"Windmill-plasty" for coverage of large defects of the scalp

The closure of large circular defects on the scalp is technically difficult and cosmetically often not satisfying, if a free transplant is necessary. Following the technique of Tillmann described first in 1908, several flaps shaped like a windmill can be combined. We report on 14 patients (ages 41-88 years) where large defects resulting from the excision of various tumors (5 melanomas, 5 basal cell carcinomas, 1 keratoacanthoma, 1 trichilemmal cyst, 1 squamous cell carcinoma, 1 skin metastasis) were successfully closed by this method. The diameter of the defect ranged between 4 and 8 cm (mean 5.7 cm). Size and number of the rotating flaps (3 or 4) was varied according to the size of the defect and the mobility of the surrounding tissue. The procedure was performed with local anesthesia in all cases. Wound healing occurred without complications except in 3 cases. 2 patients (63 years, 70 years) developed small necrotic areas on the tips of the flaps. In a 74 year old man with a very large defect of 8 cm diameter, one flap of four underwent total necrosis. The cosmetic result was rated "very good" in 71.4% and "good" in 14.3%. The preservation of the terminal hair turned out to be of special advantage. The "windmill procedure" is an important addition to the surgical approaches for closure of large defects on the scalp, particularly in young patients.     

Our method of treatment of dislocated fractures of the heel bone (preliminary report)

The authors present first experience with their method of treatment of displaced fractures of calcaneus. The method is based on the combination of direct and indirect reposition of fragments and exact fixation with K-wires. Axial and AP X-ray and 2 plane CT scan are indispensible conditions for operation planning. The procedure can be divided into 4 phases: traction, elevation, compression, transfixation. Up till now 65 patients have been treated with this method. 20 patients with 24 fractures were evaluated according to the Creighton-Nebraska Health Foundation score in the interval 24 months after the operation. The average value of the score was 96.6 points, 16 patients were evaluated as excellent, in 2 patients the result was good.     

Control of carboplatin-induced emesis with a fixed low dose of granisetron (0.5 mg) plus dexamethasone

The indications, advantages, complications, and benefits of peripheral neurectomy in patients with trigeminal neuralgia were studied in detail in 40 patients treated between 1982 and 1991. Twenty-eight patients had previously received radiofrequency thermocoagulation: peripheral neurectomy was performed for pain recurrence. These patients had excellent or good pain relief for at least 5 years postsurgery. Of the 12 patients who had peripheral neurectomy as their only procedure, seven had an excellent result and five had a good result. Five of the patients had recurrence of pain after 2 years but responded well to a second neurectomy. Elderly patients who experienced pain in the first and second divisions of the trigeminal distributions were the best candidates. Peripheral neurectomy is an effective, safe procedure for elderly patients who suffer from trigeminal neuralgia and have a limited life span.     

Analysis of the self: A cognitive relabeling technique.

Describes a technique for altering self-labeling processes as the method is used in group therapy. Group members are encouraged to identify negative adjectives that they use to describe themselves. Using the assumption that polarities exist in everyone, the group members are then encouraged to identify positive adjectives that exist to counterbalance these negative adjectives. Having accomplished this, many members become aware of their rigid, global approach to self-labeling. One-dimensional extreme views such as "passivity is bad" and "activity is good" become more apparent. Construction of a lost-quality list is then attempted. Members are helped in finding new, more flexible accepting labels such as "receptivity" that formerly were suppressed or assigned to the good–bad polarized categories as "activity-passivity." Variations on this technique that can be integrated into other therapeutic approaches are discussed. (11 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

提高粗苯洗涤效率的措施

通过对粗苯系统的生产运行情况分析，找出了煤气净化过程中影响粗苯洗涤效率因素，提出了循环洗油冷却系统的改造措施和优化生产操作，取得了较好的粗苯洗涤效率，同时提高了粗苯回收率，并创造了一定的效益．     

Percutaneous transhepatic gallbladder drainage for acute acalculous cholecystitis following cardiovascular surgery

