Semi-occlusive dressing for the treatment of fingertip amputations with exposed bone: quantity and quality of soft-tissue regeneration.

Nineteen fingertip amputations with exposed bone were treated with a semi-occlusive dressing. The quantity and quality of the regenerated soft tissue was examined. In all 19 fingers there was sufficient uncomplicated healing such that secondary surgical procedures were not needed. At follow-up 6-18 months after the injury, soft tissue thickness around the bone of the distal phalanx measured 6.0 mm (SD 1.6) on the palmar aspect (opposite side 7.0 mm (SD 0.8)) and 4.2 mm (SD 1.7) distally (opposite side 4.5 mm (SD 0.8)). The two-point discrimination was 4 mm (SD 2) (opposite side 3 mm (SD 1)). The skin healed almost without scarring and the dermal ridges reformed. The regeneration of the soft tissue thickness to almost 90% of its former extent is higher than we expected.

[Anaesthesia in patients with maple syrup urine disease. Case report and perioperative anaesthetic management]. / Anästhesie und Ahornsirupkrankheit. Fallbericht und perioperatives anästhesiologisches Management.

Maple syrup urine disease is a rare autosomal-recessive metabolic disorder caused by a deficit of oxidative decarboxylation of branched-chain amino acids. First symptoms appear in the neonatal period. Without treatment the disease is characterized by rapid progression of neurological symptoms. During stressful situations, such as infection or surgery, patients may experience severe ketoacidosis, rapid neurological deterioration and hypoglycemia. The perioperative management of a 26-year-old man with maple syrup urine disease is described, a review of the disease is given and anaesthesia-related implications are discussed.

Fulminant neuroleptic malignant syndrome after perioperative withdrawal of antiParkinsonian medication.

Neuroleptic malignant syndrome is a rare complication when using neuroleptic drugs. We report the case of a patient with severe Parkinson's disease who developed neuroleptic malignant syndrome after withdrawal of his antiParkinsonian medication for elective coronary artery bypass grafting. Sodium dantrolene may be a therapeutic option in severe cases.

Diagnosis of malignant hyperthermia susceptibility during CABG surgery.

A 55-year-old man presented for coronary artery bypass graft (CABG) surgery. Malignant hyperthermia (MH) was suspected in his family. This case report describes a diagnostic approach to obtain a definite MH diagnosis by performing an in vitro contracture test at the time of CABG surgery in combination with molecular genetic investigations.

Survival and potential years of life lost after hip fracture in men and age-matched women.

Hip fracture is associated with a higher mortality rate in men than in women. However, mean age of men and women with hip fracture differs markedly. Thus, some of the differences in the clinical pattern and outcome between genders could be related to different ages. To avoid the influence of age on gender-specific outcome, we analyzed prefracture conditions and hip fracture outcome in a cohort of men and of age-matched women. Risk factors for low bone mass were recorded in 106 men (mean age +/- SD, 80.3 +/- 9.3 years) and 264 age-matched women (mean age 81.4 +/- 8.0) with hip fracture. We compared mortality rate, survival, years of potential life lost and modification of housing conditions. These outcomes were prospectively assessed during an average 3.6 years follow-up (up to 7 years). Men with hip fracture differed from age-matched hip-fractured women by a higher alcohol and tobacco consumption, a greater frequency of living in couple, and by less prevalent fractures. Mortality rate after hip fracture was significantly higher in men (RR = 1.74, 95% CI 1.34-2.24). Since mortality is higher in the general male population, we compared reduction in life expectancy taking into account the gender-specific mortality rate. The excess mortality in each age-group of hip-fractured patients, which was measured during the whole follow-up period, and is an estimate of death attributable to fracture, did not differ between genders. Reduction in life expectancy due to hip fracture was similar in both genders (5.9 +/- 4.5 and 5.8 +/- 4.8 years, in men and women, respectively; NS), but the proportion of the years of life lost was higher in men (70 +/- 33%) than in women (59 +/- 42%, p < 0.01). It was concluded that for the same age, mortality rate after hip fracture was higher in men than in women. Although the reduction in life expectancy was similar in both genders, the proportion of the years of life lost was higher in men, suggesting a worse impact of hip fracture on survival in men, even after consideration of the higher mortality rate in the general male population.

[Takayasu's arteritis--case report and review of the literature]. / Artérite de Takayasu--à propos d'un cas et revue de la littérature.

A 26 year old Albanian woman presented with intermittent claudication of upper limbs in association with alleviation of radial pulses, reduction of arterial pressures, bilateral axillary bruits and subocclusive lesions of proximal part of both humeral arteries on arteriography and MRI. Takayasu's arteritis was diagnosed according to ACR criteria. A treatment of prednisone was started together with methotrexate. The response was favourable and symptoms like claudication and malaise vanished. Takayasu's arteritis is a vasculitis which affects large vessels such as aorta and its main branches. This disease involves mainly premenopausal women; it is very rare in Europe. Diagnosis is lying on clinical features and arteriography results. Treatment of choice is corticosteroids, and immunosuppressors; sometimes a surgical procedure is necessary if stenosis is fixed.

