Nipple pain at presentation predicts success of tongue-tie division for breastfeeding problems.

INTRODUCTION: In mother-infant pairs experiencing breastfeeding difficulties, frenulotomy for tongue-tie may improve breastfeeding. We tested the hypothesis that those experiencing nipple pain are most likely to benefit from the procedure in a prospective cohort study. MATERIALS AND METHODS: Mother-infant pairs attending a dedicated clinic for the assessment and treatment of tongue-tie completed a standardised, structured symptom questionnaire. Three months later outcome was assessed by questionnaire. Multivariate logistic regression analysis was used to determine preoperative predictors of successful outcome. RESULTS: Sixty-two infants <90 days old underwent frenulotomy and completed follow-up. At presentation, 52 mothers (84%) reported nipple pain, and 32 mothers (52%) nipple trauma. Three months after frenulotomy, 78% of respondents were still breastfeeding. Feed lengths (mean reduction: 17 mins; p<0.001) and time between feeds (mean increase: 38 mins; p<0.001) had significantly improved, as had difficulty of feeding (mean improvement in self-rated difficulty score: 42%; p<0.001). Those having difficulty breastfeeding due to nipple pain showed a significant long-term benefit from frenulotomy; pre-frenulotomy nipple pain was associated with an increased likelihood of breastfeeding at 3 months in adjusted multivariate analysis (OR 5.8 [95% CI 1.1-31.6]). CONCLUSION: Mother-infant pairs with tongue-tie and breastfeeding difficulties due to nipple pain are most likely to benefit from frenulotomy.

Plasma soluble e-selectin in necrotising enterocolitis.

AIM: E-selectin is an important mediator of leukocyte-endothelial adhesion. It is expressed on activated endothelium, and shed into the circulation in its soluble form. In babies with necrotising enterocolitis (NEC), increased intestinal expression of E-selectin has been associated with multiple organ failure and an adverse outcome. The aim of this study was to determine whether increased circulating soluble E-selectin (sE-selectin) was associated with a worse prognosis. METHODS: With ethical approval, plasma samples from 20 infants with Bell stage II and III NEC were analysed. Both pre- and postoperative samples were available in 6 infants. The severity of illness was assessed using a sequential organ failure assessment score (SOFA) specifically designed for use in NEC. Plasma concentration of sE-selectin was determined by ELISA. Data, which were not normally distributed, were compared by Spearman's rank correlation coefficient and Wilcoxon signed rank test. RESULTS: Plasma sE-selectin was strongly negatively correlated with corrected gestational age at the time of sampling (r = - 0.425, p = 0.006). There was no association between plasma sE-selectin and outcome (death or survival to discharge), severity of intestinal disease (focal, multifocal or pan-intestinal), or SOFA score. Surgery for suspected perforation, however, caused a significant elevation in sE-selectin levels (p = 0.031). CONCLUSIONS: Plasma sE-selectin, a described marker of endothelial activation, is increased following surgery for NEC. However, prematurity appears to be the cause of an increase in sE-selectin level, confounding the potential use of sE-selectin levels as a predictor of severity of illness in NEC.

Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery.

BACKGROUND: Perineal wound complications may occur after visceral pelvic surgery. We reviewed our experience to determine indications for immediate tissue transfer (TT) to prevent complications. METHODS: Hospital records and computerized data were reviewed on 175 perineal repairs in 156 patients treated at The University of Texas M.D. Anderson Cancer Center for tumors involving the alimentary tract (135 of 175), genitourinary tract (15 of 175), perineum (19 of 175), or sacrum (6 of 175). Patients had either resection of only the colorectum and anus (APR) (46 of 175) or multivisceral resection (MVR) (129 of 175), and the perineal wound was closed by using TT (108 of 175) or primary closure (PC) (67 of 175) on the basis of the surgeon's judgment. Complications were compared between PC and TT groups. RESULTS: Complications occurred in 57% (100 of 175). There was no significant difference overall in PC and TT procedures or in the APR subgroup. There were significantly fewer complications for TT patients in the MVR subgroup (P =.0001). There were significantly fewer complications for TT patients with prior irradiation in both APR (P =.01) and MVR (P =.007) subgroups. CONCLUSIONS: Immediate TT for perineal wound closure is associated with fewer healing complications than PC in a subset of patients with multivisceral resection or prior radiotherapy. Surgical planning in these cases should consider immediate soft tissue reconstruction.