Four (1.2%) out of 321 patients required percutaneous transhepatic gallbladder drainage (PTGBD) following cardiovascular surgery. Cholecystitis was initially suspected based upon the occurrence of postoperative fever and the results of abdominal X-ray films. The main physical finding was tenderness of the right upper quadrant abdomen in all patients. Spontaneous pain and Blumberg's sign were not apparent. Distension of the gallbladder and sludge in the gall-bladder were detected in all four patients by ultrasonography, but calculi were not observed. Thickening and edema of the gallbladder wall, generally suggestive of cholecystitis, were observed in only one patient. PTGBD was performed from 5 to 43 (mean 16) days after surgery. The drained fluid was concentrated bile and not purulent. High fever dropped and serum transaminase and C-reactive protein levels decreased within three days after PTGBD. Bacteriologic examinations of the bile and arterial blood were negative in all cases. No complications as a result of PTGBD introduction occurred. PTGBD is a safe and effective procedure, and therefore should be actively performed even in the early phase of acute cholecystitis.     

Epidural hematoma with atypical clinical course

The prognosis of epidural haematomas (EDH) is generally favourable if an operation is carried out in good time. Suspected EDH is mostly diagnosed as a result of a "typical" neurological manifestation (initial unconsciousness/asymptomatic interval/loss of consciousness), which then leads to an in-depth diagnosis (X-ray of the skull, CT, MRI). However, atypical clinical manifestations are frequent and can result in dangerous delays in diagnosis and treatment. A decisive factor in the early detection of EDH is close clinical-neurological monitoring by specially trained staff and their prompt reaction when changes occur, no matter how minor. Qualitative changes in the patient's state of consciousness and behaviour are just as important in this respect as quantitative ones.     

Outcome evaluation after unstable injuries of the pelvic ring

Open reduction followed by internal fixation is the method of choice after unstable pelvic ring fractures and gives better results than either conservative treatment or external fixation alone. Even after anatomic reconstruction of the pelvic ring, however, a high incidence of late sequelae is reported, especially after C-type fractures (translational instability). The purpose of the study reported in this paper was evaluation of a new scoring system for the rating of the long-term outcome after pelvic fractures. In all, 28 B-type fractures and 27 C-type fractures (Tile) were subjected to surgical stabilization in 1985-1990 (both external and internal stabilizations). These patients were followed up clinically and radiologically an average of 28 months after injury. The results were summarized in a new pelvic outcome score. The scoring included the radiological result (I = max. 3 points) and the clinical result with rating of function, neurological, urological and sexual deficits (II = max. 4 points). The "critical value" for the radiological evaluation was a 5-mm residual posterior displacement or a 15-mm anterior displacement in the pelvic ring defining a "poor" result (1 point). Social reintegration, an overall reflection of all accident-related sequelae, was rated independently (III = max. 3 points). I + II were summarized as "pelvic outcome," with 7 points rated as excellent, 6 points as good, 5 and 4 points as moderate, and 3 and 2 points as a poor result. Freedom from pain was achieved in 89% of the patients who had B-type injuries, and in 30% of those with C-type injuries. Neurological deficits were seen in 32% after B-type (only sensory) and 70% after C-type fractures (33% motor nerve, 37% sensory). The maximum radiological rating was given to 86% of the patients after B-type and 27% after C-type injuries. The clinical rating was maximum (4 points) in 18% after B-type and 7% after C-type fractures, resulting in a good or excellent rating for "pelvic outcome" in 79% after B-type and only 27% after C-type injuries. The maximum rating for social reintegration was given to 57% after B-type and 44% after C-type injuries. Even after anatomical reconstruction of the pelvic ring in C-type fractures (3 points) 20% of the patients were clinically rated as "poor" (1 point). The study showed that anatomic reconstruction of the pelvic ring is an important factor in a good or excellent clinical result, but even when this goal is met, other parameters (sacral fractures, SI dislocations, primary neurological/urological injuries) can lead to an unsatisfactory result. The new rating system is comprehensive and easy to apply and allows a clear differentiation of typical late sequelae after pelvic injuries; it will therefore be used for further long-term studies.     

