Gangrene of the lung.

Case histories of four patients with gangrene of the lung are presented. All of these patients had characteristic radiographic features of the disease. Two patients had resection and survived. One patient who spontaneously coughed up necrotic tissue via the bronchus survived. One patient who died of an acute myocardial infarction was found at autopsy to have the characteristic pathologic findings of gangrene of the lung.

Therapeutic efficacy of Biobrane in partial- and full-thickness thermal injury.

Cadaver allograft skin, porcine xenograft skin, and amniotic membranes have been proved to be adequate temporary thermal wound coverings in four clinical situations: coverage of shallow wounds while awaiting epithelialization (SW), coverage of deep wounds after eschar excision (DEW), coverage of widely meshed autograft while awaiting closure of interstices (AC), and coverage of massive donor sites (DS). This study was undertaken to evaluate the therapeutic efficacy of a new biosynthetic bilaminate dressing, Biobrane. Two hundred one applications of Biobrane were studied in 82 SW, 46 DEW, 19 AC, 54 DS. A total of 124 applications were left in place until healing occurred, with a mean healing time of 12.8 days. Sixty of SW, 10/46 DEW, 10/19 AC, and 44/54 DS remained intact until complete healing. Only four DEW, two SW, and 0 AC applications had to be removed because of suppuration. Twenty five of the applications (SW and DEW) with the Biobrane glove had rare complications.

The effect of denervation on leukocyte function in soft tissue infection.

BACKGROUND: The present study was undertaken to investigate the effect of denervation on leukocyte function in soft-tissue infection in an isolated in vivo ovine flap model. METHODS: Fifteen adult ewes were divided into three groups. An island pedicle flap was raised on the right buttock. In group I (no denervation), the cutaneous nerve remained intact, whereas in group II (acute denervation) the nerve was divided acutely. In group III (prolonged denervation) the nerve was divided 7 days before flap elevation. All flaps received intradermal inoculation of 10(7) Staphylococcus aureus, and the animals were observed for 96 hours. RESULTS: In both groups II and III, the leukocyte chemiluminescence and chemotaxis were significantly decreased when compared with group I. Furthermore, there was profound impairment of leukocyte functions in group III compared with group II. Group III also had significantly higher bacterial counts, larger septic foci, lower viable leukocyte ratios, and decreased bacterial killing compared with group I. CONCLUSIONS: Denervation, particularly over a period of time, results in increased bacterial growth of soft-tissue septic foci. This appears to be due to decreased leukocyte function resulting in diminished bacterial killing.

The effect of venous obstruction in infected pedicle flap.

A new model of soft-tissue infection is used to investigate the effect of the local wound environment on the septic focus. Island pedicle flaps were raised on the buttock of 24 adult ewes and multiply inoculated with Staphylococcus aureus. Flaps with bacterial inoculation, without compromise of venous outflow, showed distal necrosis (mean +/- SEM percent of surface area, 25.8% +/- 8.6%) and developed septic foci with bacterial counts one log less than the amount injected. Flaps with inoculation and venous outflow obstruction underwent subtotal necrosis (mean percent of surface area, 73.3% +/- 11.2%) and had counts two logs higher than the nonobstructed flaps but without discrete septic foci. Flaps without inoculation, with or without venous obstruction, survived completely. Venous outflow obstruction is shown herein to potentiate tissue necrosis by raising bacterial counts in a septic focus and preventing defensive abscess formation by the host.

Esophageal perforation.

A brief synopsis of the clinical and radiographic features of esophageal perforation, including barogenic rupture, is outlined. The dependence of the thoracic surgeon on roentgenograms and their interpretation by the radiologist is emphasized.

Barogenic rupture of the esophagus (Boerhaave's syndrome): successful treatment of a late case.

This article presents a case of barogenic (postemetic) rupture of the esophagus that was diagnosed more than 48 hours after the acute event and subsequently treated successfully. The initial approach of direct esophageal repair, pleural drainage, antibiotics, and intravenous hyperalimentation was not successful. The repair site disrupted, and the patient became critically ill and septic. Salvage of the patient with closure of the fistula and normal alimentation was accomplished by partial distal esophageal occlusion, utilizing a serrated (Miles) vena cava clip.

Containment of a multiresistant Serratia marcescens outbreak.

