[Implant insertion in distracted bone for reconstruction after gunshot injury]. / Pose d'implants en os distracté chez les patients reconstruits après traumatisme balistique.

Distraction osteogenesis is a tissue engineering technique with two clinical applications in maxillofacial surgery: alveolar distraction and basal bone distraction. Even if it appears to be a binding and major surgery, distraction osteogenesis applied to facial bone, and especially to the mandible, has the great advantage of producing a pluritissular reconstruction of ideal quality and quantity, suitable for the ultimate goal of dental implant rehabilitation management. This technique had some drawbacks due to technical constraints related to the material. Distraction osteogenesis is well placed in the armamentarium of reconstructive surgery techniques for bone defects caused by trauma or tumor. It allows rapid restoration of adequate physiological conditions for mandibular dental implant placement. We reviewed the various modifications of this technique.

CT scan study of the mandibular nerve intra-mandibular path.

INTRODUCTION: It is mandatory to know the anatomic path of the mandibular nerve and its intra-mandibular connections for numerous odontology, stomatology, and maxillofacial surgical procedures. We present a computed tomography study of the mandibular nerve intra-mandibular path. PATIENTS AND METHOD: The computed tomography of 14 mandibles was performed (vestibulo-lingual cross-section) and four landmarks were defined behind the mental foramen. At each landmark, we measured the distance between the alveolar canal and the two cortical layers in the vestibulo-lingual plane, and the distance between the alveolar canal and the alveolar crest, and the inferior border of the mandible in the vertical plane. RESULTS: In the vestibulo-lingual plane, the mandibular nerve is located close to the vestibular cortical layer, then to the lingual cortical before it exits. In the crestal plane, it is located at the superior third of the inferior border of the mandible. DISCUSSION: In spite of anatomical variability, there is a globally common path which means that the utmost caution should be taken by performing systematic imaging before undertaking any surgery close to the nerve.

Evolution of lipid profile, liver function, and pattern of plasma fatty acids according to the type of lipid emulsion administered in parenteral nutrition in the early postoperative period after digestive surgery.

BACKGROUND: The metabolic effects of intravenous lipid emulsions (ILEs) used in parenteral nutrition (PN) depend on their fatty acid composition. METHODS: Subjects in this prospective and randomized double-blind study were 28 adult patients post digestive surgery. PN was started after surgery and lasts for 5 days. Randomly, patients receive 1 of 4 different ILEs: medium-chain triglycerides/long-chain triglycerides (soybean oil; MCT/LCT), olive/soybean oil (oleic), long-chain triglycerides (soybean oil; LCT), and structured lipid. On days 0 and 6, serum liver function tests were analyzed for cholesterol, triglycerides, lipoproteins, and serum fatty acids. RESULTS: No differences were found in the 4 groups according to their gender, age, body mass index, diagnosis, baseline white blood cell, C-reactive protein, glucose levels, and other study parameters. Differential significant changes were not observed in any of the hepatic function parameters or plasmatic lipid levels between the groups. A significant decrease was observed in cis monounsaturated fatty acids (MUFAs) and a significant increase in omega-6 polyunsaturated fatty acids (PUFAs) and omega-3 PUFA values in LCT and structured groups compared with MCT/LCT and oleic groups, and a tendency for a decrease in trans fatty acids in the oleic and structured groups was found. CONCLUSIONS: All ILEs administered were safe and well tolerated. The changes in serum fatty acids reflected the pattern of fatty acids administered with different ILEs. The group receiving the olive oil emulsion achieved a fatty acid composition of serum lipids that could offer major therapeutic or biological advantages.

Influence of surgical stress and parenteral nutrition on serum leptin concentration.

