Acute kidney injury following unselected emergency admission: role of the inflammatory response, medication and co-morbidity.

BACKGROUND/AIMS: Acute kidney injury (AKI) following admission to hospital is associated with increased mortality, morbidity and length of stay. Factors that predispose patients to AKI frequently co-exist. The precise description of their representation in unselected admissions could help define mechanistic inter-relationships and optimise risk stratification strategies. Our aim was therefore to define precisely, using electronically available data, the variables that are associated with AKI. METHODS: A cohort study of 112,987 emergency admissions to an urban academic medical centre between 2006 and 2010 was performed. Post-admission AKI was defined using KDIGO aligned, proportionate changes in serum creatinine, denominated by the first measured. AKI correlated with co-morbidities, medications received and the C-reactive protein concentration (CRP). RESULTS: The relationship between post-admission AKI and putative risk factors was defined in univariate and multivariate analyses. Inclusion of CRP in multivariate analyses significantly reduced the strength of association between some co-variables such as radiological contrast and gentamicin administration but not others. CONCLUSION: The effect of CRP in these analyses supports the role of systemic inflammation in susceptibility to post-admission AKI. It accounts for the greater part of univariate associations between AKI and some nephrotoxic agents, placing the risk attributable to their use in context. Quantification of the systemic inflammatory response may have utility in AKI risk stratification, integrating various determinants of susceptibility.

Inpatient electronic prescribing data can be used to identify 'lost' discharge codes for diabetes.

AIM: Accurate assessment of missed discharge codes for diabetes is critical for effective planning of hospital diabetes services. We wished to estimate the frequency of missed discharge diagnostic codes for diabetes and the impact missed codes would have on diabetes-related payments to the hospital. METHODS: We linked Patient Administration System data to the Prescribing Information and Communication System. We defined diabetes as those having a discharge code for diabetes in the Patient Administration System and those on anti-diabetic medication in the Prescribing Information and Communication System. Based on the two sources, we calculated the estimated missed discharge codes for diabetes using the capture-recapture technique. We generated the Healthcare Resource Group for a given admission before and after correction for the missed code to estimate the impact that correction would make on payments to the hospital. RESULTS: Among the 171 067 admissions linked, 22 412 (13.1%) had a code for diabetes at discharge. An additional 2706 admissions were classified as having diabetes based on prescription data. The capture-recapture technique estimated there were 4588 (2.7% of all admissions) admissions with diabetes missed by current coding, of which 2706 (60%) would be obtained from prescription data. After adding a diabetes diagnostic code, 12.8% of the missed admissions with diabetes resulted in a change to the Healthcare Resource Group tariff code and payment. CONCLUSION: The use of electronic prescription data is a simple solution to correct for missed discharge diagnostic codes.

Clinical decision support systems in the care of inpatients with diabetes in non-critical care setting: systematic review.

BACKGROUND: Computerized clinical decision support systems have been claimed to reduce prescription errors and improve patient care. They may play an important role in the care of hospitalized patients with diabetes. AIM: To collate evidence for the use of clinical decision support systems in improving the care of hospitalized patients with diabetes in a non-critical care setting and to assess their effectiveness. METHODS: We searched four databases from 1980 to 2010 without language restrictions. All types of studies other than case reports were included. Data extraction and quality assessment were carried out based on the Centre for Review and Dissemination guidance. A narrative synthesis was conducted. RESULTS: Fourteen studies met the inclusion criteria, including two cluster randomized controlled trials, eight before-and-after studies and four other descriptive studies. Generally, the quality of the studies was not very high. Nine out of 10 studies reported reduction in mean blood glucose or similar measures (patient-day-weighted mean blood glucose) during inpatient stay. The reduction using computerized physician order entry system in patient-day-weighted mean blood glucose ranged from 0.6 to 0.8 mmol/l (10.8-15.6 mg/dl). Other beneficial effects during inpatient stay included reduced use of sliding scale insulin and greater use of basal-bolus insulin regimen. Only one study found a significant increase in hypoglycaemic events. CONCLUSIONS: Clinical decision support systems have been used, often as part of a complex programme, to improve the care of hospitalized patients with diabetes. There is some evidence that they may have a beneficial effect, but this needs further confirmation.

Hypoglycaemia is associated with increased length of stay and mortality in people with diabetes who are hospitalized.

