One-stage double free flap arteriovenous loop reconstruction of a massive abdominothoracic defect following necrotizing fasciitis: A case report

We report the case of a 67-year old male with necrotizing fasciitis after injection of the glenohumeral joint. After extensive debridement a massive defect from the left hip joint to the left upper arm, exposing ribs, scapula, axillary vessels and brachial plexus (45 × 40 cm) was present. Reconstruction was performed with a conjoined right myocutaneous tensor fasciae lata/vastus lateralis flap and a left myocutaneous vastus lateralis flap in combination with an arteriovenous loop originating from the axillary vessels using the greater saphenous vein. Revisional surgeries were necessary including ribs resection and flap re-advancements. Due to multiorganic failure invasive ventilation, renal replacement- and extensive transfusion therapy was required. After 241 days the patient was discharged for rehabilitation. At the 12 months follow-up wounds were sufficiently closed without the need for further intervention. This case illustrates that immediate diagnosis followed by an aggressive multidisciplinary treatment approach is crucial for the patient survival.     

Immunological factors in milk from Brazilian mothers delivering small-for-date term neonates

Breast milk samples from three groups of Brazilian women were evaluated: G1, mothers delivering term babies of low birth weight (n=16); G2, mothers delivering preterm babies of appropriate birth weight (n = 20); G3, mothers delivering term babies of appropriate birth weight ( n = 30). Milk samples were obtained at 48 h and on the 7th, 15th, 30th and 60th days after delivery and they were analyzed for lysozyme and total IgA levels and for the presence of specific antibodies against Poliovirus types I, II, III, Rotavirus, Herpes simplex virus, Varicella zoster and Cytomegalovirus. The groups were not statistically different in relation to mother's age, parity, type of delivery or socio-economic levels. IgA levels were higher in both low-birth-weight groups (G1 & G2) compared to the control group (G3) throughout the study period. Lysozyme levels decreased up to the 15th day, increasing thereafter up to the 60th day in all groups. Specific antibodies were detected throughout the study period, with no differences among groups. We conclude that breast milk composition of mothers delivering low-birth-weight babies (G1 & G2) was similar despite the different gestational ages.     

Objectives to direct the training of emergency medicine residents on off-service rotations: Emergency medical services

Emergency Medical Services are an area of special interest in emergency medicine. Many emergency physicians are called upon to direct, train, or manage emergency medical services. Residents training in emergency medicine have a need for a defined curriculum in emergency medical services. Residency training should provide a basic foundation in EMS including on- and off-line medical control, medicolegal aspects, communications, disaster management, and EMS history, structure, and function. The resident must gain experience through on-scene observation, EMT/Paramedic education, medical direction, and quality assurance activities. This paper is one in a continuing series of goals and objectives to direct resident training in off-service rotations. Specific resources, learning objectives, and experiences are suggested.     

Risk factors for recurrence of pressure ulcers after defect reconstruction

Patients suffering from pressure ulcers remain to be a challenging task for nursing staff and doctors in the daily clinical management, putting—notably in the case of recurrences—additional strain on the constantly reduced resources in public healthcare. We aimed to assess the risk factors for the recurrence of pressure ulcers at our institution, a tertiary referral center. In this retrospective analysis of patients admitted to our division we identified risk factors for pressure ulcer recurrence. The hospital patient database search included all patients with a diagnosis of pressure ulcers of the torso and lower extremity. One hundred sixty‐three patients were diagnosed with pressure ulcers and 55 patients with 63 pressure ulcers met our inclusion criteria. The 17 recurrences (27%) had an average follow‐up of 728 days. Most presented with lesions of the ischial tuberosity (n=24). Recurrence was statistically associated with defect size (p = 0.013, Cox regression analysis), and serum albumin levels (p = 0.045, Spearman correlation), but no association was found for body mass index, bacterial profile, comorbidities, localization, previous surgery, or time‐to‐admission for reconstruction (all p > 0.05). Supported by the recent literature we identified factors like defect size to be associated with pressure ulcer recurrence, but not with time‐to admission for reconstruction or number of previous debridements. Whether laboratory values like serum albumin levels were the cause, the result or associated with pressure ulcer recurrence warrants further investigation.     

A longitudinal study of the association between tooth loss and age-related hearing loss

The purpose of this study was to investigate cross-sectional and longitudinal associations between hearing acuity and tooth loss in 1156 US veterans taking part in the Veterans Affairs' Normative Aging (NAS) and Dental Longitudinal (DLS) Studies in the Boston, MA, area. The mean age was 48 years (SD = 8.9), 5.3% were edentulous, and 15.4% had < 17 teeth at baseline. Hearing acuity was determined by puretone, air- and bone-conduction audiometry, and speech discrimination tests at triennial examinations over a 20-year follow-up period. Hearing decline was defined as a change from baseline in the average puretone air-conduction thresholds of ≥ 20 dB at 0.25, 0.5, 1, 2, 3, 4, 6, and 8 kHz. The explanatory variables of interest were change since baseline in dentate status (cut points at < 1, < 17, and < 20 teeth), and in the number of teeth lost (linear). Linear and logistic regression models—which controlled for baseline audiological status, age, air-bone gap, and otoscopic examination at current visit—showed that subjects who went from having ≥ 17 to < 17 teeth had 1.64 times (95% CI, 1.24-2.17) as high odds of having hearing decline as those with no change in their dentate status. For every tooth lost since baseline, there was a 1.04 times as high odds (95% CI, 1.02-1.06) for hearing decline, when additional baseline and time-varying covariates were taken into account in the model.     

Endovascular Treatment of a Left Carotid Artery "Bowtie" Pseudoaneurysm with a Covered Wallgraft Stent

The authors present an unusual case of a young male patient with a large left common carotid artery pseudoaneurysm in a shape similar to that of a bowtie treated with a covered Wallgraft. The Wallgraft is a covered stent originally designed to be used in the treatment of tracheobronchial fistula and peripheral arterial applications. The favorable outcome of this case illustrates its endovascular application in nonsurgical traumatic injuries of the carotid artery.     

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

Background:

There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.

Materials and Methods:

Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.

Results:

Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9–54). The median number of PDs per surgeon per year was 16 (range 7–38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2–5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3–32.2%), and the median post-operative duration of hospital stay was 16 days (range 4–100 days).

Conclusions:

This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.