Magnesium levels in serum and erythrocytes of children from Kerala

BACKGROUND: Magnesium is required in higher quantities, during the phase of rapid growth, in children. Its level in the ground water in Kerala is low. This can cause magnesium deficiency especially in children from the lower socio-economic groups who also suffer from nutritional insufficiency. METHODS: We compared the serum and erythrocyte magnesium levels of school children from high and low (agricultural labourers and fisherfolk) socio-economic groups. These levels were determined using atomic absorption spectrophotometry. Body mass indices and haemoglobin levels were used as indirect measures of nutritional status. RESULTS: Serum and erythrocyte magnesium levels were significantly lower in both boys and girls from low socio-economic groups who also had lower body mass indices. CONCLUSION: Nutritional insufficiency is prevalent in children from the low socio-economic groups and is associated with low serum and erythrocyte magnesium levels.     

Surgical complications of open spinal dysraphism

The embryogenesis, closure technique, and preoperative preparation of open myelomeningocele are described in this article. Both early and late complications of myelomeningocele closure are discussed with respect to predisposing factors, diagnosis, treatment, and prevention. These complications include worsened neurological level, wound dehiscence, wound infection, cerebrospinal fluid leak, postoperative ileus, symptomatic Chiari malformation, shunt infection, necrotizing enterocolitis, and problems related to kyphectomy.     

Use of tissue meshing technique to facilitate side to side closure of large defects

BACKGROUND: Primary closure of a large wound usually needs flaps of sophisticated design or skin grafts, both require more skill and wound care. Motley and Holt first reported the use of meshed advancement flap, a relative simple technique to close large defects of the lower leg in five patients. OBJECTIVE: To report the use of tissue meshing technique to close large wounds with significant tension on various sites of the body. METHODS: Six patients with large benign or malignant neoplasms at various sites of the body were included. Tissue meshing technique was used to facilitate wound closure after elliptical excision of the tumors at office visits. RESULTS: The wound defects, ranging from 3.0-3.5 cm in width, were closed with satisfactory cosmetic results, except for the occurrence of transient small hypertrophic scars in one patient. There was no complication of wound dehiscence, ischemia, infection or hematoma. CONCLUSION: Tissue meshing technique is a simple procedure and appears to be a satisfactory alternative to facilitate the closure of large wounds under tension. This technique is suitable for most body sites excluding central face and neck because there may be a stippled appearance in the area of meshing.     

Postoperative fistulas after gastrectomy: risk factors in relation to incidence and mortality

The relations between incidence and prognosis of postoperative fistulas after gastrectomy and some different variables were analysed in the present retrospective study. Thirteen digestive fistulas of 113 patients (11.9%) submitted to gastrectomy during the period 1989-1994 represent the study population. The incidence of postoperative fistulas was compared to the kind of gastric pathology, to the extension of gastrectomy, to different nutritional (serum haemoglobin, albumin and transferrin level, weight loss) and immunological factors (serum lymphocytes) and, for oncological patients, to the stage of the disease. Incidence was directly related to the extension of gastrectomy, to serum albumin and haemoglobin level, and to weight loss rate. The results were not statistically significant at Kruskal-Wallis and ANOVA tests. No relation was found between incidence of fistulas and serum transferrin level, number of lymphocytes and adoption of early postoperative enteral nutrition. Six patients had spontaneous closure of the fistula with conservative therapy. Seven patients required reoperation because of abdominal sepsis (53.8%). Three patients died (23%). Although spontaneous closure, reoperation and mortality were related to nutritional and immunological state, no examined variables showed a statistically significative relation. The adoption of early postoperative enteral nutrition was not related to the prognosis, unlike the stage of the disease: patients submitted to reoperation had a TNM III or IV stage; dead patients had a TNM IV stage. Treatment of metabolic-nutritional unbalance can prevent anastomotic failure and fistula after gastrectomy and improve the prognosis. The relation between early postoperative enteral nutrition and incidence and prognosis of postoperative fistulas remains unclear.     