AIM: To study the length of stay and inpatient mortality of patients with diabetes who had an episode of hypoglycaemia in a non critical care setting at University Hospital Birmingham, UK. METHODS: Retrospective analysis of routinely available electronic data of 6374 admissions with a recording of either laboratory or point-of-care blood glucose value. Based on the lowest recorded blood glucose values, patients were categorized into a group without hypoglycaemia (> 3.9 mmol/l), a group with mild to moderate hypoglycaemia (2.3-3.9 mmol/l) and a group with severe hypoglycaemic (≤ 2.2 mmol/l). Length of stay and inpatient mortality were compared between the three groups, adjusting for age, gender, ethnicity, deprivation, admission type, use of insulin and modified Charlson co-morbidity score. RESULTS: There were 148 admissions (2.3%) with severe hypoglycaemia (≤ 2.2 mmol/l), 500 admissions (7.8%) with mild to moderate hypoglycaemia (2.2-3.9 mmol/l) and 5726 admissions with no recorded hypoglycaemic episode (> 3.9 mmol/l). After adjustment, length of stay, when compared with those without a recorded hypoglycaemic episode, was 1.51 (95% CI 1.35-1.68) times higher in the group with blood glucose values of 2.3-3.9 mmol/l and 2.33 (95% CI 1.91-2.84) higher in the group with blood glucose values ≤ 2.2 mmol/l. Adjusted odds ratio of inpatient mortality when compared with the group without hypoglycaemia was 1.62 (95% CI 1.16-2.27) in the group with blood glucose values of 2.3-3.9 mmol/l and 2.05 (95% CI 1.24-3.38) in the group with blood glucose values ≤ 2.2 mmol/l. CONCLUSION: Hypoglycaemia is associated with increased length of stay and inpatient mortality. Whilst causative evidence is lacking, our data are consistent with the need to avoid hypoglycaemia in our current and continued approach for optimal glycaemic control in people with diabetes admitted to hospital.

Decision support for sensible dosing in electronic prescribing systems.

WHAT IS KNOWN AND OBJECTIVE: The sensible dosing of medicines can ensure that patients receive neither excessive doses leading to toxicity nor inappropriately low doses leading to undertreatment. Computerized prescribing systems with embedded decision support can check doses during prescription order entry and display alerts when the prescribed doses are out of range. We have been unable to identify any scheme for the systematic addition of dosing information to CPOE systems. We used pharmacological data to design an algorithm for dose range checking that we tested on a subset of medicines in an electronic prescribing system to ensure that the rules could be implemented in practice. METHODS: We drafted an initial algorithm based on pharmacological principles, tested it on a subset of frequently prescribed drugs in an electronic prescribing system and then refined it. We considered which clinical decision support functions systems would require to be maximally effective. RESULTS AND DISCUSSION: The final algorithm contained eleven broad factors. We tested it on 30 drug-route-form combinations, and it accommodated the information for all of these combinations. We also identified a variety of system functions that would be required for comprehensive dosing decision support. WHAT IS NEW AND CONCLUSION: The dose range checking algorithm that we have derived from first principles will allow the clinical workflow and warnings to be constructed more effectively within systems to enhance patient safety. This will form a basis for the development of optimal schemes for adding decision support to prescribing systems.

Antimicrobial stewardship using electronic prescribing systems in hospital settings: a scoping review of interventions and outcome measures.

Objectives: To identify interventions implemented in hospital electronic prescribing systems and the outcome measures used to monitor their impact. Methods: We systematically searched CINAHL, EMBASE, Google Scholar and Medline using keywords in three strands: (i) population: hospital inpatient or emergency department; (ii) intervention: electronic prescribing functionality; and (iii) outcome: antimicrobial stewardship. The interventions were grouped into six themes: alerts, order sets, restriction of access, mandated documentation, embedded guidelines and automatic prescription stop. The outcome measures were organized into those that measure the quality or quantity of prescribing or clinical decision support (CDS) activity. The impact of each intervention reported was grouped into a positive, negative or no change. Results: A total of 28 studies were eligible for inclusion. There were 28 different interventions grouped into the six themes. Alerts visible to the practitioner in the electronic health record (EHR) were most frequently implemented (n = 11/28). Twenty different outcome measures were identified, divided into quality (n = 13/20) and quantity outcomes (n = 4/20) and CDS activity (n = 3/20). One-third of outcomes reported across the 28 studies showed positive change (34.4%, n = 42/122) and 61.4% (n = 75/122) showed no change. Conclusions: The most frequently implemented interventions were alerts, the majority of which were to influence behaviour or decision-making of the practitioner within the EHR. Quality outcomes were most frequently selected by researchers. The review supports previous research that larger well-designed randomized studies are needed to investigate the impact of interventions on AMS and outcome measures to be standardized.

