Reducing Opposed Multilobed Flaps Results in Fewer Complications Than Traditional Repair Techniques When Closing Medium-Sized Defects on the Leg after Excision of Skin Tumor

BACKGROUND: The reducing opposed multilobed (ROM) flap involves a series of transpositions effected cephalic and caudal to the primary defect, sequentially mobilized toward and then into the primary defect. OBJECTIVE: To compare the ROM flap with other techniques to close defects below the knee after excision of skin tumor. METHOD: This retrospective study compares 140 defects closed with a ROM flap with 85 defects closed with traditional techniques. RESULTS: A total of 225 defects between 11 and 44 mm in diameter were excised over 3 years from July 1, 2002. There were 140 defects closed by ROM flap and 85 non-ROM closures including 29 "O-to-Z" flaps and 12 bilateral transposition flaps. A total of 111 squamous cell carcinomas, 64 basal cell carcinomas, and 11 melanoma were excised. ROM flap closures developed 20 complications (14.3%): 13 infections, 5 partial dehiscence, and 2 partial end flap necrosis. Non-ROM closures developed 27 complications (31.8%): 13 infections, 6 partial end flap necrosis, 4 partial dehiscence, 2 wound depression, 1 hemorrhage, and 1 persisting pain. Three ROM and 7 non-ROM cases suffered two complications. The total complication rate was significantly lower with ROM flaps (p=.003), including lower end flap necrosis incidence (p=.027). CONCLUSION: The ROM flap results in fewer complications than traditional techniques when closing defects 11 to 45 mm in size on the leg and foot. In particular, end flap necrosis incidence is lower with ROM flap closure.     

The Automatic Implantable Defibrillator

New Modality for treatment of life-threatening ventricular arrhythmias. The automatic implantable defibrillator continuously monitors cardiac rhythm, identifies ventricuiar fibrillation and then delivers corrective defibrillatory discharges when indicated: it weighs 250 grams and has a volume of 145 cc. When a suitable arrhythmia is detected, a 25 Joule pulse is delivered through a superior vena cava catheter electrode and another electrode placed over the cardiac apex. As oj March 1981, sixteen survivors of multiple cardiac arrests refractory io antiarrhythmic therapy had undergone implantation of the automatic defibrillator. There was no operative mortality and the morbidity was minimal. Electrophysiologic studies were performed before and after surgery to confirm failure of drug therapy and to ensure the device's ability to terminate malignant arrhythmias. Eight spontaneous and fourteen of the seventeen induced malignant arrhythmias were properly recognized and corrected by the device. The discharges were well tolerated by awake patients. A number of problems including recycling delays and spurious discharges have been identified and corrected. There were three late deaths with pulmonary edema noted in two patients, and asystole in one. The autopsies revealed no myocardial damage attributable to the automatic defibrillator. Although the ultimate role of this approach to prevention of sudden arrhythmic death has yet to be determined, the results obtained to date are encouraging and indicate that a useful modality for treating malignant ventricular arrhythmias has been added to our armamentarium. (PACE, Vol. 5, May-June, 1982)     

External Non-invasive Cardiac Pacing: A Comparative Hemodynamic Study of Two Techniques with Conventional Endocardial Pacing

Out-of-hospital therapy for cardiac arrest due to bradyarrhythmias or asystole is pharmacologic and the outcome is uniformly dismal. Optimal therapy for the latter disturbances may be artificial cardiac pacing, but conventional invasive pacing techniques are not employed or are of limited value in the out-of-hospital and emergency department setting. This investigation compared the hemodynamic effects of two techniques of non-invasive external pacing: 1) transcutaneous transthoracic pacing (TTP) and 2) tongue-to-epigastrium pacing (TEP), with conventional transvenous right ventricular endocardial pacing (RVEP) in a closed-chest, chronic heart block canine model. All techniques significantly increased (p less than .001) cardiac output (CO). However, CO and mean arterial pressure (MAP) measured during external pacing with either non-invasive technique were significantly greater than that during RVEP (p less than .001). TEP produced vigorous skeletal muscle stimulation and, in the canine model, it produced contraction resulting in impaired ventilation, hypoxemia, and a decrease in systemic vascular resistance. TTP in this model resulted in improved MAP and CO when compared with control and RVEP values and did not affect arterial or mixed venous blood gas values. Thus, this study demonstrates that noninvasive TTP is comparable to RVEP in its hemodynamic effects. TTP may offer definitive non-invasive therapy for a subset of victims of out-of-hospital cardiac arrest.     