UNLABELLED: Experimental studies suggest that leptin may be an important metabolic signal for energy regulation. AIM: To assess whether surgical stress produces changes in serum leptin concentration and to investigate and compare the effect of total parenteral nutrition and hypocaloric parenteral nutrition on serum leptin levels. PATIENTS AND METHODS: Twenty-two surgical patients (11 male and 11 female) in need of parenteral nutrition were recruited. Parenteral nutrition was always initiated 24 h after surgical procedure. Group I (n=15) received total parenteral nutrition, while Group II (n=7) were treated with hypocaloric parenteral nutrition. Serum leptin concentration was determined before surgical procedure (day -1), after surgery and before parenteral nutrition was started (day +1), and after 5 days of treatment with parenteral nutrition (day +6). RESULTS: A tendency to increase serum leptin levels was observed after surgical procedure (6.0+/-1.9 vs 9.9+/-2.7 ng/ml;P= 0.07). After starting parenteral nutrition no significant changes on serum leptin concentrations were found in both groups, but a trend to raise serum leptin was observed in Group I (6.2+/-1.7 vs 8.3+/-2.7 ng/ml) whereas a trend to decrease serum leptin was detected in Group II (4.6+/-2.5 vs 1.6+/-0.5 ng/ml). On day +6 an increase of serum leptin and insulin levels was observed in Group I in comparison with Group II (8.3+/-2.7 vs 1.6+/-0.5 ng/ml;P<< 0.05 and 58+/-41 vs 12+/-15 microU/l;P<< 0.05 respectively). Finally, a positive correlation at day +6 between insulin and serum leptin levels was observed (r= 0.66;P<< 0.01). CONCLUSIONS: a) Surgical stress is associated to an increase of serum leptin concentrations; b) Total and hypocaloric parenteral nutrition produces quite different effects on serum leptin levels that could be related to distinct insulin response.

Early curbing of protein hyper-catabolism in postoperative patients by nutritional support with glucose plus amino acids, but not with glucose alone.

This work attempts to determine if there are differences in protein metabolism in post-surgical patients who receive parenteral nutrition with amino acids plus glucose (G+AA) or conventional gluco-salinal solution (GS). Eighteen patients submitted to gastrointestinal surgery were randomized and double-blindly administered either G+AA (1 g AA/kg x d and 28 kJ/kg x d), or GS (28 kJ/kg x d). Protein metabolism was determined 12 h after surgery (day 0) and after 5 days of nutritional support. On day 0, protein breakdown was similarly elevated, with respect to reference values, in both groups (GS: 4.62 +/- 0.25; G+AA: 5.25 +/- 0.50 g prot/kg x d) as a result of surgical stress. These values increased significantly at day 5 (P < 0.03) with the administration of GS to 6.93 +/- 1.00 g prot/kg x d, while they decreased (P < 0.002, 3.30 +/- 0.42 g prot/kg x d) with G+AA. Protein synthesis was increased (5.69 +/- 0.86 g prot/kg x d) with GS (P < 0.02), and was decreased (2.79 +/- 0.44 g prot/kg x d) with G+AA (P < 0.0002). Both synthesis and breakdown were inside normal reference values after 5 days for group G+AA. In both groups, nitrogen balance did not change significantly at day 5 compared to day 0. G+AA is effective in curbing the hypermetabolism produced by postoperative stress, achieving normal protein metabolism in 5 days, while GS increases the protein breakdown and synthesis. Nitrogen balance does not detect these modifications of the protein metabolism. Undernutrition on prognosis is not yet fully recognized.

The importance of clinical factors in parenteral nutrition-associated hypertriglyceridemia.

