Enhanced survival using the distally based sural artery interpolation flap

The reverse sural artery flap is frequently used for reconstruction of the distal third of the leg, ankle, and heel. The major disadvantage of the flap is compression of the pedicle within the subcutaneous tunnel and venous congestion. Others have cited a decrease in this problem by harvesting a midline cuff of gastrocnemius muscle, including more subcutaneous tissue and using a wider-than-usual pedicle. We describe an interpolation flap technique of simply avoiding a subcutaneous tunnel and exteriorizing the pedicle with no other alterations to flap design or elevation techniques. Seven distally based reverse sural artery flaps were performed on ambulatory patients between 2001 and 2002. Venous congestion did not occur in any of the flaps. All patients were ambulatory after surgery and did not require the use of a custom shoe. We conclude that transferring the flap in 2 stages without the use of a tunnel improves the reliability of the flap and eliminates venous congestion.     

Free-tissue transfer experience at a county hospital

As reimbursement for free-tissue transfer decreases, the authors find an increase in the number of free flaps performed at their county facility. Over 60 percent of the free flaps performed during the past 10 years were completed within the last 4 years. This influx of patients prompted a review of their experience with free-tissue transfer. This retrospective study of the free-flap experience at a county hospital reviewed 49 patients with 53 free flaps between 1991 and 1999. Forty-five free flaps (85 percent) were successful, with an overall failure rate of 15 percent. Most free flaps were performed on traumatic wounds. Risk factors, such as smoking, diabetes, and peripheral vascular disease, did not reliably predict free-flap failure. Irradiated, chronic wounds were associated with the highest failure rates. Seventy-five percent of the free-flap failures were due to delayed return to the operating room, once the flap appeared compromised. Delay in reexploration resulted in a zero salvage rate. Prompt recognition of failed flaps and emergent exploration will improve the success rate.     

Blood loss and replacement in total hip arthroplasty: a multicenter study. The Preoperative Autologous Blood Donation Study Group

To determine blood loss, the number of transfusions, and the hemoglobin levels achieved in patients via transfusion in the course of total hip arthroplasty, 324 patient records from 1987 through 1989 were reviewed at three university and three community hospitals. Calculated blood loss was 3.2 +/- 1.3 units in primary procedures and 4.0 +/- 2.1 units in revision procedures (mean +/- SD). Of 777 red cell units transfused, 455 (59%) were autologous units. Transfused patients received 2.0 +/- 1.8 units for primary procedures and 2.9 +/- 2.3 units for revision procedures (mean +/- SD). The maximum number of units given to 95 percent of the transfused patients was 4 for primary procedures and 6 for revision procedures. The mean postoperative hemoglobin level after all transfusions was 103 to 110 g per L, regardless of patient age group of physical status, autologous donor status, or hospital. No difference in length of hospital stay was observed for patients less than 65 years old with hemoglobin concentrations of 80 to 139 g per L at discharge.     

Glucose-6-phosphate dehydrogenase deficiency and hereditary hemolytic anemia

G6PD deficiency is the most common enzymopathy in the world. The highest frequency values are found in tropical Africa, in the Middle East, in some areas of the Mediterranean, in tropical and sub-tropical Asia and in Oceania. This genetic defect shows sex linked inheritance and a marked heterogeneity. At least 400 abnormal variants with different biochemical characteristics and about 100 diverse mutations have been identified. In most cases the phenotypic expression is a marked decrease in erythrocyte G6PD activity. The most common clinical consequences are neonatal jaundice and sporadic haemolytic crises caused by a number of drugs, by infections or by ingestion of fava beans. A few cases of chronic non-spherocytic haemolytic anaemia associated with rare molecular variants have been reported. Early diagnosis, education and epidemiologic surveillance have been proved to be cornerstones in the prevention of the haemolytic disease. Therefore they should be taken into account in the national health programmes, especially in the countries with high prevalence rates.     

Utilization of screening mammography: comparison of different physician specialties

Data obtained on 426 consecutive patients referred to a breast center by 122 physicians, including family practitioners, general surgeons, and other specialists, showed that the obstetricians-gynecologists referred the greatest average number of patients per physician, with more than 50% of these referrals for screening mammography. Internists referred fewer patients by nearly a factor of ten, with only one-third of these patients referred for screening mammography. Internists may be the weakest link in the utilization of screening mammography.     

