A case of distal limb arterial tortuosity and dilation: observations and potential clinical significance.

Arterial tortuosity describes variation via bending of the arterial wall and has been noted in several arteries throughout the body. Tortuous blood vessels can cause nerve compression, as well as present difficulties to surgeons and radiologists. Here we present an unusual case of multi-vessel arterial tortuosity discovered in 78-year-old Hispanic male cadaver, independent of systemic pathology. The left ulnar and right tibial arteries were dissected, and using calibrated digital callipers, their external and internal diameters were measured both at the origin site and at the site of greatest dilation. Both wall thickness and the number of inflection points were also measured. Six bends were noticed in the ulnar artery and its diameter measured 8.11 mm at its widest, with a wall thickness of 0.88 mm. On the lower extremity, the right tibial artery had three bends and its diameter measured 4.86 mm at its widest, with a wall thickness of 1.32 mm. This uncommon tortuosity is not only more prone to laceration during surgery, but the bending and thickening can be mistaken for tumours. Finally, fluid dynamics can be altered, resulting in an impact on blood pressure in the extremities. Thus, raising awareness is crucial to prevent both symptoms and iatrogenic complications.

Lacunar-canalicular network in femoral cortical bone is reduced in aged women and is predominantly due to a loss of canalicular porosity.

The lacunar-canalicular network (LCN) of bone contains osteocytes and their dendritic extensions, which allow for intercellular communication, and are believed to serve as the mechanosensors that coordinate the processes of bone modeling and remodeling. Imbalances in remodeling, for example, are linked to bone disease, including fragility associated with aging. We have reported that there is a reduction in scale for one component of the LCN, osteocyte lacunar volume, across the human lifespan in females. In the present study, we explore the hypothesis that canalicular porosity also declines with age. To visualize the LCN and to determine how its components are altered with aging, we examined samples from young (age: 20-23 y; n = 5) and aged (age: 70-86 y; n = 6) healthy women donors utilizing a fluorescent labelling technique in combination with confocal laser scanning microscopy. A large cross-sectional area of cortical bone spanning the endosteal to periosteal surfaces from the anterior proximal femoral shaft was examined in order to account for potential trans-cortical variation in the LCN. Overall, we found that LCN areal fraction was reduced by 40.6% in the samples from aged women. This reduction was due, in part, to a reduction in lacunar density (21.4% decline in lacunae number per given area of bone), but much more so due to a 44.6% decline in canalicular areal fraction. While the areal fraction of larger vascular canals was higher in endosteal vs. periosteal regions for both age groups, no regional differences were observed in the areal fractions of the LCN and its components for either age group. Our data indicate that the LCN is diminished in aged women, and is largely due to a decline in the canalicular areal fraction, and that, unlike vascular canal porosity, this diminished LCN is uniform across the cortex.

Improvement of rejection-induced diastolic abnormalities in rat cardiac allografts with inducible nitric oxide synthase inhibition.

OBJECTIVE: Inhibition of inducible nitric oxide synthase (nitric oxide II) activity has been proposed as a method to attenuate capillary leak and edema during rejection of heterotopically transplanted rat hearts. Myocardial edema has previously been implicated in diastolic dysfunction during allograft rejection. Accordingly, we tested the hypothesis that inducible nitric oxide synthase inhibition with aminoguanidine would alleviate left ventricular stiffening and myocardial edema formation in 4-day heterotopic rat heart allografts. METHODS: Passive left ventricular filling was studied in American Cancer Institute Lewis rats receiving heterotopic heart transplants receiving either aminoguanidine, a selective nitric oxide synthase inhibitor (n = 6); dexamethasone (1 mg. kg(-1). d(-1) administered subcutaneously) for 4 days after transplantation (n = 6); or intravenous saline solution (n = 6). American Cancer Institute-to-American Cancer Institute isografts (n = 6) were used as controls. RESULTS: Serum nitrite/nitrate levels in the aminoguanidine group (18 +/- 3 mmol/L) and dexamethasone group (22 +/- 4 mmol/L) were reduced versus the intravenous saline group (144 +/- 36 mmol/L [SEM]) to levels seen in controls (25 +/- 9 mmol/L). Left ventricular volume at 15 mm Hg for the aminoguanidine group was increased versus that for the intravenous saline solution group, similar to that for controls, and reduced versus dexamethasone-treated animals. Myocardial water content for the aminoguanidine-treated animals (78.3% +/- 0.4%) was similar to those of intravenous saline-treated animals (78.0% +/- 0. 3%) but greater than those of controls (77.1% +/- 0.2%) and dexamethasone-treated animals (76.7% +/- 0.3%). CONCLUSIONS: Nitric oxide II inhibition with aminoguanidine minimizes the reduction in left ventricular filling that is seen with allograft rejection through a mechanism that is not associated with attenuation of myocardial edema.