Photon antibunching from a single lithographically defined InGaAs/GaAs quantum dot.

We demonstrate photon antibunching from a single lithographically defined quantum dot fabricated by electron beam lithography, wet chemical etching, and overgrowth of the barrier layers by metalorganic chemical vapor deposition. Measurement of the second-order autocorrelation function indicates g(2)(0)=0.395±0.030, below the 0.5 limit necessary for classification as a single photon source.

Use of ACE inhibitors and ARBs in hypertensive women of childbearing age.

BACKGROUND AND OBJECTIVE: Treatment with angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) during pregnancy can cause severe foetal abnormalities. This study aimed to identify the proportion of women of childbearing age taking ACE inhibitors or ARBs on referral to a tertiary Hypertension Clinic. DESIGN: Retrospective cohort study. METHODS: A cohort of female patients aged 16-45 years was identified from approximately 1500 new referrals from January 2004 to October 2006, excluding those not taking antihypertensive medication. ACE inhibitors and ARBs were grouped together for the purposes of the study. Contraceptive status was established where possible. RESULTS: Forty seven of 101 (47%) women aged 16-45 years were taking an ACE inhibitor (35) an ARB (11) or both (1) of whom 26 (55%) were aged 16-40 years. In this younger group, eight were using no contraception and three were using barrier methods only. CONCLUSIONS: Many GPs continue to prescribe ACE inhibitors and ARBs to women of childbearing age. A quarter of women in the study were taking these agents and were 40 years or less; of these many were not using reliable contraception. These women are at risk of foetal malformation and poor perinatal outcomes if they become pregnant. The British Hypertension Guidelines may put younger women at risk if general practitioners are unaware of potential foetotoxic and teratogenic consequences of prescribing ACE inhibitors and ARBs to women of child bearing age.

Best practice in primary care pathology: review 6.

This sixth best practice review examines four series of common primary care questions in laboratory medicine: (1) laboratory monitoring in hypertension and heart failure abnormalities; (2) markers of inflammatory joint disease; (3) laboratory investigation of chronic diarrhoea; and (4) mumps and chickenpox. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus based rather than evidence based. They will be updated periodically to take account of new information.

Prospective study of fluorodeoxyglucose-positron emission tomography imaging of lymph node basins in melanoma patients undergoing sentinel node biopsy.

PURPOSE: To prospectively compare positron emission tomography (PET) imaging of regional lymph node basins to sentinel node biopsy (SNB) in patients with American Joint Committee on Cancer (AJCC) stage I, II, and III melanoma localized to the skin. METHODS: Patients with cutaneous melanoma with Breslow's depth greater than 1 mm (AJCC T2-4N0M0) or localized regional cutaneous recurrence (TxN2bM0) underwent whole-body imaging of glucose metabolism with fluorodeoxyglucose (FDG) PET followed by SNB. PET scans were interpreted in a blinded fashion and compared with histologic analyses of SNB specimens and clinical follow-up examination. Nodal tumor volumes were estimated. RESULTS: Eighty-nine lymph node basins were evaluated by FDG-PET and SNB in 70 assessable patients. Eighteen patients (25.7%) had lymph node metastases at the time of FDG-PET imaging: 17 proved by SNB (24.3%) and one by follow-up examination (1.4%). Median tumor volume in positive sentinel node basins was 4.3 mm3 (range, 0.07 to 523 mm3). Sensitivity of SNB for detection of occult regional lymph node metastases was 94.4%, specificity was 100%, positive predictive value (PPV) was 100%, and negative predictive value (NPV) was 98.6%. Sensitivity of FDG-PET was 16.7%, specificity was 95.8%, PPV was 50%, and NPV was 81.9%. At a median follow-up duration of 16.6 months, seven patients (10%) developed recurrent disease. PET predicted one recurrence (14.3%) in a node basin missed by SNB. CONCLUSION: FDG-PET is an insensitive indicator of occult regional lymph node metastases in patients with melanoma because of the minute tumor volumes in this population. FDG-PET does not have a primary role for staging regional nodes in patients with clinically localized melanoma.

