Competitive forces and academic plastic surgery.

Economic constraints developing as a result of rising health care costs in the United States pose significant challenges for and threats to the survival of academic plastic surgery. Declining clinical revenues, competition for patients and resources from other health care providers, and reductions in support of its education and research efforts necessitate a paradigm shift if it is to survive. Questionnaires were used to collect data from 92 of the 100 postgraduate training program directors of plastic surgery in the United States. The most common source of clinical income on a national basis was indemnity insurance. Sources of clinical income varied by region. The majority of programs, 80 percent, report that at least 75 percent of the income support for faculty came from practice income. Financial support for ancillary and research personnel, in large part, came from this same source. Resident salaries and benefits came largely from other resources. Generally as population density within the metropolitan area in which a program was located increased, so too did the number of competing plastic surgeons, including graduates of the program and nonacademic cosmetic and hand surgeons. However, levels of competition for cosmetic surgery in smaller metropolitan areas of some regions seem to be similar to those reported by programs in larger communities. Plastic surgery programs in very competitive communities received significantly greater amounts of their income from indemnity insurance and self-paying patients than did programs in less competitive metropolitan areas. Internal competition from other surgical and nonsurgical specialists within the same institution is likewise keen. Virtually all respondents, 93 percent, report that their institutions provided patient care in a least one designated center of excellence in the following disciplines: hand, microsurgery, craniofacial, cleft lip and palate, burn, and cosmetic surgery. This study suggests that centers of excellence are more likely to be present in metropolitan areas with fewer competing surgeons than in areas with large numbers of competing surgeons. The data did not demonstrate that the presence of a center of excellence substantially affected the sources or levels of clinical income. To survive as an academic entity, program directors must correctly perceive and fulfill the needs and wants of its stakeholders, particularly with regard to quality of life issues.

Tissue repair after Mohs surgery. A plastic surgeon's view.

BACKGROUND: Goals of the treatment for skin cancer include completeness of removal of the lesion, minimal functional disability, and a good aesthetic result. With increasing standards for the quality assurance and the demand for cost-effectiveness, assessment of resource-consuming treatment modalities, especially those involving multidisciplinary approaches, seems appropriate. OBJECTIVE: The purpose of this study was to review the strategy of management and the approaches to tissue repair following cutaneous micrographic surgery from the plastic surgeon's point of view. METHOD: Retrospective review of personal experience based on approximately 800 patients treated between 1989 and 1996 and current plastic surgery literature. RESULTS AND CONCLUSIONS: Teamwork with the Mohs surgeon, recognition of the post-Mohs' procedure wound components, and familiarity with reconstructive techniques are essential for the multidisciplinary practice success. The pitfalls of the reconstructive approaches are discussed.

New trends in skin tumor surgery.

Over 8 years, 1700 patients were referred from the Mohs' Surgery and Cutaneous Laser Unit after Mohs micrographic skin tumor excision to the Division of Plastic and Reconstructive Surgery. Preoperative coordination between the two divisions was emphasised in wound preparation and timing of reconstruction for maximized patient convenience and outcome. Most repairs of facial and extremity defects were carried out under local anesthesia. Techniques of repair were selected based upon algorithmic priorities emphasizing simple techniques over complex ones. Direct closure, skin grafts and flaps were used. Preference for aesthetic subunit reconstruction of the face and the use of particular flap techniques including the O-to-S, O-to-T, V-to-Y island advancement, islandized nasolabial flap for alar reconstruction and the forehead flap for nasal dorsum and tip repair are illustrated.

Transmissibility of live Mycoplasma gallisepticum vaccine strains ts-11 and 6/85 from vaccinated layer pullets to sentinel poultry.

In separate trials, layer pullets were vaccinated with Mycoplasma gallisepticum (MG) strain 6/85 or strain ts-11 commercially produced live vaccines. For a 15-wk postvaccination (PV) period, vaccinates were commingled with unvaccinated pullets and were in indirect contact with sentinel groups of pullets, broiler breeders, turkey breeders, or meat turkeys in adjoining pens. Infectivity and transmissibility of vaccine strains were determined by tracheal culture and serology at 1 wk followed by 3-wk intervals PV. Strain 6/85 was recovered from 0%-20% of vaccinates, but not from commingled pullets or sentinel birds. Strain ts-11 was recovered from 60%-90% of vaccinates and 0%-40% of commingled pullets but not from any of the sentinel birds. No birds in the 6/85 vaccine trial tested positive for MG antibodies by serology. MG enzyme-linked immunosorbent assays detected positive responses in ts-11 vaccinates (range = 10%-70%) at 42, 63, 84, and 105 days PV, and commingled pullets (10%) at 84 and 105 days PV. MG serum plate agglutination tests detected positive responses in 90% and 20% of ts-11 vaccinates at 42 and 105 days PV, respectively, and commingled pullets (10%) at day 42 PV. Clinical signs, morbidity, or mortality suggestive of pathogenic MG infection were not observed in any bird during either trial, and no gross lesions were observed at necropsy. Random amplified polymorphic DNA analysis was capable of distinguishing each of the vaccinal strains 6/85 and ts-11 from each other by their distinct DNA banding patterns.

Infectious bursal disease viral RNA amplification using RT/PCR from bursa tissue following phenol: chloroform inactivation of the virus.