Diastolic properties, myocardial water content, and histologic condition of the rat left ventricle: effect of varied osmolarity of a coronary perfusate.

BACKGROUND: Although myocardial edema is known to impair diastolic filling of the left ventricle, the interrelation of edema, histologic condition, and function has not been quantitated sufficiently for extrapolation to studies of multifactorial influences on diastolic properties. METHODS: Accordingly, ACI rat hearts arrested at 4 degrees C underwent coronary artery perfusion with a cardioplegia solution that was either unaltered (288 mOsm/L, P288 group, n = 6), diluted (144 mOsm/L, P144 group, n = 6), or concentrated (380 mOsm/L, P380 group, n = 6). Postmortem left ventricular pressure-volume curves and myocardial water content were measured. Myocardial samples were fixed in varying dilutions of glutaraldehyde. After dehydration and paraffin embedding, edema was graded subjectively (0 to 5), and myocardial interstitial spaces were determined by use of a semiquantitative method. RESULTS: Mean normalized left ventricular filling volume at 20 mm Hg filling pressure in the P144 group, 189 +/- 16 microliters (SEM), was reduced versus both the P288 (278 +/- 26 microliters) and the P380 (332 +/- 18 microliters) groups (p < 0.05, ANOVA). Mean myocardial water content in the P144 group, 80.7% +/- 1%, was increased versus the P380 (76.7% +/- 0.4%, p < 0.05) but not versus the P288 group (78.4% +/- 0.8%). In hearts preserved with 2.5% glutaraldehyde, mean edema grade and interstitial space in the P144 group (4.0 +/- 0.3) were increased versus the P380 (1.8 +/- 0.3, p < 0.05) but not the P288 group (2.7 +/- 0.5). Derived linear regressions relate water content to filling volume and histologic condition. CONCLUSIONS: Coronary perfusate osmolarity is thus associated with predictable changes in myocardial water content, left ventricular filling volume, and edema. These correlations allow definition of new hypotheses for the study of cardiac allograft rejection in patients and experimental animals.

Effect of improved myocardial protection on edema and diastolic properties of the rat left ventricle during acute allograft rejection.

BACKGROUND: Studies of myocardial edema and diastolic dysfunction in rat heart transplantation have been flawed by ischemic injury. This study uses improved methods to prevent ischemic contracture. METHODS: Hearts of 30 ACI rats were transplanted into the abdomen of Lewis rats by use of cold University of Wisconsin solution for improved preservation. Left ventricular diastolic properties were expressed as volume at standardized pressure intervals. RESULTS: On posttransplantation day 3, mean left ventricular volume at 15 mm Hg in allografts (290 +/- 9 microl, SEM) was not significantly different vs isografts (299 +/- 32 microl), allografts on day 0 (337 +/- 28 ml) or day 1 (324 +/- 20 microl), or native hearts (334 +/- 19 microl). However, volume was reduced to 173 +/- 17 microl on day 4 and to 70 +/- 23 microl on day 5 (p < 0.05). Similar findings were obtained for volume at 5 and 10 mm Hg. Allograft myocardial water content on day 3, 76.3% +/- 5%, similar to allografts on day 0 and 1 and to isografts on day 3, increased to 77.6% +/- 8% on day 4 (NS) and 79.4% +/- 6% on day 5 (p < 0.05 vs day 0). Histologically, rejection in allografts was mild on day 3, moderate on day 4, and severe on day 5. CONCLUSIONS: Reduced left ventricular filling volume during rejection is only partially explained by edema. Abnormalities of diastolic properties previously attributed to the unloaded state of nonworking heart models may actually reflect inadequate peritransplantation myocardial protection.

Choice of venous cannulation for bypass during repair of traumatic rupture of the aorta.