Teaching the use of fiberoptic intubation in anesthetized, spontaneously breathing patients.

UNLABELLED: In patients with difficult airways, the standard of care involves fiberoptic intubation under spontaneous ventilation. However, the safety and feasibility of a fiberoptic intubation teaching program has only been documented in paralyzed and apneic patients, whereas data obtained in patients under spontaneous respiration are limited and conflicting. We evaluated 100 anesthetized patients undergoing orotracheal fiberoptic intubation. Five anesthesia residents with no prior experience in fiberoptic laryngoscopy participated in the study. In a randomized fashion, each participant tracheally intubated 10 spontaneously breathing patients (Group A: sevoflurane anesthesia via an airway endoscopy mask) and 10 paralyzed patients (Group B: total IV anesthesia with propofol, fentanyl, atracurium). Overall rate of success (96%), defined as successful intubation of the trachea within two attempts, was not different between groups. During fiberoptic intubation, Spo2 values remained >95% in Group A, whereas Spo2 decreased to <95% in two patients in Group B. Failure to pass the tube into the trachea over the bronchoscope was encountered in four patients in Group A and in no patient in Group B. Our data suggest that it is safe to teach the use of fiberoptic intubation in anesthetized, spontaneously breathing patients with normal airway anatomy. IMPLICATIONS: Fiberoptic intubation under spontaneous respiration is a well established technique for management of difficult airways. Our study demonstrates the feasibility and safety of a novice training program for fiberoptic intubation under general anesthesia, not only in paralyzed patients but also in those breathing spontaneously.

Protein supplements increase serum insulin-like growth factor-I levels and attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial.

BACKGROUND: Elderly persons who have osteoporotic hip fracture are often undernourished, particularly with respect to protein. Protein malnutrition may contribute to the occurrence and outcome of hip fracture. OBJECTIVE: To investigate whether oral protein supplements benefit bone metabolism in patients with recent hip fracture. DESIGN: 6-month, randomized, double-blind, placebo-controlled trial with a 6-month post-treatment follow-up. SETTING: University orthopedic ward. PATIENTS: 82 patients (mean age, 80.7 +/- 7.4 years) with recent osteoporotic hip fracture. Patients received calcium supplementation, 550 mg/d, and one dose of vitamin D, 200,000 IU (at baseline). INTERVENTION: Protein supplementation, 20 g/d, or isocaloric placebo (among controls). MEASUREMENTS: Bone mineral density, biochemical markers of bone remodeling, calciotropic hormone levels, biochemically evaluated nutritional and immunologic status, and muscle strength were measured every 6 months. RESULTS: Compared with controls, patients who received protein supplements had significantly greater increases in serum levels of insulin-like growth factor-I (85.6% +/- 14.8% and 34.1% +/- 7.2% at 6 months; difference, 51.5 percentage points [95% CI, 18.6 to 84.4 percentage points]; P = 0.003) and an attenuation of the decrease in proximal femur bone mineral density (-2.29% +/- 0.75% and -4.71% +/- 0.77% at 12 months; difference, 2.42 percentage points [CI, 0.26 to 4.59 percentage points]; P = 0.029). Seven and 13 new vertebral deformities were found among patients who received protein supplements and controls, respectively (P > 0.2). Median stay in rehabilitation wards was shorter for patients who received protein supplements than for controls (33 days [CI, 29 to 56 days] and 54 days [CI, 44 to 62 days]; difference, 21 days [CI, 4 to 25 days]; P = 0.018). CONCLUSION: Protein repletion after hip fracture was associated with increased serum levels of insulin-like growth factor-I, attenuation of proximal femur bone loss, and shorter stay in rehabilitation hospitals.

Proteins and bone health.

Hip fracture consecutive to osteoporosis represents a major health problem in terms of both morbidity and financial burden for the community. Deficiency in nutritional elements appear to play a major role in the pathogenesis of osteoporosis and of fractures in elderly. Correction of an inadequate supply in both calcium and vitamin D can reduce bone loss and fracture incidence in elderly subjects. In addition, low protein intake could be particularly detrimental for the conservation of bone integrity with aging. Thus, in hospitalized elderly patients reduced protein intake is associated with lower femoral neck bone mineral density (BMD) and poor physical performance. Furthermore, state of malnutrition or undernutrition is often observed in elderly patients with hip fracture. In these patients, in who we detected very low femoral neck (BMD) at the level of the proximal femur, the self-selected intake of protein and energy was insufficient during their hospitalization. Interestingly, the clinical outcome after hip fracture was significantly improved by daily oral nutritional supplement normalizing the protein intake, documented as a reduction in both complication rate and median duration of hospital stay. Further studies showed that normalization of the protein intake, independently of that of energy, calcium and vitamin D, was responsible for this more favorable outcome, and could prevent further bone loss, at least at the level of weight-bearing cortical bone. In undernourished elderly subjects an increase in the protein intake, from low to normal, could be beneficial for bone integrity. This could act through an increase in the growth factor IGF-1 which has been found to decrease with aging.

A prospective study on socioeconomic aspects of fracture of the proximal femur.