AIMS: The purpose of this study was to establish the relevance of several clinical factors associated with parenteral nutrition (PN) hypertriglyceridemia and to construct a predictive model for this complication. METHOD: This multicenter study included all patients with initial serum triglyceridemia <3 mmol and receiving a minimum of 7 days' PN therapy. The study ended for each patient when hypertriglyceridemia developed or PN was terminated. Two multivariate models were constructed, one to study the clinical factors and the second to predict plasma triglyceridemia. A total of 22 clinical factors studied as independent variables were included in the multiple-step regression models only when they showed a P-value over 0.1. Statistical significance was determined by the confidence interval of the odds ratio (OR) and the partial regression coefficient (b). RESULTS: The study included 260 patients from 14 hospitals. Lipid administration was 0.83+/-0.37 g/kg/day. Among the total, 68 patients (26.2%) showed hypertriglyceridemia. Variables included in both models were serum glucose (OR, 2.63; b, 0.06), renal failure (OR, 10.56; b, 1.70), corticoid administration >0.5 mg/kg (OR, 7.98; b, 0.97), pancreatitis (OR, 4.38; b, 0.64), sepsis (OR, 4.48; b, 0.24), lipids infused (OR, 3.03; b, 0.24) and heparin administration >3 mg/kg/day (OR, 0.11; b, -1.21). CONCLUSION: Although the rate of lipid infusion was low, certain clinical factors modified triglyceridemia. Nevertheless, relatively fast plasma clearance of lipids infused indicates that a reduction in lipid supply could be a quick, effective measure for controlling hypertriglyceridemia. Thus, careful monitoring of patients with clinical factors predicting risk in the model studied, with adjustment of lipid perfusion rates accordingly, is suggested to avoid hypertriglyceridemia.

[Practice guideline for the administration of drugs with parenteral nutrition]. / Guía práctica para la administración de fármacos con la nutrición parenteral.

The "Y" administering of drugs or administering them during parenteral nutrition should not be a normal practice in daily clinical operations, due to the problems of the possible lack of physio-chemical stability in the lipid emulsion forming the mixture of aminoacids, glucose, lipids, electrolytes, vitamins and oligoelements or the chemistry of the drug itself with these components. Also, the "Y" administration of drugs in parenteral nutrition increases the risk of infection in the catheter, since it is handled much more often. Despite these problems, there are clinical situations (such as preoedema of the lung, inadequate syndrome of the antidiuretic hormone in bone marrow transplants), in which it is necessary to restrict to a minimum the fluids to be perfused. As an example, we could mention Ranitidine in TPN or the elimination of second line peripheric maintenance serum and the administering of other drugs in "Y" using a syringe or microdrop system. The same case as in patients subjected to bone marrow transplants, where due to polypharmacy and transfusions, drugs should be administered in "Y". This study is an updated review of the chemical stability of drugs administered in "Y" or in parenteral nutrition, and the physio-chemical stability of the lipid emulsion.

[Stability of a lipid emulsion in formulations for total parenteral nutrition]. / Estabilidad de una emulsión de lípidos en mezclas para nutrición parenteral total.

The complex nature of "all in one" formulas for TPN, makes it difficult to ensure the stability of the lipid emulsions in these preparations. Despite the fact that studies on this issue are increasing, official guidelines on maximum acceptable particle size and the methods to control it are still lacking. The objective of this study was to assess the stability of a lipid emulsion in four standard mixtures also containing amino acids, glucose or F-G-X, electrolytes and vitamins or trace elements. Lipid stability was assessed visually through electronic counts and microphotographs. The pH of mixtures ranges between 5.3 and 5.9, not changing with time nor storage temperature. Visual observation showed a possible rupture of the emulsion in one mixture after storing 96 hours at room temperature, but not when stored at 4 degrees C. Mean diameter of fat particles did not change. The percentage of droplets having a diameters under 1.2 micron was higher than 90%, although particles greater than 6 micron appeared in all mixtures. Micrographic observation revealed the presence of aggregates with a diameter greater than 8 microns in one mixture. According to the results obtained, one of the mixtures may be considered physically unstable. The clinical viability of this mixture and of the other three stable mixtures, depends on the limits considered acceptable regarding particle size. Due to the slight composition differences of the mixtures studied, it is difficult to explain the difference in behavior observed. Therefore, it would be adviceable to study standard "all in one" mixtures of known stability, while waiting for more conclusive studies to be performed, especially in the case of critical mixtures.

[Parenteral nutrition: a utilization study in a general hospital]. / Nutrición parenteral: estudio de utilización en un hospital general.