BACKGROUND: Choices for venous cannulation for left heart bypass, to assist repair of traumatic rupture of the thoracic aorta, are between the left atrial appendage and pulmonary veins. METHODS: A retrospective chart review was performed of patients who underwent operative repair of ruptured aorta. RESULTS: Over a 15-year period between March 1985 and February 2000, 133 patients were admitted to a level I trauma center with aortic rupture. Of the 50 procedures performed with left heart bypass, the left atrial appendage was cannulated in 19 and pulmonary veins in 31 (four superior, 27 inferior). Complications occurred in 7 of the 19 patients who underwent venous cannulation via the atrial appendage (two ventricular fibrillation, three atrial fibrillation, one pericardial effusion leading to tamponade, and one phrenic nerve injury). Complications occurred in 2 patients who underwent cannulation via pulmonary vein (one atrial fibrillation, one pericardial effusion requiring tapping) (p = 0.02). CONCLUSIONS: Cannulation via the pulmonary veins is associated with a decrease in complication rates compared with cannulation of the atrial appendage.

General practitioners' beliefs about their role in the prevention and treatment of accidents involving children.

This questionnaire survey set out to determine the perceptions of family doctors in north Staffordshire regarding their role in the prevention and treatment of childhood accidents. Of 277 doctors sent questionnaires, 207 (75%) replied. Only 23% of respondents considered that they did enough child accident prevention work; lack of time was mentioned as a limiting factor by 66%. Child health surveillance clinics and home visits were considered by 60% and 59% of respondents, respectively, to be appropriate occasions on which to give prevention advice. However, only 12% of respondents frequently gave safety advice while visiting a child. Significantly more older general practitioners (over 44 years) gave advice during a visit than younger doctors. Among doctors with a health visitor who was practice rather than geographically based significantly more gave advice on a home visit and discussed safety issues with their health visitors. Significantly more general practitioners in practices more than five miles from the nearest accident and emergency department offered to provide treatment for children following an accident than those in practices nearer to a hospital. Child accident prevention has recently been targeted as an important area for health promotion in primary care. However, this district based survey has identified a relatively low profile for the subject in the everyday activities of the general practitioner. The need for further research to determine the precise role of the family doctor in the prevention and treatment of children's accidents is highlighted.

Accidents among children under five years old: a general practice based study in north Staffordshire.

Information about accidental injury among children under five years old was obtained prospectively by studying children registered with one general practice (total list size 9425) who presented at the surgery and/or the accident and emergency department at the North Staffordshire Hospital Centre during a 12 month period. Details were obtained from answers to a questionnaire sent to parents within two weeks of a child's accident. Of 511 children under five years of age, 100 children (57 boys, 43 girls) had 120 accidents. The maximum number of accidents occurred in the second year of life. Parents took their children directly to the casualty department in 105 (85%) accidents. Eighty six children had only one accident and four children required hospital admission. The most common cause of injury was a fall (56%). The majority of accidents happened at home (79%), and occurred between 09.00 hours and 21.00 hours (88%). Children identified in the study following an accident were matched with other children in the practice of the same age and sex who had not had an accident. Information about the families and social factors were compared. Children who had accidents had younger mothers and were more likely to have a sibling who had had an accident in the previous year. Socioeconomic factors were not significantly different between the cases and the controls. Similar numbers of families in the study and control groups had items of safety equipment and had good awareness and knowledge of accident prevention. The results of this study cast doubt on the value of safety equipment and knowledge alone in child accident prevention.(ABSTRACT TRUNCATED AT 250 WORDS)

The grieving adult and the general practitioner: a literature review in two parts (Part 1).

This article is the first of a two-part literature review on bereavement. In part 1, those psychological theories that have improved the understanding of the bereavement process are summarized. In addition, the research examining the mortality and morbidity following a bereavement is critically analysed.

The grieving adult and the general practitioner: a literature review in two parts (Part 2).

In part 1 of this review, published last month, literature exploring the psychological bereavement theories and the health consequences of bereavement are summarized. The second part builds on this to outline the debate surrounding the characteristics of abnormal bereavement, while also focusing on risk factors for this morbidity. This leads on to a summary of the literature on bereavement care, particularly from a general practice point of view. Finally, areas for further research are highlighted.

Routine care of people with HIV infection and AIDS: should interested general practitioners take the lead?

People with HIV and AIDS in the developed world are living longer and healthier lives following the introduction of highly active antiretroviral therapy. The medical management of stable HIV infection could eventually fit into the more normal pattern of chronic disease management in the United Kingdom (UK). Routine monitoring of many chronic conditions is generally regarded as primary care business in partnership with secondary care. The latter service should be reserved for what it does best: periodic review, in-depth assessment, major changes in medication, management of complex or refractory cases, and inpatient care. We look at some of the issues and the arguments for and against any change from the current position in the UK, where almost all HIV infection is managed medically by specialist clinics in secondary and tertiary care.

