Methotrexate-induced hepatic necrosis requiring liver transplantation in a patient with rheumatoid arthritis.

MTX-induced hepatic injury and liver enzyme elevations have been demonstrated after treatment of leukemia, gestational disease and during treatment of psoriasis and rheumatoid arthritis. A 40-year-old man with a long standing history of rheumatoid arthritis was treated with MTX over a 6 month period and developed an overwhelming hepatic necrosis. He was successfully transplanted.

Portable fluoroscopy in the management of zygomatic arch fractures.

Operative methods that do not allow intraoperative visualization of the fracture fragments in patients with isolated zygomatic arch fractures often result in inadequate reduction. This article describes a technique using a portable, surgeon-operated fluoroscopic machine that can be used preoperatively, intraoperatively, and postoperatively in patients with isolated zygomatic arch fractures. Using the portable fluoroscopic unit, reduction of isolated zygomatic arch fractures was performed in 9 consecutive patients over a period of 1.5 years. Postoperative alignment was confirmed using computed tomography (CT). These CT images were compared with the fluoroscopic images in several of the patients. Eight of the nine fractures were reduced via an intraoral approach and one through a Gillies approach. All nine fractures were easily visualized and their reductions were confirmed with intraoperative dynamic visualization using a portable fluoroscopic unit. Postoperative CT revealed images of the reduction that were comparable with intraoperative and postoperative fluoroscopic images. The use of portable fluoroscopy intraoperatively allows for dynamic visualization of instrumentation and the immediate confirmation of the adequacy of fracture reduction. Moreover, this technique may eliminate the need for postoperative CT in isolated zygomatic arch fractures. Portable fluoroscopy may also have a place in the management of certain zygomatic complex fractures.

Cross-sectional area of the mandible.

PURPOSE: The anatomy of the mandible was examined by measuring the cross-sectional area (CSA) of multiple regions of 10 fully dentulous hemimandibles to provide a better understanding of regional structural differences that may have implications regarding biomechanical strength, surgical reconstruction, and fracture site frequency. MATERIALS AND METHODS: Fifteen cuts from the condyle to the symphysis were made of each hemimandible (n = 150 cuts). A Zeiss Videoplan digitizer was used to determine the CSA. RESULTS: The total CSA through the condyle was greater than the CSA through the condylar neck. The CSA through the ramus exceeded that of the condylar neck. The total CSA of the midramus was significantly greater than that of the upper ramus. The total CSA at the body, parasymphysis, and symphysis was significantly greater than at the mid-angle. The total CSA of the cortex increased anteriorly; these differences become significant between the condylar neck and the body, parasymphysis, and symphysis. The total CSA, and the CSA of the cortex and spongiosa, remained relatively constant from the inferior angle anteriorly. CONCLUSIONS: Significant differences exist in the CSA at different points, with an increase in the total, cortical, and spongiosal CSA anteriorly from the condylar neck to the angle. The total CSA and the CSA of the cortex and spongiosa remain relatively constant anterior to the inferior angle. These data suggest that bony CSA alone is not the sole factor in determining fracture site frequency.

Preexpanded radial forearm free flap to the scalp.

The radial forearm flap is a versatile tool for the reconstructive surgeon because of its thinness, durable skin quality, aesthetic match, and relative ease of dissection. This flap is an ideal candidate for reconstruction of head and neck defects. One of the drawbacks is its relative small size, which may limit its use in certain applications. We describe the preexpansion of the radial forearm flap for its use in covering a large scalp defect. Preexpansion of the radial forearm free flap enables the reconstructive surgeon to increase the size of the flap markedly without altering its neurovascular anatomic relationships. Also described is the unexpected benefit of a periprosthetic capsule that covers the flexor tendons of the forearm and acts as an excellent bed for a skin graft.

Nonenzymatic isolation and culture of adult islets from atrophic pancreata of copper-deficient rats: a morphologic analysis.

The purpose of this study was to develop a nonenzymatic method of isolating adult islets using atrophied pancreata from copper-deficient rats and to analyze their morphologic characteristics and behavior in culture. This unusual model of isolation was studied because islets remain intact in the course of dietary copper deficiency while the acinar glandular component of the pancreas undergoes selective atrophy and lipomatosis. Small fragments containing islets were readily microdissected from atrophied glands and placed in culture. Within 24 h the fragments congealed into small irregular- to spherical-shaped masses within which the darker profile of islets could be distinguished. Within a period of 3 to 5 d, islet tissue began to bud from the lipocytic mass until by Day 7 spherical aggregates of intact islet tissue separated from the residual fragments. Subsequent to further in vitro treatment, these islets could be maintained as free viable spherical masses if periodically agitated, as attached stationary islets which developed monolayer growth if left undisturbed and as aggregated masses of islet tissue forming megaislets if combined in small groups. Grouped islets treated with actinomycin D and cycloheximide did not exhibit aggregation when incubated with these inhibitors. This suggests that megaislet formation was an active process requiring protein-RNA synthesis rather than passive clumping or aggregation that can accompany metabolically altered or dying islets undergoing cellular shedding and adhesion. Immunohistochemical localization demonstrated that insulin, glucagon, somatostatin, and pancreatic polypeptide-immunoreactive cell types were present within the islets derived from this technique. The cellular topography of these islets was not unlike that described by others for islets cultured from enzymatic isolation. This culture model may serve as a resource for mature, viable islets isolated without mechanical or enzymatic disaggregation which can have attenuating effects on islet function.