A follow-up of 116 patients initiating parenteral nutrition was performed from December 1990 to March 1991 (average of 18 patients on parenteral nutrition per day, which accounted for a prevalence of 2% compared to total patients admitted), in order to determine a series of characteristics related to the use of parenteral nutrition in our hospital, by means of obtaining concrete, updated information. With regard to the patients, it was observed that 37% of these were suffering from chronic ailments, with more or less incapacitating pathologies. The nutritional state prior to parenteral nutrition was normal in 53% of cases, and the most common reasons for admittance to hospital were neoplasias (27%) and digestive pathology (18%). 42% of the patients were admitted to the ICU and 34% to General Surgery. Indication for parenteral nutrition was intestinal pathology in 23% of cases, followed by pancreatic pathology in 16% of cases and pathology of the oesophagus in 10%; in 45% of cases, it was commenced during the postoperative period. With regard to the composition of the parenteral nutrition, we should mention the use of polyols instead of glucose in 80% of diabetic patients and 75% of patients with pancreatitis, the widespread use of mixture of 50% medium and long chain triglycerides and the use of amino acid solutions with 20% branched chain in most patients, both in situations of stress and maintenance.

[Idiopathic cholestasis associated with progressive ductopenia in two patients with hodgkin's disease]. / Colestasis idiopática asociada a ductopenia progresiva en dos pacientes con linfoma de Hodgkin.

INTRODUCTION: Jaundice in Hodgkin's disease can be due to several causes. Ductal lesions and ductopenia, which we describe below, have rarely been reported. CASE REPORT: We describe 2 cases of idiopathic cholestasis associated with Hodgkin's disease in which duction lesions and ductopenia were found. In one case, the ductal lesion progressed to ductopenia and the patient died from complications of her oncological disease while in the second case, outcome was favorable with improvement of cholestasis and remission of Hodgkin's lymphoma. DISCUSSION: Ductopenia should be included in the differential diagnosis of cholestasis associated with Hodgkin's disease, for which a high degree of suspicion is required. Hodgkin's disease should be suspected when ductopenia is found.

[Orbito-palpebral prosthesis retained by intraosseous implants]. / Prothèse orbito-palpébrale fixée par implants endo-osseux.

The use of intraosseous implants, whose tolerance is continually improving, constitutes an important progress in the field of prosthetic rehabilitation. In particular, titanium implants largely resolve the problem of retention of craniofacial prostheses. Our experience, based on that of Swedish authors concerning the extra-oral use of intraosseous implants, was sufficiently convincing to adopt this effective technique in our patients candidates for prosthetic rehabilitation. The case of a patient rehabilitated by means of an orbito-palpebral prosthesis is presented after a brief biomechanical review and presentation of the technique. Our results, although preliminary, are very encouraging in terms of the technical aspects as well as patient comfort. A further study could reinforce our decision.

The cost of quality assurance: an exploratory study.

This paper documents the resource consumption of the quality assurance program at St. Marys Hospital Medical Center, a 357-bed, community, acute care hospital located in Madison, WI. To date, little exists in the literature documenting the financial commitment of an institution to its quality assurance program. Furthermore, no standard with respect to appropriateness has been established, although 1% of the operating budget of an institution has been suggested. In 1986, St. Marys spent 0.6% of its operating budget on its quality assurance function. This calculates out to approximately $20 per admission. In addition, the medical staff and others contributed 1013 hr of time to the quality assurance program. It is important that institutions determine and document their resource commitment to the quality assurance function so that standards can be established and discussion with respect to appropriateness and efficiency can be stimulated. Finally, it is important to document this expenditure so that it can be contemplated in light of fiscal pressure and availability of service.

[Maxillofacial prosthesis, fixation by endo-osseous implants and transcutaneous pillars]. / Epithèses maxillo-faciales, fixation par implants endo-osseux et piliers trans-cutanés.

Osseointegrated facial prostheses are an interesting solution in maxillo-facial rehabilitation when reconstructive plastic surgery is not envisageable. Authors report two cases and give their opinion on the use of this kind of prostheses.