A study of perineal wound healing after abdominoperineal resection

A comparative study of 53 cases has revealed that a technique of complete primary closure of the perineal wound after abdominoperineal resection of the rectum and anal canal appears to be a superior, more rational approach than other orthodox techniques. (It is unsuitable for any case contaminated with pus or faeces during operation.) Redivac apparatus used through a separate route for continuous drainage from the sacral cavity has made the postoperative care easier for nurses and surgeons and this period more comfortable for the patient. It provides a simple method compared with other suction apparatus used for the same purpose. Of the 53 cases, 12 were operated on using a traditional technique involving the closure of the perineal wound around a tube drain connected to an underwater seal, while in the remaining 41 the approach described here was used. Primary healing of the perineal wound with the later approach was obtained in about 88 per cent. With the other technique the figures were 34 and 66 per cent respectively for early healing within 3 weeks and delayed healing between 3-8 weeks. Primary healing of the perineal wound reduces the total stay in hospital and the morbidity.     

The double dermal keyhole pattern for breast reduction

A small contribution is made to the dependable keyhole pattern in breast reduction. A double dermal modified keyhole closure is described. It is a simple, versatile, and adaptable method of closure regardless of the pedicle technique used for reduction mammaplasty. A triangular flap (skin and dermis) is incorporated on the medial keyhole flap. A deepithelialized dermal flap is created on the lateral keyhole flap. In the final closure of the wound, the medial triangular flap is sutured over the lateral deepithelialized dermal flap. A double dermal closure at the inverted T region is thereby created. The frequency of occurrence of wound spread and early postoperative wound dehiscence is decreased by this closure, which provides cosmetic improvement and wound support where it is needed the most.     

HIV infection amongst leprosy patients in south India

We use the trapezoidal lamellar incision as standard construction for sutureless self-sealing wound closure in our clinic: a 7 mm incision for phacoemulsification and implantation of a 6.5 mm optic diameter PMMA posterior chamber less (PCL) and an incision up to 11 mm for ECCE with standard PCL. The operation can be performed in a nearly closed system because of the self-sealing wound construction. Experiments in cadaver eyes showed that the wound closure of a 7 mm incision with the no-stitch technique ruptured at a pressure five times greater than the cross-stitch-sutured corneoscleral incision and in an 11 mm incision four times greater (602 +/- 149 mmHg and 150 +/- 29 mmHg). Due to the high stability of the wound closure, no sutures are necessary. Complications arising in connection with sutures are therefore avoided. Clinically, two typical postoperative complications were observed: hypotony occurred in 1% and anterior chamber hemorrhage in 5%. These complications are exclusively caused by imperfection of the internal corneal opening.     

Factors involved in the anaemia of chronic disorders in elderly patients

Erythropoietin secretion was evaluated in the anaemia of chronic disorders in elderly patients, since it has been shown that this secretion is impaired in adults. We looked for a possible role of inflammatory cytokines: tumor necrosis factor-alpha (TNF alpha) and interleukin-1 beta (IL-1 beta) on erythropoietin production. The influence of nutritional status on the anaemia was also investigated. Erythropoietin secretion was significantly increased in elderly patients with anaemia of chronic disorders (ACD) and inversely correlated with haemoglobin concentrations in infectious and inflammatory diseases. Plasma TNF alpha levels were significantly enhanced only in cancerous patients, but no correlation could be established between TNF alpha and erythropoietin or haemoglobin. No noticeable increase of IL-1 beta levels was observed in ACD. These findings suggest that systemic TNF alpha or IL-1 beta are not involved in the erythropoietin response to ACD. Albumin levels were decreased in anaemic patients. Further investigations of the effects of a nutritional supplementation in elderly patients with ACD may be of interest.     