Twenty-three years of experience with sphincterotomy and sphincteroplasty for stenosis of the sphincter of Oddi

A 23 year experience with papillotomy, sphincterotomy and sphincteroplasty for stenosis of the sphincter of Oddi shows sphincteroplasty to be the best procedure, with 79% of the patients obtaining a good result. The procedure was done for a demonstrable organic change in the sphincter, often associated with acute cholecystitis in older patients, the postcholecystectomy syndrome in those in whom a long cystic stump had been left at the first operation or in patients with chronic recurring pancreatitis. The study included 138 private patients observed from two months to 22 years. There were four postoperative deaths, an operative mortality of 2.9%, as two patients had been operated upon twice. The poor results were associated with recurring attacks of pancreatitis not cured by the procedure or developing subsequent to it, probably being attributable to persistent obstruction of the terminal part of the pancreatic duct. The results suggest that sphincteroplasty, if performed on suitably selected patients, is a safe procedure which should give good results in more than 75% of the patients.     

Toe transplantation in congenital malformations of the hand

Toe transfer is a well established procedure for thumb and finger reconstruction after mutilation. The indications in congenital malformations are a mater of controversy. Out of a personal series of 209 patients, 42 were children presenting a congenital malformation. Thirty six, with 46 transfers were available for review. There is only one failure at the beginning of our experience. The main indication was absence of pinch either due to absence of thumb (like in congenital band syndrome or some extreme cases of ulnar club hand or cleft hand) or absence of long finger (like in symbrachydactyly monodactylous type) or lack of both thumb and finger (like in peromelic type of symbrachydactyly). In this last type, we have been disappointed by the functional result of the distal implantation of two second toes taken from both feet; we have proposed a "stub" operation consisting in a second toe transfer on the anterior aspect of the radial epiphysis to take advantage of the mobility of the wrist and the availability of plenty tendon transfer (in this proximal situation). When planing to "built" an absent pincer, an early age is mandatory for operation (mean 12 months), to ensure a good cortical integration. A less frequent indication is a partial toe transfer with a vascularized epiphysis to provide growth and mobility in some cases of thumb hypoplasia (like in symbrachydactyly or Blauth and Manske type III b). Results are difficult to assess due to the early operation but if the mobility has been disappointing (mean 32 degrees), sensibility (mean 2PD 5 mm) and growth were excellent.     

Radial closing wedge osteotomy for Kienb?ck's disease

Twenty-six patients with Kienb?ck's disease who were treated with a radial closing wedge osteotomy and then followed for a total of 4 years and 5 months were studied. Their mean age at surgery was 31.7 years. Clinical results were excellent in 8, good in 11, fair in 6, and poor in 1 patient using the Nakamura scoring system. Nineteen (73%) patients had excellent or good results, and 25 (96%) were content with their results. Factors affecting the clinical results included the postoperative St?hl index and the preoperative radiolunate angle. It was concluded that radial closing wedge osteotomy is an effective procedure for patients with Kienb?ck's disease but that a flexion deformity of the lunate limits clinical success.     

TRAM flap perforator ligation and the delay phenomenon: development of an endoscopic/laparoscopic delay procedure

Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.     