Identification of G6PD Mediterranean mutation by amplification refractory mutation system

Aim: To examine the plasma nitrate/nitrite (NOx—two end products of the nitric oxide metabolism) and endothelin (ET) concentrations, and response to acute adrenaline induced hypertension in diabetic rats. Materials and methods: Four groups of 4-month-old rats were used: control rats (C, n=10) rats received adrenaline (A, 40 μg/kg i.v., n=10), rats received streptozotocin (S, 50 mg/kg i.v., n=8), and rats received STZ and adrenaline (SA, n=9). The experiments were performed 4 weeks after the STZ administration. Plasma NOx, ET, glucose, and mean arterial blood pressure (MAP) were measured. Results: Plasma ET concentrations were significantly increased in diabetic rats (S and SA) in comparison with the controls and adrenaline-only administered rats. NOx concentrations in diabetic groups (S and SA) were significantly decreased in comparison with the controls. Acute adrenaline induced hypertension in diabetes leads to a significant decrease of NOx concentrations in comparison with the controls, adrenaline-only administered and STZ-only administered rats. There was no difference between the MAP in diabetic and control rats. Adrenaline injection caused a significant increase of MAP in A and SA groups. Plasma glucose concentrations in diabetic rats (S and SA) were significantly increased in comparison with the nondiabetic groups (C and A). There was a weak but significant correlation between the NOx and ET concentrations in the controls, which probably reveal the balance between these vasoactive factors. In A, S, and SA groups, no significant correlation between the NOx/ET was found. Conclusion: An impairment of the NOx and ET formation could be involved in the pathogenesis of diabetes mellitus and especially acute hypertension and diabetes. A lack of correlation between the NOx and ET probably indicated that in diabetes and acute hypertension, a primary mechanism of compensatory nitric oxide might be lost.     

Blood group A immunodeterminants on human red cells differ in biologic activity and sensitivity to alpha-N-acetylgalactosaminidase

BACKGROUND: Epitopes of blood group A antigen can be enzymatically cleaved from red cells (RBCs), but the extent of cleavage required for normal survival in allogeneic blood transfusion recipients is unknown. Therefore, the cleavage rates were studied for A antigen epitope binding of 1) complement-activating anti-A, 2) Dolichos biflorus anti- A, lectin, and 3) hemagglutinating anti-A during incubation with a purified alpha-N-acetylgalactosaminidase, E.C. 3.2.1.49 (alpha- GalNAc'ase). STUDY DESIGN AND METHODS: Suspensions of group A RBCs were incubated with alpha-GalNAc'ase. Cells were removed at intervals, washed, and tested for loss of binding by monoclonal, polyclonal, and complement-activating anti-A, D. biflorus anti-A1 lectin, and Ulex europaeus anti-H lectin. RESULTS: A epitopes binding D. biflorus lectin were highly susceptible to alpha-GalNAc'ase; simultaneously with their loss, binding with U. europaeus lectin emerged. Loss of complement- mediated hemolysis was slower. A epitopes binding hemagglutinating anti- A were most resistant. Cleavage of A epitopes from membrane glycosphingolipids with short oligosaccharide chains was similarly resistant. Rates of cleavage from A1 and A2 RBCs were similar. CONCLUSION: RBC epitopes of blood group A differ in susceptibility to cleavage and biologic reactivity, which suggests that subsets mediating important biologic functions exist on functionally and topographically distinct membrane glycoconjugates.     

Metabolic effects of successful intraportal islet transplantation in insulin-dependent diabetes mellitus.

The intraportal injection of human pancreatic islets has been indicated as a possible alternative to the pancreas transplant in insulin-dependent diabetic patients. Aim of the present work was to study the effect of intraportal injection of purified human islets on: (a) the basal hepatic glucose production; (b) the whole body glucose homeostasis and insulin action; and (c) the regulation of insulin secretion in insulin-dependent diabetes mellitus patients bearing a kidney transplant. 15 recipients of purified islets from cadaver donors (intraportal injection) were studied by means of the infusion of labeled glucose to quantify the hepatic glucose production. Islet transplanted patients were subdivided in two groups based on graft function and underwent: (a) a 120-min euglycemic insulin infusion (1 mU/kg/min) to assess insulin action; (b) a 120-min glucose infusion (+75 mg/di) to study the pattern of insulin secretion. Seven patients with chronic uveitis on the same immunosuppressive therapy as grafted patients, twelve healthy volunteers, and seven insulin-dependent diabetic patients with combined pancreas and kidney transplantation were also studied as control groups. Islet transplanted patients have: (a) a higher basal hepatic glucose production (HGP: 5.1 +/- 1.4 mg/kg/ min; P < 0.05 with respect to all other groups) if without graft function, and a normal HGP (2.4 +/- 0.2 mg/kg/min) with a functioning graft; (b) a defective tissue glucose disposal (3.9 +/- 0.5 mg/kg/min in patients without islet function and 5.3 +/- 0.4 mg/kg/min in patients with islet function) with respect to normals (P < 0.01 for both comparisons); (c) a blunted first phase insulin peak and a similar second phase secretion with respect to controls. In conclusion, in spite of the persistence of an abnormal pattern of insulin secretion, successful intraportal islet graft normalizes the basal HGP and improves total tissue glucose disposal in insulin-dependent diabetes mellitus.