Salvage of failed amputation about the hip in peripheral vascular disease by open wound care and nutritional support

Five consecutive patients with wound and/or plastic surgical flap failure after hip disarticulation or amputation at the lesser trochanteric transfemoral level were treated with local tissue debridement, open wound management, culture-specific antibiotic therapy, and nutritional supplementation. All of the patients underwent amputation about the hip as a result of ischemic necrosis of the lower extremity. Four of the five patients were able to achieve wound healing by second intention. The fifth patient died 2 months after the surgery. None of the patients required revision surgery. One patient underwent split-thickness skin grafting to minimize the need for continued wound care. Local wound management combined with nutritional support and culture-specific antibiotic therapy is an acceptable alternative to major amputation stump revision in patients with potentially high morbidity who fail to heal after amputation about the hip.     

Symposium on gene abnormalities in medical diseases. 4. Neurodegenerative diseases: molecular mechanisms of spinocerebellar ataxia

A case of successful delayed primary closure of an upper extremity electrical blow-out injury is described using an alternative technique. The Sure-Closure skin-stretching device was used for permanent wound closure following serial debridement to protect the radial artery which was exposed over a distance of 21 cm. This method increases the options possible to achieve wound closure. However, the potential risks of this method include potentially high compartment pressures over a prolonged time in the postoperative period which requires close monitoring of limb perfusion.     

Studies with recombinant proteins of Ehrlichia risticii: identification of strain-specific antigen as a protective antigen

Reconstitution of basement membrane structures after "sandwich-technique" grafting of severe deep burns is demonstrated with use of immunohistochemical techniques. Cryosections of human skin after epifascial burn wound excision and sandwich grafting were stained with monoclonal antibodies against type IV and VII collagen, polyvalent antiserum against type VI collagen, and polyvalent antibody against laminin. Standard hematoxylin and eosin histologies were performed for morphologic correlation. Reorganization of the mesenchymal border zone (basement membrane), after transplantation of extremely expanded split-thickness skin autografts overlaid with glycerolized split-thickness skin allografts onto debrided human full-thickness wounds, occurred from day 5 to day 35. The autografts reepithelize the spaces between the mesh structure, which has been covered primarily exclusively with allogenic skin, and form a layered squamous epithelium, with an underlying three-dimensional basket-weave array of collagen in the remodeled neodermis after epifascial excision. Immunochemical techniques detect the reconstitution of a basement membrane zone with a typical architecture and distribution of laminin, type IV, and type VII collagen being built up 1 week to 5 weeks after sandwich grafting. These structures can be seen in the autografts during the first 2 weeks and are consistent in the whole reconstituted skin after day 35. To our knowledge this is the first report of the expression of type VI collagen in these types of wounds. The findings are compared with the expression of type VI collagen in healthy skin. The results indicate that the modified sandwich-grafting technique is an adequate means for early burn wound closure and resurfacing of third-degree burn wounds and leads to the reconstitution of dermal qualities.     

Spontaneous rupture of a liver cell adenoma

Temporary closure of the abdomen with a synthetic mesh and multiple planned relaparotomies are the essentials of the modern strategy for treating severe intra-abdominal sepsis or pancreatic necrosis. One of the complications associated with mesh closure of the abdomen is facial necrosis at the wound edges leading to evisceration. Tension of the strictures between mesh and facia called local ischemia, which combined with infection leads to the facial disintegration and separation of the mesh from the abdominal wall. A modified technique of suturing the mesh was developed in our department and its technical details are presented. Twenty-four patients treated with the "open abdominal technique and planned relaparotomies" are presented. The new technique was used in 9 patients for closure of evisceration after mesh separation.     

Clinical aspects of tuberculosis in the upper aero-digestive tract

To study the effect of cardioprotection type on haemolysis, 100 patients scheduled for elective coronary artery bypass grafting were allocated to receive either blood cardioplegia (BCP) or crystalloid cardioplegia (CCP). Haemoglobin concentrations in plasma and urine were measured after induction of anaesthesia, 1 hour postoperatively and the next morning; blood acid-base status was determined at the end of cardiopulmonary perfusion; serum electrolytes and creatinine were measured before and 1 and 3 hours after the operation and serum creatinine also the next morning. Plasma haemoglobin values tended to be higher in the CCP than in the BCP group (47.6, 200.2 and 69.1 vs 31.5, 207.5 and 39.2 mg/l, p = 0.084). The urinary haemoglobin concentrations did not differ between the groups. The acid-base status showed greater buffer capacity with BCP technique. These results contradict association of blood cardioplegia technique with increased haemolysis during coronary artery bypass grafting.     