A prospective survey of hip fracture incidence and outcome was conducted to evaluate their socioeconomic impact. Over the course of 1 year, 404 hip fractures were recorded in 339 women and 65 men following minor or moderate trauma. The subjects' ages were 82.8 +/- 10.0 years (mean +/- SD): 84.1 +/- 9.2 in female and 76.4 +/- 13.7 in male subjects. The overall annual incidence was 104.4/100,000; the incidence in women was 167.1 versus 35.3 in men, with a crude female-to-male ratio of 4.7. However, when adjusted for age, this ratio was 2.7. When adjusted to the 1985 U.S.A. population, the incidence rates were 68.6 overall, 108.8 female, and 26.3 male, and were, respectively, 119.1, 188.8, and 46.1 when adjusted to the 1992 Swiss population. As compared with 105 age-matched non-hip-fracture fallers studied in the same emergency ward, fracture subjects lived more often in nursing homes and took cardiovascular drugs (p < 0.001). The mean length of stay in the orthopedic ward was 16.3 +/- 12.0 days (median 14; range 2-193 days), for a total of 6566 bed-days representing 19.8% of available bed-days. The mean length of stay in rehabilitation hospitals was 63.6 +/- 52.6 days (median 50; range 2-349 days), for a total of 17,099 bed-days, representing 5.2% of available bed-days. For patients who where independent before fracture, the greater length of stay was associated with advanced age and consumption of cardiovascular drugs. The total cost of hospital stay amounted to approximately $44,000 per patient. Mortality was 3.2% in the orthopedic ward and 10.8% in rehabilitation hospitals, for an overall in-hospital mortality rate of 10.4%. Overall, the 1-year mortality was 23.8% (21.5% for women and 35.4% for men), and it was significantly higher than in the general population (p < 0.001). Prognostic factors for mortality were age, sex, consumption of cardiovascular drugs, and previous living circumstances. One year after fracture, 62.6% of the fracture patients had returned to their previous living circumstances, but 17.9% needed a more care-intensive environment. The likelihood of returning to autonomous living circumstances 1 year after fracture was higher in younger subjects, in females, in those living with a partner, and in those in overall better health before the fracture. This prospective survey highlights the high socioeconomic impact and burden of osteoporotic fractures of the proximal femur.

Nutritional aspects of hip fractures.

Prevalence of malnutrition, particularly undernutrition, increases with advancing age, and patients with hip fracture are often particularly malnourished and/or undernourished. Deficiency in both micronutrients and macronutrients appears to be strongly implicated in the pathogenesis and the consequences of hip fracture in osteoporotic elderly. Such deficiencies can accelerate age-dependent bone loss, increase the propensity to fall by impairing movement coordination, and affect protective mechanisms that reduce the impact of falling. With respect to micronutrients, the most documented information concerns calcium and vitamin D. Studies conducted in the elderly have shown that administration of calcium and vitamin D can reduce femoral bone loss and, in institutionalized patients, lower the incidence of hip fracture. Besides hypovitaminosis D, deficiency in vitamin K has been suggested to contribute to bone fragility in patients sustaining hip fracture. As far as macronutrients are concerned, low protein intake appears to play a distinct detrimental role in the causes and complications of hip fracture. In a recent survey in hospitalized elderly patients, reduced protein intake was associated with lower femoral neck bone mineral density (BMD) and poor physical performance. This observation is in keeping with several studies in which a state of energy-protein malnutrition was documented in elderly patients with hip fracture. In these patients, in whom we detected very low femoral neck bone mineral density at the level of the proximal femur, the self-selected intake of protein and energy was insufficient during their hospital stay. Interestingly, the clinical outcome after hip fracture was significantly improved by daily oral nutritional supplement normalizing the protein intake, documented as a reduction in both complication rate and median duration of hospital stay. Further studies showed that normalization of the protein intake, independently of that of energy, calcium, and vitamin D, was responsible for this more favorable outcome. Preliminary data suggest that protein supplementation may also reduce further bone loss in elderly patients having sustained hip fracture. Increasing the protein intake from low to normal could act through an increase in the plasma level of IGF-I, a growth factor that exerts a positive effect on bone mass and that has been found to decrease with aging.

Cold follicles in a multinodular human goiter arise partly from a failing iodide pump and partly from deficient iodine organification.

To investigate whether the common cold follicles in human multinodular goiters are the consequence of a functional defect of the apical membrane peroxidase, a failure of the iodide transport system, or both deficiencies, we studied iodide accumulation and iodine organification in 30 fragments of a large multinodular goiter transplanted to nude mice and labeled with 125I. Transplants were frozen to -80 C immediately after removal to avoid diffusion of inorganic iodide. Autoradiographic assessment of over 1000 cryosections (exposed either at -20 C or after thawing and washing out unbound iodide) showed two types of cold follicles, namely those that failed to accumulate iodide and, therefore, did not organify iodine, and those that readily accumulated iodide but failed to bind it, suggesting a failure of apical membrane peroxidase. The two types of pathogenetically different cold follicles coexisted in an apparently randomly intermingled fashion throughout the whole goiter.