Factors affecting surgical results of Wassel type IV thumb duplications.

The aim of this study is to review the outcomes of Wassel type IV thumb duplications with a minimum of one year follow-up, and to identify any factors that may compromise the quality of results. Forty one patients (42 thumbs) returned for assessment of thumb alignment, metacarpophalangeal joint and interphalangeal joint stability and motion; carpometacarpal joint motion; pinch and grip strengths; and thumb size. The subjective assessment considered thumb shape and contour, scarring, nail deformity and examiner and patient/parent satisfaction. The mean age at surgery was 16 months and the mean follow-up time was 79 months. Metacarpophalangeal joint and interphalangeal joint mal-alignment was present in 56% and 38% of cases, respectively. Interphalangeal ulnar collateral ligament laxity was significant. Metacarpophalangeal joint and interphalangeal joint motion was significantly decreased. Pinch and grip strength measurements were normal. A novel and comprehensive assessment scale is introduced, which revealed results of one (2.5%) excellent, 23 (59%) good, 14 (36%) fair and one (2.5%) poor. We consider that greater attention should be directed to the avoidance of mal-alignment and instability to improve these results.

Keloid formation resulting in acquired syndactyly of an initially normal web space following syndactyly release of an adjacent web space.

We present a case of acquired syndactyly secondary to keloid formation in a previously normal web space following release of syndactyly in the adjacent web space.

Digital infestation with the human bot fly.

We report a finger infestation by the human bot fly, Dermatobia hominis, describe the biology and life cycle of the fly and review the diagnosis and treatment of the condition.

BASIC program for reduction of data from community-level physiological profiling using biolog microplates: rationale and critical interpretation of data.

A BASIC program is offered that reduces data resulting from mixed-species inoculations into Biolog microplates. The procedures of the program are supported by a critical review of the literature relating to Biolog data reduction. The availability of standardized, accelerated data reduction protocols will facilitate study comparisons and allow efficient evaluation of new data reduction approaches.

Implementing an integrated program of resource management.

The physicians at Methodist Hospitals of Memphis have designed a program of resource management that has resulted in significant patient care cost savings while maintaining an excellent quality of care. The program combines methods of increasing physician awareness of cost issues, sharing physician utilization and quality data with them, and coordinating patient care through the use of multidisciplinary clinical pathways and case management. Our physicians, patients, nursing staff, and quality management personnel are enthusiastic about the program's positive effect on costs and improved quality patient care.

Sharing financial information with doctors: making it work.

Physicians are becoming increasingly aware of how their practice patterns affect the financial viability of their practices and of the hospitals in which they work. Programs of diagnosis-related group (DRG) analysis may be used not only to educate physicians but to provide data for physician-directed efforts to reduce variations in practice patterns and deal with physicians whose practice habits may be counter to cost-effective, high-quality care. A combination of early, extensive physician involvement and subsequent multidisciplinary interaction will ensure the development of and adherence to cost-effective, high-quality patient care.

Ticarcillin-clavulanate therapy for infections with ticarcillin-resistant microorganisms.

In a prospective study, 46 episodes of serious infection with ticarcillin-resistant microorganisms were treated with the combination ticarcillin disodium and clavulanate potassium (Timentin). Clinical cure was achieved in 35 of the 46 episodes (76%), and microbiologic eradication was achieved in 30 (65%). We found no development of resistance to ticarcillin-clavulanate and observed no serious side effects.

A randomized study of tobramycin plus ticarcillin, tobramycin plus cephalothin and ticarcillin, or tobramycin plus mezlocillin in the treatment of infection in neutropenic patients with malignancies.

Two hundred twenty-five patients with 358 febrile episodes were treated with tobramycin and ticarcillin (TT), tobramycin and mezlocillin (TM), or tobramycin, ticarcillin and cephalothin (TTC). There were no statistically significant differences in the response rates for patients who were proven to have infection (67% with TT, 69% with TTC and 53% with TM). Patients were more often cured of their infection if their neutrophil count rose during therapy. In this study, the addition of cephalothin to TT did not increase the frequency of azotemia (10% and 12%, respectively). Although mezlocillin has a broader spectrum of activity in vitro than ticarcillin, it was not more efficacious when combined with tobramycin than ticarcillin plus tobramycin for the treatment of infections in neutropenic patients.

Amdinocillin: use alone or in combination with cefoxitin or carbenicillin-ticarcillin.

One hundred fifty-five patients with 157 febrile episodes were treated with amdinocillin or amdinocillin and cefoxitin as second-line therapy, or amdinocillin and ticarcillin or carbenicillin as initial therapy in three separate studies. Overall responses were 57 percent, 55 percent, and 54 percent for amdinocillin, amdinocillin-cefoxitin, and amdinocillin-ticarcillin or amdinocillin-carbenicillin, respectively. In all three studies, patients with septicemia responded less often than patients with other infections. Most patients were profoundly neutropenic at the initiation of therapy, and both the initial neutrophil level and neutrophil trend during therapy influenced response. A significant number of superinfections occurred when amdinocillin alone was used. Although amdinocillin, alone or in combination with cefoxitin, appeared effective as second-line therapy in infections with organisms shown sensitive in vitro, the combination of amdinocillin and ticarcillin or carbenicillin was only moderately effective in initial therapy for neutropenic, febrile, cancer patients.

New schedule for tobramycin administration.

Ten patients received a loading dose of tobramycin of 60 mg/m2 intravenously over 0.5 h followed immediately by 60 mg/m2 over 2 h every 4 h. The highest mean serum concentration (at the end of the loading dose) was 6.0 +/- 0.3 microgram/ml (range, 3.2 to 10.9 microgram/ml). The mean serum concentration 2 h after the end of the initial 2-h infusion was 3.0 +/- 0.2 microgram/ml (range, 1.6 to 3.9 microgram/ml). This schedule of tobramycin was used to treat 117 patients with presumed or proven infection. There were no differences in the mean serum concentrations of tobramycin at comparable times on days 3 to 4 and 6 to 7. Only 60% of patients had serum levels between 3 micrograms/ml (trough) and 10 micrograms/ml (peak). This intermittent schedule of administration resulted in substantial fluctuations in serum concentrations of tobramycin and produced trough concentrations which were too low or peak concentrations which were too high in some patients.

Systemic mycosis due to Trichosporon cutaneum: a report of two additional cases.

Two additional cases of systemic mycosis due to Trichosporon cutaneum are reported and are compared with the previously published case of Rivera and Cangir. Both patients (a four-year-old male and a 57-year-old female) had acute leukemia for which they were receiving chemotherapy, and both presented with fever that was unresponsive to conventional antibiotics. Both had positive blood cultures for Trichosporon cutaneum. The disease was further documented in the four-year-old male by renal biopsy and by bone marrow culture; he was treated with apparent success with amphotericin B. However, the 57-year-old female died shortly after the begining of similar treatment, and autopsy demonstrated involvement of the left kidney, spleen, bone marrow, and liver. The organism in both these cases, as well as the case of Rivera and Cangir, exhibited both hyphal and yeastlike forms in tissue sections. We believe that the therapeutic success in the case of the four-year-old male was primarily related to his remission from leukemia.