50 Shades of Red: The Predictive Value of Closed Suction Drains for the Detection of Postoperative Bleeding in Breast Surgery.

BACKGROUND: While closed suction drains (CSDs) are still frequently employed in clinical practice, the supporting evidence is limited with some studies demonstrating a failure of routine CSD use in preventing hematoma or seroma. Nonetheless, CSD quantity and quality fluid assessment is still appreciated by clinicians to detect postoperative bleeding. This study investigates the value of routine CSD use, in breast surgery, to predict postoperative bleeding. METHODS: A retrospective, intra-individual analysis, of CSD fluid volumes between the hematoma side and the unaffected contralateral breast, was undertaken in patients (n = 20) with unilateral postoperative bleeding following bilateral breast surgery (2003-2018). Statistical analysis was undertaken to establish a minimum cutoff fluid volume that might assist in the detection of postoperative bleeding. To determine the usefulness of quality assessment of CSD fluid output by visual inspection, surgeons (n = 56) prospectively matched six eligible hemoglobin concentrations corresponding to pre-filled CSDs. RESULTS: Statistical analysis did not yield a clinically reliable cutoff fluid volume indicating postoperative bleeding. All six eligible hemoglobin concentrations were completely successfully matched to pre-filled CSDs by 30.4% (17/56) of surgeons. CONCLUSIONS: This study questions the significance of routine CSD use to assist in the decision-making process to return to the theater and address postoperative bleeding. Quantity as well as quality analysis of CSD fluid output failed the reliability and diagnostic validity tests. Hemoglobin measurements in drain fluid specimens via blood gas analysis might contribute to the detection of postoperative bleeding. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evidence based postoperative treatment of distal radius fractures following internal locking plate fixation.

Originally, the treatment method of choice for distal radial fractures (DRF) has been a non-operative approach with six to eight weeks of plaster casting. The introduction of volar locking plate systems at the beginning of the 21 st century has pushed trends towards open reduction and internal fixation (ORIF). While the introduction of fixed angle locking plates together with the increasing knowledge on wrist function and related variable outcomes has led to consensus that operative fixation in instable DRF is the treatment method of choice, there is no agreement on a postoperative care of these injuries. The authors will discuss the available evidence for current concepts of postoperative treatment of DRFs following fixed angle fixation under socioeconomical, biomechanical and burden of disease aspects. Further, relevant randomized controlled trials are evaluated with regard to applied postoperative treatment regimes and related risks for complications.

A favorable donor site in microsurgery: Nerve and vein graft harvest from the dorsum of the foot.

BACKGROUND AND OBJECTIVES: In complex hand traumas nerves and vessels are often destructed without the possibility for primary repair. For bridging defects of nerves, veins and arteries grafts are necessary. Commonly nerve and vein grafts from adjacent donor sites as the wrist, forearm or cubital region are harvested. METHODS: This study is a retrospective cohort study. Between 2017 and 2019, 10 patients with complex hand injuries were treated. There were 8 males and 2 females, with an average age of 39 years (range 8-63 years). In all cases grafts were used of the dorsum of the foot for reconstructing of the severed digital nerves and arteries. All donor sites could be closed primarily. RESULTS: In 100% of cases nerves and veins of the dorsum of the foot showed a good size match as well as adequate length for a sufficient repair. The overall Hand Injury Severity Score (HISS) was determined with a median of 86 (range 57 to 286). In the area of the donor site no relevant complications were seen. CONCLUSIONS: In complex hand injuries the dorsum of the foot is a favorable donor site for nerve and vein graft harvest.

Iron diapirs entrain silicates to the core and initiate thermochemical plumes.