Infection among 210 patients with surgically staged Hodgkin's disease.

To determine the incidence and types of infections in Hodgkin's disease, particularly those related to the overwhelming pneumococcal sepsis syndrome, 210 consecutive patients with previously untreated Hodgkin's disease who underwent staging laparotomy with splenectomy from March 1968 to October 1979 were reviewed. For 178 patients (85 percent) alive at the end of the study, the mean follow-up time was 68.1 months. Eighty-two serious infections occurred among 59 (28 percent) of the patients; 47 (57 percent) serious infections were microbiologically documented and 35 (43 percent) were clinically documented. Forty-seven microbiologically documented serious infections occurred in 34 patients and consisted of 23 episodes of pneumonia, 10 cases of bacteremia, seven wound infections, two cases of disseminated herpes zoster, one subphrenic abscess, and four miscellaneous infections. Microbiologically documented serious infections occurring during initial treatment or remission had lower incidences of leukopenia (29 versus 58 percent) (p = 0.09) and death (11 versus 53 percent) (p = 0.005) than those occurring after relapse of Hodgkin's disease. Of the microbiologically documented serious infections, 76 percent were associated with a predisposing factor(s) (leukopenia, postoperative state, steroids, peripheral neuropathy, leukemia), of which 34 percent were fatal. Microbiologically documented serious infections unassociated with a predisposing factor were never fatal, including the only episode of pneumococcal sepsis in the series. In contrast to microbiologically documented serious infections, only 14 percent of clinically documented serious infections (versus 38 percent) were fatal. The overwhelming pneumococcal sepsis syndrome and other infections thought to be associated with the asplenic state are uncommon problems in patients with Hodgkin's disease after splenectomy.

Cardiac arrhythmias during the combined use of beta-adrenergic agonist drugs and theophylline.

We studied 15 nonsmoking, clinically stable asthmatic subjects aged 27 to 39 years to evaluate the potential cardiotoxic effects of combined use of a beta-adrenergic agonist drug and theophylline in the treatment of asthma. Subjects underwent a one-week washout period followed by two one-week periods of study receiving either oral terbutaline or sustained-release theophylline during week 1 and both drugs during week 2. Thirty-six-hour Holter monitoring was performed at the end of each period of study. No significant increase in the total number of ventricular premature beats was noted, although the average heart rate increased significantly between each period of study. Although not statistically significant, the number of individuals with multiform or complete and repetitive ventricular premature beats increased from one at baseline to three during each period of study, including one subject with ventricular tachycardia on combined therapy. These data suggest that combined therapy with theophylline and a beta-adrenergic agonist in young, otherwise healthy asthmatic subjects does not lead to an increase in the total number of ectopic beats but may increase the degree of complexity of ventricular premature beats.

Latissimus dorsi dynamic cardiomyoplasty of the right ventricle. Potential for use as a partial myocardial substitute.

Full-thickness right ventricular latissimus dorsi dynamic cardiomyoplasty with the Medtronic Cardiomyostimulator (Medtronic, Inc., Minneapolis, Minn.) was performed in a chronic canine model. In one group (n = 2) the latissimus dorsi was electrically preconditioned before cardiomyoplasty. In a second group (n = 3) cardiomyoplasty was performed and the muscle was progressively stimulated, with conditioning accomplished while the latissimus dorsi was functioning on the ventricle. The contribution of the stimulated latissimus dorsi to global ventricular function was assessed, and the effects of varying muscle stimulation parameters on latissimus dorsi function and hemodynamics were examined. Right ventricular systolic pressure increased 8%, from 23.2 +/- 0.95 to 25.1 +/- 1.5 mm Hg. The rate of pressure rise increased 37% from 226 +/- 13 to 309 +/- 12 mm Hg/sec. Right ventricular ejection fraction was measured in two dogs and increased 29% with latissimus dorsi stimulation, from 51.5% +/- 13.5% to 66.5% +/- 14.5%. Although the sample size was small, there was no difference observed between the preconditioned and nonpreconditioned groups. Right ventricular systolic pressure, rate of pressure rise, and percent latissimus dorsi fiber shortening increased as voltage and burst frequency of the muscle stimulus increased, whereas increasing the burst duration had little effect in two dogs so studied. Latissimus dorsi dynamic cardiomyoplasty can function as a partial myocardial replacement in a chronic canine model, apparently without preconditioning of the muscle. The degree of cardiac assist obtained with cardiomyoplasty appears to be influenced by the voltage and frequency of the stimulus applied to the muscle. Although it is unclear whether these results can be extrapolated to the left ventricle, this technique may find application in the treatment of ventricular aneurysm or ventricular tumor.