[Permanent percutaneous electric connection. General principles]. / La connexion electrique percutanée permanente. Principes généraux.

The Swedes for more than twenty years, and the Germans for over five years have been able to maintain inert or active prostheses with permanent percutaneous connections, thanks to the dependable and proven material and techniques of extraoral implants. The significant improvement extra-oral implants have brought about is not only in a new therapeutic approach to the treatment of important facial defects or transmission deafness; it is also because for some twenty old years now, the few millimeter wide cylinders of Titanium, the <> affixed on the implants, have crossed the cutaneous barrier for extended periods without complications. The percutaneous abutment thus creates a permanent communication between the interior and the exterior of the organism. If the abutment, instead of simply carrying a Maxillo-Facial Prosthesis or an auditive prosthesis, is modified by placing an electric conductor inside it, the simple "percutaneous peg" will turn out to be, in a way, a "percutaneous electric plug". By adapting classic "mechanical" abutments and implants, authors have created a Permanent Percutaneous Electric Connection (PPEC) which has been successfully experimented on rabbits to record EEG. Clinical applications on humans would make it possible either to receive "bio-electrical information" coming from within the organism, or to send electrical energy into the organism. This last application opens vast perspectives of improvement both in diagnosis and therapy in many fields.

[Bone-anchored implants: comparison of the techniques and values of endo- and juxta-bone implants]. / Les épithèses implanto-portées: technique et intérêt comparés des implants endo et juxta-osseux.

Extra-oral implants have been used for well-defined application for nearly 20 years; for tupoorting maxillo-facial prostheses and for bone anchored hearing aids (BAHA). In both of these applications, the bone-anchored prostheses support transcutaneous abutments. It is the junction between the implant and the abutment which ensures, given certain preconditions, the permanent percutaneous connection (PPC). The authors describe the two types of implants currently in use-intra- and juxta-osseous implants. They then give a brief description of the two techniques. The advantages and disadvantages of each system are summarised, as well as the conditions required for permanent survival of a PPC.

Hospital cost accounting and the new imperative.

Government regulatory structures, prospective payment mechanisms, a more competitive environment, and attempts to link cost accounting principles to planning, budgeting, and fiscal control all have served as catalysts for hospitals to increase their reliance and emphasis on cost accounting. Current hospital accounting systems are relatively inexpensive to develop and maintain, and they fulfill the financial reporting requirements mandated by Medicare and other third-party payers. These systems, however, do not provide information on what specific service units cost, and managers must have this information to make optimal trade-offs between quality, availability, and cost of medical services. Most health care organizations have a predetermined charge for each type of service, but the charge may not accurately portray the cost of providing the service. Knowing true costs will enable managers to select the most cost-effective method of treating a patient; know the financial implications of adding tests or procedures; relate costs to established norms of care; establish ranges of acceptable costs in various diagnostic groups; negotiate more successfully with rate review organizations and health maintenance organizations; and vigorously market and advertise the services that most contribute to the organization's overall financial health. The goal of microcosting is to determine the full cost of providing specific service units. The microcosting process comprises three components: data collection, cost modeling, and cost analysis. Microcosting is used to determine full costs for 20 percent of the hospital's procedures that are responsible for generating 80 percent of the hospital's gross revenue. Full costs are established by adding labor costs, materials costs, equipment depreciation costs, departmental overhead costs, and corporate overhead costs.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute MI in a young hypertensive woman: could it be due to tranexamic acid?

The case report illustrates an acute myocardial infarction (MI) in a 41-year-old hypertensive woman possibly because of an intake of a combination of tranexamic acid and mefenamic acid for dysmenorrhoea and menorrhagia. There are multiple case reports of MI occurring in the setting of the use of antifibrinolytic agents including tranexamic acid. The present case serves as a warning that, even in patients with an apparently low risk for arterial thrombosis, these drugs may be implicated as a precipitant of MI.