Segregation of the iron core from rocky silicates is a massive evolutionary event in planetary accretion, yet the process of metal segregation remains obscure, due to obstacles in simulating the extreme physical properties of liquid iron and silicates at finite length scales. We present new experimental results studying gravitational instability of an emulsified liquid gallium layer, initially at rest at the interface between two glucose solutions. Metal settling coats liquid metal drops with a film of low density material. The emulsified metal pond descends as a coherent Rayleigh-Taylor instability with a trailing fluid-filled conduit. Scaling to planetary interiors and high pressure mineral experiments indicates that molten silicates and volatiles are entrained toward the iron core and initiate buoyant thermochemical plumes that later oxidize and hydrate the upper mantle. Surface volcanism from thermochemical plumes releases oxygen and volatiles linking atmospheric growth to the Earth's mantle and core processes.

Vasopressor support vs. liberal fluid administration in deep inferior epigastric perforator (DIEP) free flap breast reconstruction - a randomized controlled trial.

BACKGROUND: Perioperatively, patients' hemodynamics are modulated predominantly by intravenous fluid administration and vasoactive pharmacological support. Vasopressor agents are suspected to be detrimental on free flap survival by the cause of vasoconstriction of the pedicle with consecutive reduced overall flap perfusion and by aggravation of flap dissection. OBJECTIVE: A novel, standardized fluid restrictive perioperative hemodynamic management was assessed for its feasibility in clinical practice in free flap patients undergoing breast reconstruction. METHODS: Patients were randomized to two perioperative regimens with different fluid and vasopressor limits. The primary endpoint regarded flap survival. Secondary endpoints included surgery times, time of patient ambulation and length of hospital stay. RESULTS: There was one total flap failure with liberal fluid administration (LFA). No total or partial flap failure was noted in the fluid restrictive regimen with norepinephrine administration up to 0.04µg/kg/min (FRV). No delay regarding operation time (p = 0.217), patient mobilization (p = 0.550) or hospital discharge (p = 0.662) was registered in the FRV study subpopulation compared to LFA. CONCLUSIONS: The results of this prospective interventional trial could not detect any negative impact of vasopressors, neither for the primary endpoint of flap survival nor for the overall patient outcome. The fear of vasopressor associated flap complications has led to a traditional liberal fluid administration, which failed to demonstrate any benefits when compared to a fluid restrictive vasopressor strategy.

Circulating serum CK level vs. muscle impairment for in situ monitoring burden of disease in Mdx-mice.

BACKGROUND: Duchenne muscular dystrophy (DMD) consists of a lack in the expression of the subsarcolemmal protein dystrophin causing progressive muscle dysfunction. Among the widely applied animal models in DMD research is the C57BL/1010ScSn-Dmdmdx mouse, commonly referred to as the "mdx mouse". The potential benefit of novel interventions in this model is often assessed by variables such as functional improvement, histological changes, and creatine kinase (CK) serum levels as an indicator for the extent of in situ muscle damage. OBJECTIVE: Our objective was to determine to what extent the serum CK-level serves a surrogate for muscle dysfunction. METHODS: In this trial mdx mice were subjected to a four-limb wire-hanging test (WHT) to assess the physical performance as a reference for muscle function. As CK is a component of the muscle fiber cytosol, its serum activity is supposed to positively correlate with progressing muscle damage. Hence serum CK levels were measured to detect the degree of muscle impairment. The functional tests and the serum CK levels were analyzed for their specific correlation. RESULTS: Although physical performance decreased during the course of the experiment, latency to fall times in the WHT did not correlate with the CK level in mdx mice. CONCLUSION: Our data suggests that the serum CK activity might be a critical parameter to monitor the progression of muscle impairment in mdx mice. Further this study emphasizes the complexity of the DMD phenotype in the mdx mouse, and the care with which isolated parameters in this model should be interpreted.

Composition of a photosystem I chlorophyll protein complex from Anabaena flos-aquae.