Aggressive surgical management of sternoclavicular joint infections.

BACKGROUND: Although the sternoclavicular joint is an unusual site for infection, thoracic surgeons may preferentially be called on to coordinate management of cases refractory to antibiotic therapy because of the anatomic relationship of this joint to major vascular structures. METHODS: Since 1994 we have surgically managed nine sternoclavicular joint infections in eight patients. Associated medical problems were frequent and included diabetes mellitus (n = 2), end-stage renal disease (n = 2), hematologic disorders (n = 2), and multiple joints affected by sepsis (n = 4). Open joint exploration with drainage and débridement with the use of general anesthesia was performed in four patients. The remaining four patients (one with bilateral sternoclavicular joint infections) had computed tomographic evidence of diffuse joint and surrounding bone destruction with infection extending into mediastinal soft tissues. Surgical therapy for these five joint infections involved en bloc resection of the sternoclavicular joint with an ipsilateral pectoralis major muscle covering the bony defect. RESULTS: There were two deaths unrelated to the surgical procedure. After a mean follow-up of 20 months, the remaining six survivors (seven joints) have complete healing with no apparent limitation in the range of motion even after en bloc resection. CONCLUSIONS: Most cases of early sternoclavicular joint infections will respond to conservative measures. However, when radiographic evidence of infection beyond the sternoclavicular joint is present, en bloc resection, although seemingly aggressive, results in immediate eradication of all infection with negligible functional morbidity. Prolonged antibiotic therapy or continued local drainage procedures appear to have little value in these cases, adding only to patient care costs and the potential sequelae of chronic infections.

Microvascular free-tissue transfer. The Atlanta Veterans Administration Medical Center experience.

The entire microvascular tissue transfer experience from 1977 through 1987 at the Atlanta Veterans Administration Medical Center has been reviewed. Seventy-four free flaps were done in 68 patients. Assessable records were available in 52 patients who had 58 reconstructive procedures. The most frequently used flaps were jejunum in 15 patients (25.8%), latissimus dorsi in 11 patients (18.9%), rectus abdominis in eight patients (13.8%), and gracilis in seven patients (12.1%). Major complications occurred in 43.1% of the cases. Total flap loss occurred in eight patients (13.8%); from 1977 through 1982, four (28.6%) of 14 patients had total flap loss, and from 1983 through 1987, four (9.1%) had total flap loss. Partial flap loss occurred in four cases (6.9%). Of the 52 patients, 43 had their problems resolved expeditiously by free-tissue transfer. We conclude that in a university-affiliated Veterans Administration medical center, microvascular reconstruction is an important and necessary surgical tool. Failure rates have decreased markedly with time and increasing experience. Definition of new anatomic microvascular units for transfer has increased the number of reconstructive choices.

Treatment of severe leg wounds with muscle and musculocutaneous flaps.

The ten-year experience with difficult wounds of the lower extremity at the Atlanta Veterans Administration Medical Center is reviewed in order to evaluate the use of the muscle and musculocutaneous flap as regional and free-tissue transfers. Twenty-four patients had chronic wounds and five had acute bony and soft-tissue injury. A total of 34 procedures, including 18 regional flaps and 16 microvascular free-tissue transfers, were performed with an overall success rate of 74%. Regional transfer succeeded in 12 (67%) of 18 cases. Free-tissue transfer succeeded in 13 (81%) of 16 cases. Experience with regional muscle transfer has shown the gastrocnemius and soleus muscles to be excellent choices for reconstruction of the proximal and middle third of the lower leg. Free microvascular transfer of the latissimus dorsi, gracilis, and rectus muscles has provided reliable closure in wounds that are chronically infected with major bony and soft-tissue loss in the distal third of the lower extremity.

Surgery for high cervical esophageal carcinoma: experience with 11 patients.

