by fusion of protease cleavable oligomers of glucagon-like peptide-1, a type-2 diabetes drug, and a thermally responsive, depot-forming elastin-like-polypeptide that undergoes a thermally triggered inverse phase transition below body temperature, thereby forming an injectable depot. We constructed synthetic genes for glucagon-like peptide-1 PODs and demonstrated their high-yield expression in Escherichia coli and facile purification by a nonchromatographic scheme we had previously developed. Remarkably, a single injection of glucagon-like peptide-1 PODs was able to reduce blood glucose levels in mice for up to 5 d, 120 times longer than an injection of the native peptide drug. These findings demonstrate that PODs provide the first genetically encoded alternative to synthetic peptide encapsulation schemes for sustained delivery of peptide therapeutics.     

Economic assessment of pressure sore prevention using a computerized mattress system in patients with spinal cord injury

Purpose. To assess the economic profitability of a new computerized mattress system in patients with spinal cord injuries (SCI) by comparison with two other alternatives, as an example of the use of a quantitative approach for decision-making in choosing between alternatives for sore prevention.

Method. The cost of achieving one day without signs of impending pressure sore was compared between the alternative options using cost minimization analysis. Savings in nursing costs for the three options were calculated for cost-benefit analysis.

Results. A foam mattress system is significantly cheaper than the other examined alternatives, and if the nursing manpower cost is constant and the nursing staff is capable of performing sufficient repositionings, this system would achieve the desired medical outcome at a minimal cost. However, if the nursing staff cannot perform sufficient repositionings, or if the use of nursing manpower can be adjusted to the actual need, then it is the computerized mattress system that achieves the desired outcome at the minimal cost. In this case, less than 20 New Israeli Shekels (NIS) per day spent on the equipment save NIS 45 per day in labor costs.

Conclusions. The economic evaluation indicates that the computerized mattress system is advisable for patients with SCI who require assistance for repositioning, but its profitability depends on the employment terms of the nursing manpower. In addition, other possible alternative pressure management systems should be examined, and additional research may be needed to determine the optimal combination of such systems for a spinal cord rehabilitation department.