A 3-year-old male from Bolivia who sustained a full-thickness 80 per cent TBSA burn complicated by smoke inhalation on the 28 March 1995 was admitted to our burn centre on 6 April 1995. On 11 April the patient's wounds were colonized with a Serratia marcescens sensitive only to ciprofloxacin and imipenem. Sputum cultures revealed the same phenotypic S. marcescens. Two patients who were admitted days later had the same phenotypic S. marcescens. Their TBSA burns ranged from 54 to 80 per cent. Both were injured in early April. Sputum and wound cultures were also positive for S. marcescens. Precautionary measures were instituted immediately. All potential reservoirs were cultured. Cultures were negative for S. marcescens. Patient therapy was maintained via strict isolation. The first patient died on 17 May. The two remaining patients survived and were discharged colonized with S. marcescens. However, the biotype of the initial S. marcescens was different from the latter two. Early recognition of a multiresistant S. marcescens resulted in negating the spread of this agent to other patients.

Uses and abuses of a biosynthetic dressing for partial skin thickness burns.

The following report reviews 851 applications of Biobrane on partial skin thickness burn wounds awaiting epithelialization. After the patients had been evaluated and resuscitated as needed, the burn wounds were cleansed and debrided. Those evaluated as shallow were treated with Biobrane application. Joint surfaces were splinted for immobilization. The wound was inspected at 24 and 48 h and if any fluid had accumulated it was aspirated and the wound was redressed. When the Biobrane was adherent, the wound was covered with a light dressing and joint immobilization was discontinued. Treatment with Biobrane dressing provided certain advantages over other topical wound care. As the dressing changes were performed less frequently outpatient care was possible, with a resultant decrease in both the length of hospital stay and the ultimate cost of burn care. Wound desiccation is prevented and pain is decreased. Accurate diagnosis of wound depth is crucial if Biobrane is to be used. Very deep wounds will not allow Biobrane adherence, neither will it occur if the wound has a high bacterial count. If joint surfaces are not splinted, the Biobrane will shear and not adhere to the wound. Convex and concave surfaces can be treated with Biobrane, which may need to be meshed.

Langer's lines: to use or not to use.

Thirty-six differently named guidelines have developed as surgeons have searched for an ideal guide for elective incisions. Many surgeons prefer Langer's lines. These lines were developed by Karl Langer, an anatomy professor, from cadavers in rigor mortis. However, Kraissl preferred lines oriented perpendicular to the action of the underlying muscles. Later, Borges described relaxed skin tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. However, these are only guidelines; there are many contributors to the camouflaging of scars, including wrinkle and contour lines. Borges's and Kraissl's lines (not Langer's) may be the best guides for elective incisions of the face and body, respectively.

Bipedicle paraspinous muscle flaps for spinal wound closure: an anatomic and clinical study.

The purpose of this study was to evaluate the vascular anatomy of the paraspinous muscles and review their clinical use as bipedicled flaps in spinal wound closure. Anatomically, through cadaver dissections, lead oxide injections, and radiographic imaging, the blood supply to the paraspinous muscles was determined. Clinically, 29 consecutive patients treated with spinal wounds and exposed bone or hardware were reviewed retrospectively. Of these patients, 19 underwent closure in delayed primary fashion, whereas 10 were referred to plastic surgery for reconstruction because of the complex nature of their wounds. The cadaver study demonstrated the paraspinous muscles to possess a segmental arterial supply through medial and lateral perforators. Division of the medial perforators allowed for medial advancement of the muscles. Lead oxide injection of the lateral perforators demonstrated adequate medial muscle perfusion with ligation of the medial perforators. Ten of the 29 patients (six women, four men, 32 to 62 years of age) were reconstructed with paraspinous (eight), latissimus (one), and trapezius (one) muscle flaps. A higher complication rate was found in wounds closed in delayed primary fashion (13 of 19 patients, 68 percent) than those reconstructed with muscle flaps (2 of 10 patients, 20 percent) (p = 0.021). Follow-up of the muscle flap reconstructed patients averaged 12 months (range, 3 to 27 months). Cadaver muscle injections predicted and clinical cases confirmed that the paraspinous muscles can be raised on lateral perforators and advanced medially to close lumbar spine wounds reliably with fewer complications.

Another indication for liposuction: small facial lipomas.

The treatment of facial lipomas at times requires the use of incisions that are less than satisfactory in either size or location. In an effort to minimize scarring, the authors have been removing these lesions with liposuction. The purpose of this study was to review the authors' experience in treating small facial lipomas using liposuction. Over the last 10 years, the authors treated five patients with forehead lipomas by removal with liposuction through hair-bearing scalp incisions. All patients were evaluated after the procedure for bleeding, paresthesias, recurrence, scarring, and overall satisfaction with the procedure. All of these patients had lipomas that measured 4 cm or less at the time of surgery. No patient experienced hematoma, nerve injury, or recurrence. All patients were completely satisfied with their result and scar. The literature describes an advantage to using liposuction for the treatment of medium (4 to 10 cm) and large (>10 cm) lipomas. Because small lipomas (<4 cm) can be extracted through small incisions, the literature reports no advantage to removal with liposuction. However, favorable aesthetic results can be obtained by removing small facial lipomas with liposuction through strategically placed incisions.