The treatment of carcinoma of the cervical esophagus remains controversial. Eleven patients with carcinoma of the high cervical esophagus were encountered over the past 7 years at our institution. There were 6 men and 5 women whose ages ranged from 51 to 72 years. Six patients had tracheal or laryngeal invasion. In all instances one-stage pharyngolaryngoesophagectomy with pharyngogastric (6 patients) or pharyngocolic (5 patients) reconstruction was performed. There was one hospital death. Six patients died 6 to 35 months postoperatively: 1 from recurrence, 2 from generalized metastases, and 3 with both local recurrent and metastatic disease. One other patient died free of disease 6 weeks postoperatively of pneumonia. The remaining 3 patients are alive 12 to 84 months after operation with excellent rehabilitation and good quality of life. We conclude that one-stage surgical resection and reconstruction for high cervical carcinoma of the esophagus offers good palliation and possible long-term survival with acceptable operative risk.

Combination chemotherapy for advanced squamous cell carcinoma of the head and neck.

Fifty-one patients (32 previously untreated, 19 previously treated) with advanced squamous cell carcinoma of the head and neck received a single course of combination chemotherapy consisting of high dose cis-platinum (DDP), bleomycin (Bleo), +/- high dose methotrexate (MTX). Thirty-three (65%) patients responded to therapy; 5 (10%) of these patients had a complete response. Previously untreated patients and those who received the three drugs (DDP, Bleo and MTX) had the highest response rates. The duration of response was 8 to 12 weeks. Seven (15%) patients showed a two-year survival rate. All nonresponders were dead of disease within two years. Three (56%) of the five complete-response patients and 4 (21%) of the partial-response patients survived for two years. The role of preoperative chemotherapy in head and neck cancer is yet to be conclusively defined.

Microvascular approach to function and appearance of large orbital maxillary defects.

Forty-three patients with major three-dimensional orbitomaxillary defects underwent 48 free-tissue transfers for defects arising from resection of a neoplasm or trauma. Defects were complex, involving the malar skin, mandible, lateral nasal wall, orbit, palate, and brain. A three-dimensional approach attempting to recreate the midface by folding the flaps was the usual method, with subsequent revisions if necessary. Ten patients had simultaneous free bone grafts and 6 had vascularized bone grafts. There were three flap failures and four perioperative deaths. Excluding the 4 deaths, the results were assessed as excellent in 25 patients, good in 12, and poor in 2. Free-tissue transfer is a reliable method of providing enough tissue at one initial operation to satisfy complex three-dimensional defects of the orbitomaxillary region. Followed by minor revision, it provides a means of restoring function and appearance without multiple staged procedures with a high risk of failure.

Mandibular reconstruction with composite microvascular tissue transfer.

Microvascular free tissue transfer has provided a variety of methods of restoring vascularized bone and soft tissue to difficult defects created by tumor resection and trauma. Over 7 years, 26 patients have undergone 28 free flaps for mandibular reconstruction, 15 for primary squamous cell carcinoma of the floor of the mouth or tongue, 7 for recurrent tumor, and 6 for other reasons [lymphangioma (1), infection (1), gunshot wound (1), and osteoradionecrosis (3)]. Primary reconstruction was performed in 19 cases and secondary in 9. All repairs were composite flaps including 12 scapula, 5 radial forearm, 3 fibula, 2 serratus, and 6 deep circumflex iliac artery. Mandibular defects included the symphysis alone (7), symphysis and body (5), symphysis-body-ramus condyle (2), body or ramus (13), and bilateral body (1). Fourteen patients had received prior radiotherapy to adjuvant or curative doses. Eight received postoperative radiotherapy. All patients had initially successful vascularized reconstruction by clinical examination (28) and positive radionuclide scan (22 of 22). Bony stability was achieved in 25 of 26 patients and oral continence in 24 of 26. One complete flap loss occurred at 14 days. Complications of some degree developed in 22 patients including partial skin necrosis (3), orocutaneous fistula (3), plate exposure (1), donor site infection (3), fracture of reconstruction (1), and fracture of the radius (1). Microvascular transfer of bone and soft tissue allows a reliable reconstruction--despite previous radiotherapy, infection, foreign body, or surgery--in almost every situation in which mandible and soft tissue are absent. Bony union, a healed wound, and reasonable function and appearance are likely despite early fistula, skin loss, or metal plate or bone exposure.