Chronic rupture of abdominal aortic aneurysms

INTRODUCTION: Rupture of abdominal aortic aneurysms (RAAA) can take place in one of the 4 following ways: 1. "Open" rupture in the free peritoneal cavity; 2. "Closed" rupture with formation of retroperitoneal haematoma; 3. Rupture into surrounding cavity structures, such as veins and bowels; 4. In rare cases rupture is effectively "sealed of" by the surrounding tissue reaction, and retroperitoneal haematoma is "chronically" contained [1]. The terms "sealed" [2], "spontaneously healed" [3], "leakig" [4] RAAA, were also used in the previous papers connected to this situation. The "sealed" rupture was first described by Szilagyi and associates in 1961 [2]. In their case the rupture was small and haemorrhage was effectively encircled by the tissue surrounding the aortic wall. The slow rate of blood loss contributed to the patient's haemodinamically stable condition. Christenson et al. reported a case of "spontaneously healed" RAAA [3]. Rosenthal and associates described 2 patients who had aortic aneuryms that ruptured several months before repair and contributed to the term "leaking AAA" [4], while Jones et al. introduced the term "chronic contained rupture" [1]. The aim of this paper is the presentation of 5 such patients. CASE REPORT: Between December 1, 1988 and May 30, 1997 411 patients with abdominal aortic aneurysms (AAA) have been operated at our institute. Of this number 137 (33%) had RAAA, while 5 patients (12%) had a contained RAAA (CRAAA). CRAAA were found in 3 male and two female patients, average age 62 years. All of them had a previously proved AAA and initial symptoms lasted for days or months before the admission. In all patients haematocrit, pulse rate and arterial tension during the admission, were normal. All typical signs of RAAA were absent in these patients. Patient 1. A 56-year-old man, smoker, with previous history of arterial hypertension had an isolated episode of abdominal pain and collapse 30 days before the admission. Physical examination revealed a pulsatile abdominal mass. Doppler ultrasonography identified an infrarenal AAA, with right lobular extraaneurysmal mass which displaced the inferior vena cava (ICV). Angiographically (Figure 1a) an unusual saccular intrarenal AAA was detected, while simultaneous cavography (Figure 1b) confirmed the-dislocated inferior vena cava to the right. The intraoperative finding showed infrarenal CRAAA with organized retroperitoneal haematoma between AAA, ICV and duodenum. After aortic cross clamping and aneurysmal opening, the rupture at the right posterior aneurysmal wall was discovered. The partial aneurysmactomy and aortobilliar bypass procedure with bifurcated knitted Dacron graft (16 x 8 mm), were performed. The patient recovered very well. After a 4-year follow-up period the graft is still patent. Patient 2. A 72-year-old woman with low back pain, fever and disuric problems was urgently admitted to the Institute of Urology and Nephrology. The standard urological examination (X-ray, intravenous pyelography, retrograde urography, kidney Duplex ultrasonography) excluded urological diseases. However, intrarenal AAA an a giant aneurysm of the right common iliac artery, were found. The proximal dilatation of the right excretory urinary system was also found by retrograde urography. The patient was transported to our Institute 20 days after the initial symptoms. Translumbar aortography (Figure 3) showed the right common iliac artery aneurysm and gave the false negative picture of normal abdominal aorta because of parietal thrombosis of AAA. The intraoperative finding showed chronic rupture of the posterior wall of the right common artery aneurysm. The retroperitoneal haematoma compressed the right ureter. Both aneurysm have been resected and replaced by bifurcated Dacron graft (16 x 8 mm). The patient recovered successfully. After a 2-year period of follow-up the graft is still patent. Patient 3. (ABSTRACT TRUNCATED)     

Role of emergency reconstruction of fingers by the "reposition-flap" technique. Report of eight cases

Following replantation failure, fingertip reconstruction was performed as an emergency "reposition-flap" procedure in seven patients (eight fingers). This technique was intended for amputations distal to the DIP joint in long fingers, and IP joint in the thumb. Pulp was excised on the amputated segment, and the remaining bone and nail bed were reattached to the proximal stump with Kirschner wires. Pulp was reconstructed with a local advancement and sensitive flap. Trophicity and nail regrowth as well as mobility and strength were satisfactory in five cases. MRI examination showed revascularization of the distal bone fragment in four cases. This procedure is an alternative to amputation after replantation failure when patients do not accept finger shortening. The more distal the amputation, the better is the result.     