The use of Triton X-100 to solubilize membrane fragments from Anabaena flos-aquae in conjunction with DEAE cellulose chromatography allows the separation of three green fractions. Fraction 1 is detergent-solubilized chlorophyll, and Fraction 2 contains one polypeptide in the 15 kdalton area. Fraction 3, which contains most of the chlorophyll and shows P-700 and photosystem I activity, shows by SDS gel electrophoresis varying polypeptide profiles which reflect the presence of four fundamental bands as well as varying amounts of other polypeptides which appear to be aggregates containing the 15 kdalton polypeptide. The four fundamental bands are designated Band I at 120, Band II at 52, Band III at 46, and Band IV at 15 kdaltons. Band I obtained using 0.1% SDS contains chlorophyll and P-700 associated with it. When this band is cut out and rerun, the 120 kdalton band is lost, but significant increases occur in the intensities of Bands II, III, and IV as well as other polypeptides in the 20-30 kdalton range. The use of 1% Triton X-100 coupled with sucrose density gradient centrifugation allows the separation of three green bands at 10, 25 and 40% sucrose. The 10% layer contains a major polypeptide which appears to be Band IV. The 25 and 40% layers show essentially similar polypeptide profiles, resembling Fraction 3 in this regard, except that the 40% layer shows a marked decrease in Band III. Treatment of the material layering at the 40% sucrose level with a higher (4%) concentration of Triton X-100 causes a loss (disaggregation) of the polypeptides occurring in the 60-80 kdalton region and in increase in the lower molecular weight polypeptides. Thus, aggregation of the lower molecular weight polypeptides accounts for the variability seen in the electrophoresis patterns. Possible relations of the principal polypeptides to the known photochemical functions in the original membrane are discussed.

Photophosphorylation and related properties of reaggregated vesicles from spinach photosystem I particles.

The small Photosystem I particles prepared from spinach chloroplasts by the action of Triton X-100 (TSF 1 particles) reaggregate into membrane structures when they are incubated with soybean phospholipids and cholate and then subjected to a slow dialysis. The membranes so formed are vesicular in nature and show the capability of catalyzing phenazine methosulfate-mediated cyclic photophosphorylation at rates which are usually about 20% of those observed with chloroplasts, but higher rates have been obtained. When coupling factor is removed from the chloroplasts by treatment with EDTA, a requirement for coupling factor can be shown for the subsequent ATP formation. The uncouplers carbonylcyanide 3-chlorophenyl-hydrazone, valinomycin, Triton X-100 and NH+4 are effective with the reformed vesicles, which do not show the typical light-induced pH gradient observed with chloroplasts. Incubation of the TSF 1 particles with phospholipids alone allows for the formation of membrane vesicles, but such vesicles are only slightly active in ATP formation. In most properties investigated, the reformed membrane vesicles resemble the original chloroplast membrane so far as phenazine methosulfate-mediated cyclic photophosphorylation is concerned, which indicates a high degree of selectivity in the reaggregation process. The major difference between chloroplasts and the reformed vesicles is the failure of the latter to show a light-induced pH gradient.

Human liver carbamazepine metabolism. Role of CYP3A4 and CYP2C8 in 10,11-epoxide formation.

A number of drugs inhibit the metabolism of carbamazepine catalyzed by cytochrome P450, sometimes resulting in carbamazepine intoxication. However, there is little information available concerning the identity of the specific isoforms of P450 responsible for the metabolism of this drug. This study addressed the role of CYP3A4 in the formation of carbamazepine-10,11-epoxide, the major metabolite of carbamazepine. Results of the study showed that: (1) purified CYP3A4 catalyzed 10,11-epoxidation; (2) cDNA-expressed CYP3A4 catalyzed 10,11-epoxidation (Vmax = 1730 pmol/min/nmol P450, Km = 442 microM); (3) the rate of 10,11-epoxidation correlated with CYP3A4 content in microsomes from sixteen human livers (r2 = 0.57, P < 0.001); (4) triacetyloleandomycin and anti-CYP3A4 IgG reduced 10,11-epoxidation to 31 +/- 6% (sixteen livers) and 43 +/- 2% (four livers) of control rates, respectively; and (5) microsomal 10,11-epoxidation but not phenol formation was activated 2- to 3-fold by alpha-naphthoflavone and progesterone and by carbamazepine itself (substrate activation). These findings indicate that CYP3A4 is the principal catalyst of 10,11-epoxide formation in human liver. Experiments utilizing a panel of P450 isoform selective inhibitors also suggested a minor involvement of CYP2C8 in liver microsomal 10,11-epoxidation. Epoxidation by CYP2C8 was confirmed in incubations of carbamazepine with cDNA-expressed CYP2C8. The role of CYP3A4 in the major pathway of carbamazepine elimination is consistent with the number of inhibitory drug interactions associated with its clinical use, interactions that result from a perturbation of CYP3A4 catalytic activity.