The preservation of viable infectious agents for future studies could create complicated logistic problems, and at times it is not feasible. Methods for preserving the genetic integrity of inactivated agents would not only facilitate these studies but would also make it possible to transport inactivated preparations around the world. In this report, the effect of inactivation on the genetic material of infectious bursal disease virus (IBDV) was studied. Tissues from the bursa of Fabricius of birds experimentally infected 3 days earlier with the classic STC strain of IBDV were collected and immediately placed in a solution of phenol:chloroform:isoamyl alcohol (25:24:1) for 24, 48, 72, or 96 hr. Infected bursal tissue not treated with the phenol:chloroform solution and uninfected phenol: chloroform bursal tissue were used as controls. In a separate experiment, bursal tissues collected 5 days following infection of specific-pathogen-free birds with the classic STC or variant 1084-E strain were placed in the phenol:chloroform solution for 2 wk. All bursal samples were tested for viable IBDV following phenol:chloroform treatment. The tissues were washed in phosphate-buffered saline to remove phenol and then homogenized. Viability of the viruses in homogenized bursal tissue was examined by inoculation of embryonated chicken eggs. Viable IBDV was not observed in any phenol:chloroform-treated bursal tissue but was observed in the infected but non-phenol:chloroform-treated control bursa. The reverse transcriptase/polymerase chain reaction (RT/PCR) was used to test the integrity of the viral RNA. Viral RNA from the nontreated control and all infected bursal samples treated with phenol:chloroform solution at all the time points examined were transcribed into DNA, and a 394-bp fragment of the VP2 gene was amplified using specific primers in the PCR. The RT/PCR assay was negative using the phenol:chloroform-treated uninfected bursal tissue. This study clearly demonstrated that phenol:chloroform treatment of infected bursal tissue inactivated the classic and variant IBDV strains tested and preserved the viral RNA for use in the RT/PCR assay.

Pharmacodynamic modeling of the antihypertensive response to amlodipine.

The distinctive pharmacokinetic characteristics of amlodipine, particularly the long half-life, are presumed to translate directly to a prolonged duration of action, but the concentration-effect relationship for the antihypertensive response has not been clearly established. In this study of 12 patients with essential hypertension, treatment with 5 mg amlodipine once daily has been evaluated with use of an integrated pharmacokinetic-pharmacodynamic model to calculate individual patient responsiveness for the decrease in blood pressure per unit change in drug concentration. Amlodipine concentrations were well correlated with the placebo-corrected reductions in blood pressure in individual patients and responsiveness, for example, for erect systolic blood pressure was -3.1 +/- 0.9 mm Hg/ng/ml. By characterizing the concentration-effect relationships in individual patients, this study has confirmed that the plasma concentration-time profile is an appropriate index of the effect-time profile, as reflected by an antihypertensive response that is sustained throughout 24 hours with relatively little trough-to-peak variability.

Spect brain imaging in neurologic disease.

In recent years cerebral SPECT imaging is rapidly evolving as a clinical tool in the evaluation of a variety of neurologic disorders. In large part, the major advances in brain imaging which have occurred in the last four years are related to new developments in instrumentation and radiopharmaceuticals. In particular, the increased availability of multidetector and dedicated ring detector systems has given rise to improved image resolution and more rapid patient throughput. Advances in the field of radiopharmaceutical development, particularly as it pertains to perfusion brain SPECT agents, has also contributed to the advances in the field. As a result of these developments, there has been an expanded interest in and use of brain SPECT imaging procedures in the evaluation of cerebrovascular disease, dementia, epilepsy, and head trauma.

Reconstruction after Mohs cancer excision.

At our institution, 363 skin defects following Mohs excision for carcinoma were repaired in a two-year period. The majority of the patients were women (62%). Most repairs were to the nose (42%), and almost all followed basal cell carcinoma excision (91% of tumor types). Flaps were preferable to skin grafts for facial repair, with forehead and nasolabial flaps particularly useful for the nose. Injection of Kenalog (triamcinolone acetonide, 5-20 mg/mL) speeds the maturation of scars and flaps.

Consumer satisfaction survey: an outcome measure for work services.

This article describes a consumer satisfaction survey of work services in a community mental health center. The development of a satisfaction survey tool is discussed, the results from 41 respondents are given, and the implications of the survey's results are outlined.

Gastric lesions in the excluded gastric segment undetected by endoscopy or radiography in patients status post vertical banded gastroplasty.

A patient had two surgical revisions and another patient had one surgical revision of a vertical banded gastroplasty because of intraoperative findings of gastric ulceration, incomplete penetration, and transmural penetration of the silicone band. Preoperative esophagogastroduodenoscopy in all three cases and an upper gastrointestinal series in two of the cases failed to demonstrate these lesions, because the lesions were located in the surgically excluded gastric segment. These reports demonstrate that a normal upper gastrointestinal series or panendoscopy in a patient after vertical banded gastroplasty does not exclude significant lesions in the endoscopically inaccessible, excluded gastric segment, and that it may be necessary to perform a laparotomy on a severely symptomatic patient even when an endoscopy is normal.

Complications of nasoenteral tubes. Intragastric tube knotting and intragastric tube breakage.

We report two complications of nasoenteral tubes. A nasogastric tube became knotted during gastric intubation in a patient with a small gastric remnant, created during gastric surgery for morbid obesity. A clogged Dobbhoff tube ruptured while it was being flushed manually with a syringe containing normal saline under great pressure. To retrieve the knotted tube, we grasped the distal knotted part visible in the oropharynx with forceps, pulled it out of the mouth, and cut it. To retrieve the broken tube, we snared the intragastric fragment at endoscopy. These case reports suggest that a small gastric remnant may be a risk factor for nasogastric tube coiling and knot formation and that flushing a clogged tube at high pressure may rupture it. To prevent these complications, a nasogastric tube should be carefully passed just into the stomach in a patient with a small gastric remnant, and a clogged feeding tube should be flushed with only moderate pressure. Failure to clear a blocked tube by flushing with normal saline at moderate pressure should lead to tube removal and not to use of excessive pressure.