Percutaneous stereotactic differential radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia

PURPOSE: The purpose of this study was to evaluate the effectiveness of radiofrequency thermal rhizotomy (RTR) for trigeminal neuralgia, after failure of pharmacological management. PATIENTS AND METHODS: Two hundred fifteen patients underwent RTR from 1991 to 1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face, and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring reoperation, and the type and rate of complications. They were followed-up by serial clinical evaluation and telephone interview. Patients were categorized into groups: 1) Successful result: excellent, good pain relief; and 2) Unsuccessful result: fair, poor, or no pain relief. The RTR group was compared with historical controls. Follow-up ranged from 9 to 68 months (mean, 32 months) and results were evaluated at early and long-term follow-up. RESULTS: At early follow-up (defined as immediately postoperatively to 6 months), pain relief of excellent or good quality (successful result) occurred in 198 of 215 patients (92%). Fair or poor or no pain relief (unsuccessful result) occurred in 17 (8%) patients. At long-term follow-up (>6 months to 68 months), recurrence of pain that required reoperation occurred in 24 patients (11%) and recurrence of pain that did not require reoperation (medically managed) occurred in 34 patients (16%). Dysesthesia developed in 18 patients (8%); seven patients (3%) had dysesthesia alone (medically managed) and 11 patients (5%) had dysesthesia with recurrence of pain (medically or surgically managed). "Anesthesia/analgesia dolorosa" developed in four patients (1.8%) and was medically managed. At long-term follow-up, 83% of patients had good to excellent pain relief (successful result). There were no mortalities, no significant morbidity, and a low rate of minor complications. CONCLUSION: With the use of this specific diagnostic approach and management algorithm, patients with trigeminal neuralgia can be successfully managed.     

Arthroscopic Bankart repair with the Suretac device. Part I: Clinical observations

Although arthroscopic Bankart repair has become an accepted surgical stabilization technique for anterior shoulder instability, the failure rate remains unacceptably high. Little information is available concerning healing of the Bankart repair. The purpose of this article is to clarify this issue by analyzing a cohort of 15 patients who underwent a "second-look" arthroscopy to evaluate and treat pain or recurrent instability following arthroscopic Bankart repair with the Suretac device (Acufex Microsurgical, Mansfield, MA). "Second-look" arthroscopy was performed at an average of 9 months following the index surgical procedure. The reasons for this second surgery were recurrent instability in 7, pain in 6, and pain and stiffness in 2. In the 7 patients with recurrent instability, the Bankart repair was found to be completely healed in 3 (43%), partially healed in 1 (14%), and had recurred in 3 (43%); however, 6 of 7 were observed to have lax capsular tissue. In 4 of these cases, retrospective review of the index surgical procedure showed that a technical error had been made during the repair. Two cases had biopsy of the repair site on "second-look" at 6 to 8 months, and this showed residual polyglyconate polymer debris surrounded by a histiocytic infiltrate. In the remaining 8 cases with stable shoulders, the Bankart repair had completely healed in 5 cases (62.5%) and partially healed in 3 cases (37.5%). The higher failure rate with this approach compared with open approaches appears to result from improper patient selection and errors in surgical technique. There is some question concerning healing strength of the Bankart repair, although complete healing of the Bankart does not seem to be a prerequesite for shoulder stability. Success of the procedure might be expected to improve by selecting only patients with unidirectional, posttraumatic, anterior instability who are found to have a discrete Bankart lesion and well-developed ligamentous tissue.     

3D Shape Characterization and Image-Based DEM Simulation of the Lunar Soil Simulant FJS-1

This paper describes a procedure used to characterize the three-dimensional (3D) grain shape of lunar soil and undertake simulations of lunar soil by image-based discrete element method (DEM). Given that detailed 3D grain-shape information is unavailable for real lunar soil, a simulant material, FJS-1, is used in this study. We use the high-resolution micro X-ray CT system at SPring-8, a synchrotron radiation facility in Japan, to visualize precise 3D images of the granular assembly of FJS-1. A newly developed image-analysis procedure is then applied to identify individual grains. Using the obtained grain-shape data, a sufficient number of FJS-1 grains are directly modeled for DEM simulation using an efficient modeling scheme. A series of particle flow simulations are then performed with the modeled grains. The resulting slope angles are in good agreement with experimental results. We discuss the effect on the slope angle of grain parameters such as contact stiffness, restitution coefficient, and interparticle friction.     