New murine cell line derived from a spontaneous lung tumor induces paraneoplastic syndromes.

LP07 is a new cell line derived from P07 lung tumor, spontaneously arisen in a BALB/c mouse. LP07 is composed of heterogeneous epithelioid polyhedric cells that proliferate at a slow rate, have low plating efficiency and are unable to grow in soft agar. Only some LP07 cells expressed cytokeratins while most of them were positive for vimentin. Ultrastructure studies showed that LP07 cells established rudimentary intercellular unions, formed glandular-like conducts and presented conspicuous secretory granules, suggesting an epithelial-glandular origin, with neuroendocrine components. Upon injection LP07 cells formed poorly differentiated non-invasive adenocarcinomas, and tumor bearing mice developed leukocytosis, hypercalcemia and cachexia. This tumor cell line constitutes a useful tool to study lung tumor biology and paraneoplastic syndromes.

Effect of tyrosine kinase inhibition on sepsis-induced vascular hyporesponsiveness, inos mrna expression and NF-kappaB nuclear translocation in rats.

The dependence of the critical steps in the sepsis cascade on the transcription factor NF-kappaB andation to nitric oxide (NO) production are controversial. Tyrosine kinase (TK) is involved in several of the steps, and TK inhibitors (TKI) inhibit lipopolysaccharide (LPS)-induced vascular hyporesponsiveness in septic animals. We studied the relationship of TK inhibition, hemodynamics, vascular contraction, iNOS mRNA expression and NF-kappaB translocation in anesthetized endotoxic rats. The TKI AG556 (2.5 mg/kg i.p.), given 1 h before i.v. endotoxin (LPS) resulted in attenuation of early (<60 min) and late (60-120 min) hypotension, improved contraction of mesenteric arteries to norepinephrine 4 h after LPS, and attenuated tissue iNOS mRNA expression. LPS-induced NF-kappaB translocation was unaffected. The observed dissociation between NF-kappaB translocation and the salutary effect of TKI in vivo and ex vivo and its effect on iNOS mRNA expression suggest that although NF-kappaB may be involved in the sepsis cascade, it may not be essential for some of the molecular and vascular consequences of septic shock.

Asherman's syndrome: a critique and current review.

PIP: Asherman's syndrome is described in today's context. Meaningful literature as it relates to the description and management of this entity is reviewed, and the forms of treatment used at the Hospital of the University of Pennsylvania or at the Philadelphia General Hospital are presented. Asherman's syndrome describes a variable amount of destruction of the endometrial cavity, diminished menstrual flow, infertility, and repeated pregnancy loss. The incidence of Asherman's syndrome was believed to be low, but Eriksen reported a 20-25% incidence of intrauterine adhesions of some degree in all patients treated with a dilatation and curettage within 2 months after delivery. The number of cases of Asherman's syndrome reported by other authors is unusually high, and a table of inferred incidence and therapeutic approaches is included. The main symptoms of Asherman's syndrome are infertility, secondary amenorrhea, cyclic painful hypoamenorrhea, menstrual irregularities, and habitual abortion. 11 patients with Asherman's syndrome presenting as intrauterine distortion and diminished menstrual flow were treated at the Department of Obstetics and Gynecology of the University of Pennsylvania, at the Hospital of the University of Pennsylvania, or at the Philadelphia General Hospital during the interval between July 19678 and June 1972. The patients ranged in age from 22-37. 6 were referred for infertility, and 5 were diagnosed during the course of delivery of primary care. The therapeutic regimes which were used for most of these patients are listed in a table. The approach consisted of careful sounding of the uterine cavity, followed by dilatation and curettage with histologic examination. A pediatric Foley catheter was inserted into the uterine cavity and the bag was filled to a 3-ml volume. Conjugated estrogens were given at dosages of 5.0-7.5 mg daily in divided doses. The estrogen dose was increased in instances of breakthrough bleeding. Broad-spectrum antibiotics were initiated preoperatively in most cases. The Foley catheter was removed after 5-7 days. Antibiotics were continued for a week to 10 days, and the estrogens were continued for 21 days. It was possible to reestablish normal menstrual patterns in 6 of the 7 women with severe disease. Pregnancies were established in 4 of these patients. There were 2 spontaneous abortions. In patients with moderate disease, a return to normal menstrual pattern occurred in all instances, but only 2 became pregnant. 1 pregnancy went to term, and the other is still in progress.^ieng