Reduction of wound healing problems after median sternotomy by use of retention sutures

Obese people have a higher risk of sternal wound dehiscence resulting from traction of suprasternal tissue. In such patients we recommend the use of retention sutures with extracorporeal plates to improve tissue connection and to disburden fascia and skin sutures. This augmented closure is simple and effective and, since 1996, has prevented wound healing problems in more than 50 patients with a body mass index greater than 27.     

Unreferred: a chance to air my prejudices?

STUDY OBJECTIVE: To discern the best method of wound closure after laparoscopy based on patient acceptability of pain, complications, and cosmetic result. DESIGN: Randomized, prospective study. SETTING: A university-affiliated hospital. PATIENTS: Fifty-four women. Interventions. The women received interrupted 3-0 nylon sutures, subcuticular 3-0 polyglactin 910 sutures, or adhesive strips for skin closure. At the umbilical port site the rectus sheath was closed with a single 0 polyglactin suture and then one of the three materials for skin closure. The lateral ports were closed with a combination of these materials, allowing each patient to act as her own control. MEASUREMENTS AND MAIN RESULTS: Pain was significantly less in wounds closed by subcuticular technique than in those closed by either transcutaneous suture or adhesive strips. This was seen for the 5-mm, 10-mm, and umbilical port sites. There was no statistically significant difference in the rate of reported complications or patient satisfaction between subcuticular and transcutaneous wound sites. CONCLUSION: We believe these results support subcuticular methods of wound closure after laparoscopic procedures.     

Conservation of the Notch signalling pathway in mammalian neurogenesis

PURPOSE: To determine whether there is an association between epidermal growth factor (EGF)-induced activation of phosphatidylinositol 3-kinase (PI 3-kinase) and stimulation of wound closure in rabbit corneal epithelial cells. METHODS: Immortalized rabbit corneal epithelial cells were cultured in 24-well plates until they became confluent. Circular wounds were created in confluent cultures by cell denudation and then incubated in the absence and presence of EGF for varying intervals. Wound closure was monitored by staining the cells with Giemsa and quantifying the wound area with SigmaS can computer program. Cell proliferation during wound repair was estimated by measuring the incorporation of [3H]thymidine into nuclear DNA. Changes in PI 3-kinase activity were assessed by measuring the production of phosphatidylinositol 3,4,5-triphosphate [PI(3,4,5)P3] in 32P-labeled cells as well as by immunoprecipitating and assaying PI 3-kinase activity with phosphatidylinositol 4,5-bisphosphate and [gamma-32P]ATP as substrates. The enzyme product, PIP3, was analyzed by a combination of thin-layer and high-pressure liquid chromatography. RESULTS: Addition of 10 ng/ml EGF to the wounded corneal epithelial cells stimulated wound closure in a time-dependent manner, and the wound closed completely within 48 hours. The effect of EGF was dose dependent, and maximal wound closure occurred at 10 ng/ml EGF. As the epithelial cells were undergoing EGF-stimulated wound closure, there was a time-dependent increase in PI 3-kinase activity. The enzyme activity increased maximally at 24 hours and then decreased gradually as the incubation was continued to 48 hours. When the cells were treated with wortmannin, a PI 3-kinase inhibitor, the EGF-stimulated PIP3 formation as well as the wound closure were inhibited significantly. Treatment of the cells with genistein or tyrphostin B42 also decreased both EGF-stimulated PIP3 formation and wound closure in a dose-dependent manner. Concomitant with stimulation of wound repair, the growth factor increased [3H]thymidine incorporation into nuclear DNA, and this effect was inhibited by pretreatment of the cell with wortmannin. CONCLUSIONS: The data suggest a close correlation between EGF-stimulated wound closure and activation of PI 3-kinase in corneal epithelial cells. It can be concluded that PI 3-kinase might be an important component in signal transduction cascade initiated by EGF-receptor interaction, which leads to mitosis and cell proliferation during wound closure in corneal epithelial cells.     