Antiepileptic drug-related cognitive complaints in seizure-free children with epilepsy before and after drug discontinuation

The cognitive complaints reported by children and their parents, as subjectively associated with antiepileptic drug (AED) treatment, were evaluated in seizure-free children before and after drug discontinuation. The aim of the design was to isolate the cognitive side effects of AEDs from other factors, such as the effect of seizures. Our inventory explored the following areas: "alertness," "concentration," "activation/ tiredness," "memory," "drowsiness," "depression," "aggressiveness," and "hyperactivity," using a 5-point Likert scaling procedure. One hundred two eligible patients were selected, each matched with a healthy control and assessed when still on antiepileptic medication. All children were seizure free for at least 1 year. The medication was then discontinued gradually over a 3-month period. Four months after the children were completely medication free, a second assessment was carried out, but only in the 83 children who remained seizure free and in their matched controls. The results of the reports made by the children themselves did not show differences with the matched controls, and only showed improvement after drug discontinuation for complaints about "tiredness." Parents of the children with epilepsy reported significant improvement in all areas related to "alertness and activation" after discontinuation of the drugs. The finding that only a limited number of children have cognitive complaints, both when still on AEDs and after discontinuation, may be in line with the reports that the major factor contributing to quality of life is whether patients are seizure free or still have seizures. All patients in this study were seizure free for a period >1 year, which may have caused the favorable pattern of response in our patient group.     

Usefulness of detection of breast cancer: the part played by the internist

The prognosis of breast cancer is the result of many factors, among which the mass of the tumor at the time of diagnosis remains the most significant: small tumors have a better prognosis than larger ones and are less often accompanied by positive lymph nodes. It is therefore justifiable to search for them systematically by breast examination of all patients over 30. Large-scale mass screening campains in the USA, with clinical and mammographic examination of tens of thousands of women, have proven that it is possible to detect more "early" cancers and reduce general mortality in the groups studied. The number of cancers thus detected is nevertheless so small that it does not justify the investment of so much labour and money in this kind of campaign. Systematic breast examination at regular intervals (6 months to 1 year) with regular mammographies should be confined to patients in the high risk groups: women who have already undergone surgery for cancer of one breast, and patients with a marked family history of breast cancer. For the rest of the female population, the solution seems obvious: every physician should get into the habit of performing regular clinical examination of the breasts. Most gynecologists are already doing so, but they only examine a small part of the population. The most important role in the detection of breast cancer falls to the internists and the general practitioners: they should assume responsibility for all their patients' breasts, in the same manner as they do for heart and lung examinations. They will then request additional examinations (mammography, thermography) as soon as clinical examination reveals a pathological finding. The results of GILBERTSEN [5] confirm that clinical examination remains the most valuable and least expensive method for breast cancer detection.     

When implicit learning fails: amnesia and the problem of error elimination

We propose that one of the major functions of explicit memory is the elimination of learning errors. The hypothesis is explored by means of a stem completion task in which subjects are presented with stems having many potential completions, and in the initial phase are either encouraged to guess, the "errorful" procedure, or are provided with the correct completion, the "errorless" condition. Learning is then tested over a sequence of nine trials. The performance of amnesic subjects who are assumed to have good implicit but bad explicit learning is compared with that of normal elderly subjects, who are assumed to have an intermediate level of explicit learning skill, and young controls who are expected to be high in both implicit and explicit learning capacity. As predicted, errorless learning is beneficial, with the effect being particularly marked for the amnesic group. A detailed analysis of the intrusion errors supports an interpretation of the results in terms of the relative contribution to the three groups of implicit learning, which is assumed to be particularly vulnerable to interference. Implications for the analysis of normal learning, and for the rehabilitation of brain damaged patients are discussed.