Anxiety, vocalization, and agitation following peripheral nerve block with ropivacaine.

BACKGROUND AND OBJECTIVES: Central nervous system (CNS) and cardiovascular toxicity are potential side effects of local anesthetics. However, ropivacaine has been reported to be less CNS toxic than bupivacaine in human volunteers. METHODS: We describe three cases of peripheral nerve blockade with ropivacaine that resulted in unusual symptoms of CNS toxicity. RESULTS: In three patients, unexpected behavioral changes occurred during administration of ropivacaine. The patients became extremely agitated, anxious, and screamed, and they did not respond to verbal commands. CONCLUSION: This case report shows that ropivacaine may cause CNS toxicity that differs from classical signs of local anesthetic-induced toxicity. This effect might be related to the unique structure of ropivacaine, which is formulated in an S-enantiomer preparation. It has been shown that S-enantiomers bind differently to receptors in both the CNS and cardiovascular systems. This property may account for the disinhibition of select neural pathways that are specifically involved in mediation of anxiety and aggression.

Paravertebral somatic nerve block for outpatient inguinal herniorrhaphy: an expanded case report of 22 patients.

BACKGROUND AND OBJECTIVES: Inguinal herniorrhaphy is a common outpatient surgical procedure. However, anesthetic techniques for inguinal herniorrhaphy are still associated with numerous side effects. Paravertebral somatic nerve block (PSNB) has the potential advantage to offer unilateral abdominal wall anesthesia and long-lasting pain relief with minimal side effects. We report our initial trial of PSNB for outpatient inguinal herniorrhaphy. METHODS: Twenty-two patients received a PSNB at T10 to L2 using 5 mL of 0.5% bupivacaine with epinephrine 1:400,000 at each of the five levels. The onset of surgical anesthesia, duration of analgesia, side effects, and patient satisfaction with the technique were documented. RESULTS: Surgical anesthesia occurred 15-30 minutes after injection. Two patients had a failed block. The mean +/- SD time to onset of discomfort was 14 +/- 11 hours. Time until first narcotic requirement was 22 +/- 18 hours. Thirteen patients (n = 20) had no incisional discomfort 10 hours or longer after their blocks. Three patients had epidural spread. Most patients were very satisfied with their anesthetic technique. CONCLUSIONS: The results of our initial experience suggest that PSNB is a potentially safe and effective technique. In general, the block provided long-lasting pain relief in most patients with few side effects. A randomized study comparing paravertebral blocks with conventional anesthesia choices is suggested given the findings in this initial series of patients.

Continuous peripheral nerve block for ambulatory surgery.