The effect of denervation on soft-tissue infection pathophysiology.

Pressure is the sine qua non in the etiology of pressure sores; however, ischemia, denervation, edema, and infection also have been implicated. The role of denervation in tissue infection was studied in an isolated in vivo ovine flap model. Twenty-six adult ewes, divided into three groups, had 29 island pedicle flaps raised on their buttocks. In group I, the cutaneous nerve remained intact, while group II had its nerve divided acutely. Group III had prolonged denervation, where the nerve was divided 7 days before flap elevation. All flaps received intradermal inoculations of 10(7) Staphylococcus aureus. Ninety-six hours later, quantitative bacteriology showed counts of 10(7), 10(7), and 10(9) colony-forming units (CFU) per gram of tissue in groups I, II, and III, respectively. Septic foci were larger in group III, and there was a significant increase in tissue edema between groups I and III. A 25-fold increase in bacterial counts seen in the prolonged denervation group may help explain why neurologically injured patients are more susceptible to infection and pressure ulcerations.

Do not use epinephrine in digital blocks: myth or truth?

The purpose of this study was to examine the role for epinephrine augmentation of digital block anesthesia by safely prolonging its duration of action and providing a temporary hemostatic effect. After obtaining approval from the review board of the authors' institution, 60 digital block procedures were performed in a prospective randomized double-blinded study. The digital blocks were performed using the dorsal approach. All anesthetics were delivered to treat either posttraumatic injuries or elective conditions. Of the 60 digital block procedures, 31 were randomized to lidocaine with epinephrine and 29 to plain lidocaine. Of the procedures performed using lidocaine with epinephrine, one patient required an additional injection versus five of the patients who were given plain lidocaine (p = 0.098). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (p < 0.002). Two patients experienced complications after plain lidocaine blocks, while no complications occurred after lidocaine with epinephrine blocks (p = 0.23). By prolonging lidocaine's duration of action, epinephrine may prevent the need for an additional injection and prolong post-procedure pain relief. This study demonstrated that the temporary hemostatic effect of epinephrine decreased the need for, and thus the potential risk of, using a digital tourniquet (p < 0.002). As the temporary vasoconstrictor effect is reversible, the threat of complication from vasoconstrictor-induced ischemia is theoretical.

Effect of the combination of Aloe vera, nitroglycerin, and L-NAME on wound healing in the rat excisional model.

PURPOSE: Many systemic and topical therapeutic agents such as growth hormone, platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), epidermal growth factor (EGF), and insulin-like growth factor (IGF) have been used as vulnerary agents. However, the role of nitric oxide (NO) as a wound-healing stimulant has been received with mixed reviews. NO is a potent vasodilator that is thought to be an endothelium-dependent relaxing factor, and a regulator of blood pressure and regional blood flow. It affects vascular smooth muscle proliferation and inhibits platelet aggregation and leukocyte adhesion. Therefore we compared the effects of several topical substances that have similar or reverse properties. METHODS: Using the excisional rat wound model, we evaluated the topical effects of Dermaide Aloe (D-Aloe, Dermaide Research Corp, Palos Heights, IL), nitroglycerin, Aquaphor (Beuersdorf, Inc., Norwalk, CT) alone, with D-Aloe with nitroglycerin, 2%, and L-NAME (NO inhibitor) with Aquaphor, and L-NAME with Aquaphor and D-Aloe for a 21-day period. All wounds were measured by planimetry at 1, 7, 10, 13, 16, 18, and 21 days. RESULTS: At day 1, all wounds had an average wound size of 2.27 cm2 (SD +/- 0.372) with no significant difference in wound size among the groups. Topically applied D-Aloe appeared to promote wound healing faster than the remaining other topicals (p < .05, Student-Newman-Keuls and Dunn's Method) over the study period. However, topicals combined with D-Aloe, the vehicle Aquaphor, and L-NAME improved the wound healing process when compared with nitroglycerin alone (p < .05). CONCLUSIONS: D-Aloe appears to have a wound-healing advancement factor that can reverse the effects of petrolatum- and nitroglycerin-based products as observed in the remaining groups when compared with nitroglycerin alone. It appears that D-Aloe's effect of preventing dermal ischemia by reversing the effects of thromboxane synthetase (TxA2) may act synergistically with NO or could be an oxygen radical scavenger.

A nonclassifiable anaplastic tumor of the esophagus.