Squamous cell carcinoma arising in a cutaneous epidermal cyst--a case report.

INTRODUCTION: Cutaneous epidermal cysts are common lesions, but fortunately, malignant transformation of their epithelium is rare. There are only a few cases mentioned in recent literature, mostly occurring in epidermal cysts in the head and neck region. CLINICAL PICTURE: We present a case of malignant transformation in a long-standing buttock epidermal cyst, presenting a month after trauma to the cyst. TREATMENT: An excision biopsy and rotation flap was done. When the pathology was confirmed, a second resection was carried out and the defect covered with a free latissimus dorsi flap, a buttock rotation flap and a posterior thigh rotation flap. CONCLUSION: Although malignant transformation is rare, this case illustrates the importance of routine histology in excision of epidermal cysts.

A modification of the Kernahan "Y" classification in cleft lip and palate deformities.

The search for a universally accepted system of classifying cleft lip and palate deformities has yielded many models of varying complexity. Recently, there has been a trend toward symbolic classification systems that allow members of the cleft team to quickly assess the nature of the deformity. The existing systems, however, have limitations. These include inadequate description of the cleft lip deformity and complexity of nomenclature. A modification of Kernahan's striped Y classification is proposed that addresses these problems. This system was applied to 150 cleft patients, and it was found that it was able to describe all varieties of clefts encountered. In contrast, the Kernahan system could only describe 74.7 percent of the patients adequately.

Tracheobronchial cytology in inhalation injury.

The aim of this study is to establish whether tracheobronchial cytology is useful in the diagnosis of inhalation injury. Twenty patients diagnosed to have inhalation injury by existing clinical criteria and 20 control patients were admitted into the study. Bronchoscopy and brush biopsies were carried out. They were then scored using a Total Cellular Score and Differential Cellular Score. These were compared with clinical and bronchoscopic scores and respiratory outcome. The average Total Cellular Score of the patients with inhalation injury was 497.4 +/- 281.9 and that of the control patients was 1004.2 +/- 88.4. There was a strong correlation between clinical, bronchoscopic, and total cellular scores. The Differential Cellular Score showed a left shift in patients with inhalation injury. This study shows that tracheobronchial cytology is a useful adjunct in diagnosing and assessing the severity of inhalation injury. Furthermore, our results suggest that it may be superior to current methods in predicting respiratory outcome.

Total scrotal reconstruction after Fournier's gangrene--a case report using rectus abdominis myocutaneous flap.

Total loss of the scrotum is an uncommon clinical condition. A pedicled, inferiorly based rectus abdominis myocutaneous flap was successfully used to reconstruct the scrotum following total loss from Fournier's gangrene. The design and operative technique are described.

Toxic epidermal necrolysis in a burns centre: a 6-year review.

Toxic epidermal necrolysis (TEN) is the most severe of the Stevens-Johnson syndrome-toxic epidermal necrolysis (SJS-TEN) spectrum. It is characterized by epidermal exfoliation and mucositis and carries an average mortality of 25 per cent. In this 6-year retrospective study, we reviewed 23 patients with drug-induced SJS-TEN. The most common causative agents were anticonvulsants and traditional medication. The mean time of onset of symptoms was 4.1 days (range 1-16 days) and the mean body surface area involved was 57.2 per cent (range 30-90 per cent). The condition was most commonly associated with ocular complications and sepsis. Using our treatment protocol in a burns centre, we were able to achieve a mean time to complete healing of 20.2 days (range 7-53 days) and a mean duration of hospitalization of 34.1 days (range 7-134 days). The length of hospital stay was prolonged when non-ocular complications supervened. The percentage mortality in our series was 10 per cent. It is our contention that the best results are obtained with treatment of the SJS-TEN patient in a burns centre with an internist, dermatologist and infectious disease specialist as part of the management team.