BACKGROUND AND OBJECTIVES: Continuous peripheral nerve block (CPNB) can provide surgical anesthesia, prolonged postoperative analgesia, and acceptable side effects. Despite these advantages, CPNB is not in widespread use. Recently a new CPNB catheter system (Contiplex, B. Braun, Bethlehem, PA) was developed based on an insulated Tuohy needle, which allows for injection of local anesthetic and catheter insertion without disconnection or needle movement. At present, no clinical studies exist describing this system. METHODS: Data were prospectively gathered for 1 year from 228 patients in an ambulatory surgery center. All CPNB were performed using the Contiplex system to provide anesthesia and postoperative analgesia. CPNB were performed using 5 upper and lower extremity techniques. Postsurgery local anesthetic was infused and at 24 hours, a rebolus of local anesthetic was performed. The CPNB catheter was removed and patients were examined for loss of sensation. Patients were then discharged. RESULTS: Initial peripheral block was successful in 94% of patients. Failed nerve block requiring general anesthesia occurred in 6%. The catheter was patent and functional in 90% of patients at 24 hours, and 8% of patients required more than 10 mg of intravenous morphine by 24 hours postsurgery. In the postanesthesia care unit (PACU), only 4 patients (1.7%) required treatment for nausea. At 24 hours and 7 days postsurgery, no patient reported a dysesthesia. CONCLUSIONS: CPNB using the insulated Tuohy catheter system offered acceptable anesthesia and prolonged pain relief postsurgery. There were few side effects. Reg Anesth Pain Med 2001;26:209-214.

FM amplification for enhancement of conversational discourse skills: case study.

The purpose of this single-subject pilot study was to examine the efficacy of FM amplification for enhancing the discourse skills of a 4-year-old girl with a history of speech-language impairments, otitis media with effusion (OME), and motoric delays. Over a period of several weeks, language treatment sessions were conducted with and without FM amplification, in a classroom setting. Sessions were videotaped and analyzed for the appropriateness and effectiveness of the subject's conversational turns during sessions with amplification and with no amplification. Although the number of sessions was small, more appropriate and effective conversational turns occurred during sessions with amplification.

Pressure monitoring during lipofilling procedures.

BACKGROUND: Grafting of autologous lipoaspirate for various clinical applications has become a common procedure in clinical practice. With an estimated mortality rate of 10-15 percent, fat embolism is among the most severe complications to be expected after lipofilling therapies. OBJECTIVE: The aim of this study was to determine the level of interstitial pressure after the injection of defined volumes of lipoaspirate into the subcutaneous tissue of female breasts. It was hypothesized, that interstitial pressure levels exceed the physiologic capillary pressure during lipofilling procedures and hence increase the potential risk for fat embolism. Further it was investigated if external tissue expansion has the potential to significantly reduce interstitial tissue pressure. METHODS: Interstitial pressure was monitored in 36 female patients, that underwent autologous fat injections into the breast. Measurements were conducted with a sensor needle connected to a pressure transducer (LogiCal Pressure Monitoring Kit, Smiths medical int. Ltd., UK). Patients were divided into 4 subcohorts differing in their pre-treatment regimen or local tissue conditions. Pre-treatment consisted of tissue expansion, achieved with the Brava™ (Brava LLC Miami, Fla., USA) vacuum-chamber. RESULTS: The increase in interstitial pressure after injection volumes of 100 ml (p = 0.006), 200 ml (p = 0.000) and between 100 ml and 200 ml (p = 0.004) respectively, were significant in non-mastectomized patients without pre-treatment. Patients pre-treated with Brava™ did not show such statistically significant differences in interstitial pressures before and after the injection of 100 ml and 200 ml of lipoaspirate (p = 0.178). The difference in interstitial pressure in mastectomized patients between 0 ml and 100 ml (p = 0.003), as well as 0 ml and 200 ml (p = 0.028) was significant. The difference in pressures between pre-treated patients and patients without pre-treatment did not differ significantly in the mastectomized patient cohort. CONCLUSION: During lipofilling procedures interstitial pressures are reached that exceed pressure limits defined as hazardous for fat embolism. To date it is unknown what pressure levels need to be considered critical for complications in soft tissue interventions. Further the results indicate higher interstitial pressures for patients that had undergone mastectomy, whereas pre-treatment with external tissue expansion seemed to diminish pressure values.