Atropine-Induced Multilevel Block in Acute Inferior Myocardial Infarction A Possible Indication for Prophylactic Pacing

The degree of A-V block increased after intravenous administration of atropine in 10 nondigitalized patients with acute inferior myocardial infarction who had narrow QRS complexes during periods of 1:1 A-V conduction. Short episodes of 3:1, 4:1 and 5:1 A-V block were seen to emerge: (a) in 6 patients, directly from Wenckebach periods; (b) in 3 patients, from alternating Wenckebach periods; and (c) in 1 patient, from a 3:2 Wenckebach period which led to a short-lived alternating Wenckebach period. Apparently, the predominance of the chronotropic effects on the sinus node over the dromotropic effects on the A-V node led to a tachycardia-dependent (more ischemic than vagal) process, exposing or producing multi- (two, three or four) level block involving the A-V node (and perhaps the His bundle). Subsequently, therapeutic pacing was instituted in 9/10 patients because they developed spontaneous symptomatic advanced A-V block. Therefore, it is possible that the early effects of atropine identified a narrowly-defined subset of patients in whom prophylactic pacing may be indicated. However, more studies are necessary to corroborate these assumptions.     

Retroperitoneal Fibrosis Caused by Carcinoid Tumor

This report describes a 33-year-old woman who presented withrenovascular hypertension secondary to retroperitoneal fibrosis,associated with a carcinoid tumor with widespread metastases.Although the association is rare, it is important to considercarcinoid tumour as a cause of idiopathic retroperitoneal fibrosis,even in the absence of the carcinoid syndrome.     

Pingueculae--An Association with Renal Failure

One hundred and forty-four patients who had chronic renal failurewere examined for the presence of pingueculae. A significantlygreater incidence was found between the ages of 20 to 40 inthese patients compared with an age- and sex-matched controlgroup. There was no difference in sex-incidence or between thosetreated with haemodialysis or transplantation. The levels ofcholesterol, triglycerides, calcium, and inorganic phosphatein the plasma were not related to the presence of pingueculae.Detailed structural andchemical analyses of pingueculae aredescribed.     

Closed Loop Control of Rate Adaptive Pacing: Clinical Assessment of a System Analyzing the Ventricular Depolarization Gradient

Closed loop control of rate adaptive pacing has theoretical advantages over current rate responsive pacemakers. The first available system (which senses the ventricular depolarization gradient) has been evaluated in ten patients. The pacing response to a variety of exercise and nonexercise stimuli was assessed. Response to isotonic exercise was prompt and proportional to the exertion involved while isometric exercise and mental stress produced obvious but more gradual increases in pacing rate. In seven patients, comparison between the intrinsic P wave and pacing rate showed a high correlation during exercise (r = 0.91) and mental activity (r = 0.87). Postural changes induced a paradoxical response. Closed loop rate responsive pacing based upon analysis of the ventricular depolarization gradient produces a fast and appropriate rate response to most physiological stimuli.     

Impedance of Pacemaker Leads: Correlation of Different Methods

This study compares three different pacing system analyzers, which measure impedance at different points during an impulse, with measurements telemetered from implanted pacemakers from four different manufacturers. Measurements were obtained at the time of implantation in a group of 103 patients. The measurements obtained by these different methods differ significantly from each other; the later during the impulse the impedance is measured, the higher in general its value. Interpretation of impedance values should take into account the technique of measurement.