Deep-seated infective mediastinitis in post-coronary artery bypass grafting patients.

The median sternotomy is the preferred incision for coronary artery bypass grafting (CABG) but its usage was initially associated with wound infection rates of up to 5%. The advent of antibiotic prophylaxis and improved surgical technique has improved these rates to 1% to 2% in most series. During a 5-year period from January 1988 to December 1992, 2193 patients underwent CABG in the Singapore General Hospital. Of these, 22 (1%) suffered postoperative wound infection. Thirteen (0.59%) of these had deep-seated mediastinitis which involved the osteocartilagenous tissues and retrosternal space and 9 (0.41%) had superficial wound infections. The superficial infections were successfully treated with dressings and delayed closure in all cases. The deep-seated infections, however, required in addition, antibiotic therapy, povidone iodine irrigation, repeated debridement and flap closure. In total, 6 muscle and myocutaneous flaps were used with good result. This paper reviews the Plastic Surgery unit's experience in treating this difficult postoperative complication.

Occupational burns in the Burns Centre at the Singapore General Hospital.

This study reviewed all work-related burn injuries within the period 1 April 1992 to 31 March 1993 for the purpose of establishing data on occupational burns in Singapore to identify the specific at-risk population and formulate prevention strategies. All 163 patients who were admitted to the Burns Centre, Singapore General Hospital, as a result of burns suffered in the workplace were reviewed using the World Health Organisation Burns Data Protocol. Burns data recorded included demography, industrial sector involved, aetiology, extent of injury and eventual outcome in terms of mortality and morbidity. Occupational burns accounted for 45% of all admissions to the Burns Centre. Male workers in the 20 to 40-year age group predominated with 90% of admissions. The most common aetiology was flame burns and explosions (52.8%) followed by scalds (24.5%) and electrical (10.4%), chemical (6.1%) and contact (6.1%) burns. The average body surface area (BSA) involved was 8% (range 0.25% to 90%). Twenty-seven patients suffered full-thickness burns and the average area of involvement was 2% (range 0.25% to 90%). The most common anatomical regions involved were the upper limbs (46.3%) followed by lower limbs (31.9%). Eighteen patients (11.0%) sustained major burns requiring fluid resuscitation and 39 patients (23.9%) sustained respiratory burns. Seven patients died, giving a mortality rate of 4.3%. The average BSA for these patients was 46.4% and all had respiratory burns. In all, occupational burns accounted for 2011 patient-days of hospitalization, 630,637 lost days at work and inpatient treatment costs amounting to S $1.32 million.(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant change in cutaneous neurofibromas--case reports.

Neurofibromatosis is the most common single gene disorder to affect the nervous system, with an estimated incidence of 1 in 3000 live births. Neurofibromatosis (NF) may be classified into von Recklinghausen NF (NFI) and bilateral acoustic NF (NFII) based on the distribution of lesions. The most common lesion associated with the von Recklinghausen type is the neurofibroma. Various complications are associated with neurofibromatosis, the most feared of which is malignant change in the neurofibroma. This article describes the study of 7 cases of proven malignant change in neurofibromas with regards to presentation, clinical progress and treatment followed by a review of the present literature.

Primary papillary carcinoma in a thyroglossal cyst--a case report.

A benign thyroglossal cyst is a common clinical condition and is second only to a cervical lymph node as the most common cause of a solitary neck swelling. Primary carcinoma of a thyroglossal cyst, however, is rare and has been described in only 115 cases in the literature. The malignant cysts are clinically difficult to differentiate from benign lesions and the diagnosis often rests on histopathological examination. Before initiating treatment, primary papillary carcinoma of the thyroid gland must be excluded. The treatment options range from simple excision to a Sistrunk operation with concurrent cervical lymph node dissection. We describe here a case of papillary carcinoma of a thyroglossal cyst and review the 115 reported cases.