Barriers to the development of collaborative research in general practice: a qualitative study.

General practice-based research activity is increasing rapidly, particularly for large, collaborative, multi-centre studies. We conducted semi-structured interviews with general practitioners and other professionals at practices in the East London and the City Health Authority area, to investigate the difficulties presented by becoming involved in these studies. Interviewees' main concerns were: time constraints; team motivation; the perception that external researchers have unrealistic expectations; the need for good communications throughout and, specifically, for good feedback from these researchers.

Survey of research activity, training needs, departmental support, and career intentions of junior academic general practitioners.

BACKGROUND: Recent changes in the organization of the National Health Service have created new roles and responsibilities for academic general practice. Previous work on the constraints and opportunities of a career in academic general practice is largely anecdotal and is often based on the views of more senior members of the profession. AIM: To survey the research activity, perceived level of training, support needs, and career intentions of junior academic general practitioners (GPs). METHOD: A postal, validated, semistructured questionnaire was sent to the 121 eligible junior academic GPs in the academic departments of general practice in the United Kingdom and Dublin. Main outcome measures were 'research activity score', as measured by publications in peer-reviewed journals and involvement in research projects, 'training score' devised from 13 skills required for both research and teaching, and perceived level of departmental support assessed by six different support mechanisms. RESULTS: Response rate was 89% (n = 108). Forty-six responders (43%) had no publications. Twenty-five responders (23%) had no principal project. Thirty-nine responders (37%) had a mentor. Research activity appeared to be dependent on sex, having a predominantly research role rather than a full-time teaching role, and a positive perception of academic training (P < 0.05). Increasing departmental 'support scores' and length of time in the department were both significantly associated with more positive perceptions of academic training (P < 0.05). Only 29 (27%) responders wanted to progress to senior positions within academic general practice. CONCLUSION: Training and departmental support and guidance available to junior academics in primary care are perceived as variable and often inadequate. If academic general practice is to thrive, improved academic training is required, such as taught Master's degrees, supervised personal projects or 'apprenticeship' as a co-investigator, and improved methods of departmental support.

Lessons from the London Initiative Zone Educational Incentives funding: associations between practice characteristics, funding, and courses undertaken.

BACKGROUND: Following the Tomlinson report of 1992, London Initiative Zone Educational Incentives (LIZEI) funding was introduced for a three-year period to improve recruitment, retention, and educational opportunities for general practitioners working within inner London. AIM: To test the hypothesis that general practices that show evidence of good organisation achieved better access to LIZEI funding than less organised practices. METHOD: Observational practice-based study involving all 164 general practices in EAst London and the City Health Authority during the first two years of the scheme, April 1995 to March 1997. RESULTS: Univariate analysis showed that higher levels of LIZEI funding were associated with practices where there was evidence of good organisation, including higher targets for cervical cytology screening and immunisation rates for under two-year-olds, better asthma prescribing, and training status. Using ten practice and population explanatory variables, multiple regression models were developed for fundholding and non-fundholding practices. Among non-fundholding practices, the asthma prescribing ratio was the variable with the greatest predictive value, explaining 14.7% of the variation in LIZEI funding between practices. Strong positive associations existed between taking further degrees and diplomas, practice size, training, and non-fundholding status. CONCLUSION: Larger practices, training practices, and those that demonstrated aspects of good practice organisation gained more LIZEI funding: an example of the 'inverse funding law'. Practices within a multifund, based in the Newham locality, gained LIZEI funding regardless of practice organisation. Networks of practices, and, potentially, primary care groups, have a role in equalising the opportunities for education and development between practices in east London.

Reliability and feasibility of a near patient test for C-reactive protein in primary care.