Subtotal calcanectomy for osteomyelitis of the os calcis: a reasonable alternative to free tissue transfer

Composite wounds of the heel with secondary secondary osteomyelitis of the calcaneus remain a reconstructive challenge. A paucity of regional flaps has often necessitated microvascular transplantation in order to obtain wound healing. Subtotal calcanectomy, traditionally a technique of the orthopedic surgeon, can, in selected cases, eradicate infection and achieve wound closure and limb preservation. A review was undertaken of one hospital's experience with this procedure over a 4-year period. Five patients with osteomyelitis of the os calcis were identified who were successfully managed with subtotal calcanectomy.     

Evaluation of nutritional status by immunologic assessment in bulimia nervosa: influence of body mass index and vomiting episodes

The nutritional status of 21 patients suffering from bulimia nervosa was evaluated by anthropometric and immunologic indexes in comparison with a control group (n = 15). In addition, the influence of body mass index (BMI; in kg/m2) values and vomiting episodes on the nutritional status of bulimic patients was assessed. Anthropometry showed no signs of malnutrition in either group, except for those patients with low weights (BMI < 19). Bulimic patients had lower lymphocyte counts than did control subjects, except for those without vomiting (NVBN). All T lymphocyte subsets tested as well as CD57 cells were lower (22% and 55%, respectively) in bulimic patients than in control subjects, but the CD19 cell subset remained unmodified. The low-weight bulimic group (LWBN) had lower CD4 cell counts than did the normal-weight (BMI > 19) bulimic group. The NVBN group had lymphocyte subpopulations similar to those in the control group, except for CD57, which was lower. The bulimic patients with vomiting had the lowest cell subset values. These results suggest a depleted nutritional status in all bulimic patients studied, even those with normal weights. The LWBN group had the most depleted nutritional status and the NVBN group was least affected at a subclinical level. CD57 can be considered a good marker of nutritional status in this syndrome because it was the only subpopulation altered in all groups.     

Validity of the minimum data set for assessing nutritional status in nursing home residents

The Minimum Data Set (MDS), a Health Care Financing Administration (HCFA)-mandated resident assessment system used in community nursing homes, is potentially useful for assessing nutritional status. We compared anthropometric measures of nutritional status available in the MDS [weight and body mass index (BMI)] with other anthropometric and bioelectrical measures of nutritional status, not available on the MDS. We also studied associations of MDS-measured clinical characteristics of nursing home residents with anthropometric and bioelectrical measures of lower and higher nutritional status, defined as measures in the 25th percentile and below, and 75th percentile and above, respectively. Data were from a sample of residents of an academic long-term care facility (n = 186, 75% female, mean age 89.9 +/- 5.6 y). Results were as follows: 1) MDS measures of weight and BMI were significantly correlated with all the anthropometric and bioelectrical measures of nutritional status in women, and most measures in men; 2) some MDS variables, including poor oral intake and advanced cognitive decline, were significantly associated with two or more anthropometric and bioelectrical measures of low nutritional status; and 3) complaints of hunger were significantly associated with two or more anthropometric and bioelectrical measures of high nutritional status. Results suggest that 1) weight and BMI, available in the MDS, are correlated with other measures of nutritional status not available, and 2) MDS clinical variables are associated with measures of low and high nutritional status, and may be useful in identifying patients at nutritional risk.     

Combined use of single and double-cross steel wires for closure of midline sternotomy

BACKGROUND: We describe an improved technique for sternal closure which is performed using combined single and double-cross steel wires. We made a mechanical study of these single and double-cross shapes considering the effects of applied transverse and longitudinal shearing forces. METHODS: We used this technique in 80 patients who underwent coronary surgery with the use of bilateral internal mammary arteries. RESULTS: Among them no major wound complications occurred, and in all cases a firm stabilization of the sternum was achieved. CONCLUSIONS: We therefore consider this technique of sternal closure easy, safe and effective, also in patients considered at risk for sternal dehiscence.