A highly malignant, anaplastic tumor of the esophagus in a middle-aged man is described. Despite critical examination of biopsy material by several pathologists, the tumor was deemed to be anaplastic and sarcomatous but otherwise unclassifiable. Despite prompt diagnosis following admission, the tumor metastasized and the patient rapidly died.

Carcinoma of the lung and coexistent active pulmonary tuberculosis: diverse morphologic and radiographic presentations.

Five patients with coexistent carcinoma of the lung and active tuberculosis within the same pulmonary lesion were studied. These cases represent five distinctly varying radiographic presentations and point out the extreme diversity of the morphological pictures of this particular disease combination. Physicians who regularly deal with patients who might present with either entity alone are cautioned to be alert to the possibility that these two diseases may be present simultaneously within single, specific pulmonary lesions.

Giant esophageal carcinoma.

Carcinoma of the esophagus is a devastating disease that produces various degrees of esophageal obstruction by virtue of its circumferential, constricting type of growth pattern. Because of the relatively small diameter of the esophageal lumen, a limited-sized tumor can produce severe obstructive symptoms. Carcinoma of the esophagus is, as a rule, fairly well localized to its wall or the immediate mediastinal parietes in cases where there is extension beyond the esophageal musculature.(1) Large, bulky, exophytic types of esophageal carcinomas that produce symptoms mainly as a result of extrinsic pressure are unusual.

Burn and trauma units as sources of methicillin-resistant Staphylococcus aureus.

At the time that methicillin-resistant Staphylococcus aureus (MRSA) began to achieve clinical prominence, it was thought to be spread by exogenous vectors. Institution of rigorous infection control efforts, including isolation procedures, was found to have little effect on the frequency of MRSA colonization of burn wounds. It was later found that handwashing was sufficient to prevent cross-contamination. Subsequently, it has been shown that patients can be harboring MRSA at the time of admission to the burn unit and that multiple antimicrobial resistance can develop among organisms that reside in the patient through plasmid-mediated transfer of resistance genes. Excessive use of such agents as the synthetic penicillins and second- and third-generation cephalosporins has selected for the survival of these organisms. Currently, the only available agent for systemic treatment of MRSA infection is vancomycin, the use of which is expensive and associated with significant toxicity. Muciprocin is a topical antimicrobial that promises to be useful in the treatment of such infections. Other agents for systemic use are needed, since use of a single drug to combat MRSA infections seems likely to encourage the emergence of resistant organisms.

Long-term assessment of the effects of circumferential truncal burns in pediatric patients on subsequent pregnancies.

Longitudinal assessment of the long-term effects of pediatric circumferential truncal burns on subsequent pregnancies is poorly documented. Between December 1967 and August 1985, 75 female pediatric patients with circumferential truncal injuries were admitted to our institution. Twenty-two of these patients were available for long-term follow-up into early adulthood. Seven of these 22 patients had conceived. All seven patients had sustained flame-burn injuries. Mean age at injury was 7.66 +/- 2.12 years. Mean total body surface area of burns was 63.21% +/- 16.69%, with 44.21% +/- 17.54% of the injuries full thickness. Each patient was treated with excision and split-thickness skin grafting during initial hospitalization. In the group of seven patients there were 14 pregnancies. All infants were full term. There were 13 vaginal deliveries and one elective cesarean section. Prenatal complications were limited to one case in which a patient had sustained breakdown of scar tissue during the third trimester of pregnancy. There were no labor and delivery complications in this patient population. Circumferential truncal burns appear to have no impact on prenatal or labor and delivery complications.

Much ado about nothing: methicillin-resistant Staphylococcus aureus.

The pathogenic methicillin-resistant Staphylococcus aureus (MRSA) has received a voluminous amount of notoriety. The four major reasons are its morbidity, mortality rate, cost of treatment, and constant appearance in intensive care units. Both Staphylococcus aureus and S. epidermidis (MRSE) account for 82% of our gram-positive wound isolates, whereas the gram-negative account for 34% of all isolates. Therefore we compared the morbidity, mortality rate, and cost factors related to MRSA-MRSE and gram-negative infections for a 4-year period, assessing more than 214 documented infections. Morbidity and mortality rates were minor for MRSA. Pseudomonas aeruginosa and Escherichia coli accounted for 57.5% of the total gram-negative isolates. Gram-negative antimicrobial therapy usually requires two therapeutic drugs, which increases morbidity and costs, whereas the staphylococci usually can be treated by one antimicrobial. During this period there were 47 gram-negative infections requiring 10 to 15 additional days of hospital stay, with a daily antibiotic cost of $293.40. Costs for MRSA or MRSE are 28% less. Therefore our preoccupation with MRSA or MRSE infections is unwarranted and unsubstantiated.