BACKGROUND: The applications of new diagnostic technologies such as near patient tests are relevant to the further development and potential of primary care. Through their use, doctors in the community may increase the accuracy of their diagnoses and improve their ability to monitor disease. A reliable indicator of disease activity in various clinical conditions is C-reactive protein (CRP) and a near patient test for this is now available, although there is little information on its use outside hospitals. AIM: A study was set up to evaluate the feasibility of using a novel near patient test for CRP in primary care to validate the results against the laboratory "gold standard' for CRP (Beckman Array) and to compare results with the usual inflammation test used in general practice. METHOD: Prospective recording of CRP as a near patient test on an "intention to investigate' basis, with validation of results against the Beckman Array system for CRP and hospital laboratory erythrocyte sedimentation rate results, in six general medical practices in Birmingham. Main outcome measures were change in local laboratory usage, characteristics of patients chosen for testing, use of quality control, and comparison of readings with results from the same sample sent to an independent laboratory. RESULTS: Tests of CRP levels were rarely requested before the study was undertaken. During the 3-month study period, 181 near patient tests were carried out, 146 (81%) to establish a diagnosis and the remainder for disease monitoring. Out of the tests, 67% were performed by general practitioners, mostly during the consultation itself. Using a cut-off level of 10 mg I-1, the near patient test and the Beckman Array gave results which agreed in 84% of cases. The sensitivity and specificity of the near patient test results were 97 and 79%, respectively. The predictive value of a positive result was 59% and that of a negative result was 99%. Cohen's Kappa was 62% and the overall mean bias for results in the range of the test was 6.11 mg I-1 (SE = 3.07 mg I-1). Each test took 6 min on average to perform, including all preparations, blood letting, performing the test and averaging the time for quality control estimations. The cost per test averaged pounds 1.72, rising to pounds 4.17 including labour, capital costs, quality controls and consumables (general practitioner performing the assay at average frequency found in this study). CONCLUSIONS: Measurement of CRP is rarely used in primary care and awareness of its value could be raised. This near patient test proved feasible for use by general practitioners and practice nurses. Its reliability compared with a laboratory result was satisfactory overall, and excellent with adequate operator technique.

Characteristics of general practices involved in undergraduate medical teaching.

BACKGROUND: The movement of medical education into the community has accelerated the development of a new model of general practice in which core clinical services are complemented by educational and research activities involving the whole primary care team. AIM: To compare quality indicators, workload characteristics, and health authority income of general practices involved in undergraduate medical education in east London with those of other practices in the area and national figures where available. DESIGN OF STUDY: A comprehensive survey of undergraduate and postgraduate clinical placements and practice-based research activity within general practice. SETTING: One-hundred and sixty-one practices based in East London and the City Health Authority (ELCHA). METHOD: Cross-sectional survey comparing routinely-collected information on practice resources, workload, income, and performance between teaching and non-teaching practices. RESULTS: In east London, teaching practices are larger partnerships with smaller list sizes, higher staff costs, and better quality premises than non-teaching practices. Teaching practices demonstrate significantly better performance on quality indicators, such as cervical cytology coverage and prescribing indicators. Patient-related health authority income per whole time equivalent (WTE) general practitioner (GP) is significantly lower among teaching practices. A multiple regression analysis was used to explore the association between teaching status and income. Eighty-eight per cent of the variation in patient-related income could be explained by the combination of list size, list turnover, removals at doctor's request, quality of premises, and immunisation and cytology rates. CONCLUSION: This study demonstrates that practice involvement in undergraduate education in east London is associated with higher scores on a range of organisational and performance quality indicators. The lower patient-related income of teaching practices is associated with smaller list sizes and may only be partially replaced by teaching income. Lower vacancy rates suggest that teaching practices are more attractive to doctors seeking partnerships in east London.

Do practice-based preventive child health services affect the use of hospitals? A cross-sectional study of hospital use by children in east London.

BACKGROUND: Acute paediatric admissions have risen steadily over the past 20 years. During the same period, practice-based child health clinics have increased, although provision is less common in areas of deprivation where hospital use is greatest. AIM: To investigate the contribution of practice-based, preventive child health services to rates of hospital utilisation in children under five years of age. METHOD: A cross-sectional retrospective study examining practice variations in paediatric acute admissions, outpatient referrals, and accident and emergency (A&E) department attendances in the East London and the City Health authority, including all 164 practices in the inner-city boroughs of Hackney, Newham, Tower Hamlets, and the City of London. The main outcome measures were practice-based paediatric hospital attendance rates, for discrete age and sex bands, for the year to 31 March 1996. RESULTS: Hospital use varied with age and sex, with the rates being highest for the youngest children and for boys. The median A&E attendance rate (including reattendances) for boys up to one year of age was 897 per thousand children per practice. In east London, 62% of practices are registered for child health surveillance and 71% provide a child health clinic. Practice approval for child health surveillance, and the provision of child health clinics, did not account for differences between practices in hospital use, but proportionally greater health visiting hours were significantly related to lower rates of emergency hospital admission by young children. Multivariate analyses revealed that up to 23% of the variation between practice admission rates could be explained by health visiting hours. CONCLUSIONS: We found significant associations between the amount of health visiting time available to the practice population and rates of acute admission and outpatient referral among children up to five years of age. These findings suggest that increasing health visitor provision could contribute to lower paediatric emergency admission and outpatient referral rates. A small change would have a significant effect, particularly among the youngest children, given that during the study year 10,000 children under two years of age in east London were either admitted or referred to hospital.

A national survey to medical and dental schools to assess the level of undergraduate teaching and research about HIV/AIDS in the UK.

The views of heads of academic departments in UK medical and dental schools on the extent of their specialty's involvement in teaching undergraduates about HIV/AIDS and undertaking research in this area was ascertained by postal questionnaire. Three hundred and nineteen responses were received from medical schools (61.7%) and 58 responses from dental schools (53.2%). The greatest number of responses in one specialty was received from the Departments of General Practice, Paediatrics and Children's Dentistry. The amount of teaching varied widely, was dispersed throughout the curriculum within a wide range of broader subject areas and tended to be carried out by senior staff using didactic lecture format. Dental courses were more often assessed than medical courses. The small number of patients available was seen as a major problem. Involvement in research was appreciable. However, knowledge of student awareness campaigns was not widespread. We conclude that more specific teaching on HIV/AIDS is needed, particularly discussion about attitudes towards patients and ethical issues. HIV/AIDS counsellors should have an increased involvement in undergraduate teaching and teaching methods should provide opportunities for interactive discussion. Extensive research is being conducted in the UK. However, further work is needed to identify the perceived needs of students and the extent to which these are being met.

Impact of presenting physiology and associated injuries on outcome following traumatic rupture of the thoracic aorta.

We hypothesized that the predominant factor influencing outcome of traumatic rupture of the thoracic aorta (TRA) was the degree of shock on presentation and associated injuries. We reviewed our experience with TRA over a 15-year period. Patients were classified as "unstable" if presenting systolic blood pressure was <90 mm Hg or if it decreased to <90 mm Hg after admission. We determined the presence of closed head injury, cardiac risk factors, a preoperative acute lung injury (ALI). The influence of these factors on mortality, postoperative adult respiratory distress syndrome (ARDS), and paralysis was analyzed. One hundred thirty-six patients were admitted with TRA. One hundred twenty underwent operative repair with a mortality of 31 per cent. Operative mortality was significantly higher in unstable patients (62%) versus stable patients (17%, P = 0.001), in patients with cardiac risk factors (71%) versus those without (24%, P = 0.001), and in patients with preoperative free rupture (83%) with versus those without (19%, P = 0.001). Free rupture was the cause of hypotension in only 10 of 42 unstable patients, with the remainder being due to other causes. Preoperative ALI was associated with a marked increase in postoperative ARDS (47% with vs 9% without, P = 0.001) but not operative mortality. Mechanical circulatory support (MCS) was used in 59 cases, none of whom experienced paralysis, whereas eight of 61 operated on without MCS developed paralysis (P = 0.001). When logistic regression was applied the use of MCS was not determined to be statistically significant. However, preoperative instability was found to be a significant predictor of postoperative paralysis with the risk being increased 5.5 times (confidence interval 3.3-10). The predominant factor influencing mortality, postoperative ARDS, and paralysis was preoperative instability and associated injuries. In patients who are hypotensive, other injuries should take precedence over repair of TRA. Patients who are stable but who have cardiac or pulmonary risk factors may be better managed by a period of nonoperative management until their condition improves.

Incidence of the concrete scalp deformity associated with deep scalp donor sites and management with the Unna cap.

The scalp has become a popular donor site for split-thickness skin grafts. This donor site does, however, have complications, including the concrete scalp deformity, which consists of hairs embedded in a thick, desiccated, exudative crust. This article presents our burn unit's experience with this complication. Fifty-six patients underwent scalp skin graft harvesting between 1984 and 1996. All grafts were quite thick and were used for resurfacing facial burns. Thirty-eight donor sites were treated with medicated gauze, and 18 were treated with the Unna cap, which is an Unna dressing applied over Aquaphor gauze (Beiersdorf, Norwalk, Conn). Eighteen of the 38 patients (32%) treated with medicated gauze developed the concrete scalp deformity. None of the patients treated with the Unna cap developed the deformity. Although useful, the deep scalp donor site has complications, including the concrete scalp deformity. However, with use of the Unna cap dressing, we have had no occurrences of this problem.