Otolaryngology resident experience with supraclavicular, submental and other regional flaps in the United States.

OBJECTIVE: Despite the resurgence in regional flap use, otolaryngology resident regional flap experience has been incompletely studied. We sought to characterize United States (US) otolaryngology resident exposure to, and perceptions of, supraclavicular flaps (SCFs), submental flaps (SMFs), and other regional flaps. METHODS: An online survey was disseminated every two weeks to 106 US otolaryngology residency program directors for distribution to residents within their programs between August and October 2016. 121 surveys were returned of which 106 were sufficiently completed and eligible for data analysis. RESULTS: Among residents with adequate responses, 52 were postgraduate year (PGY) 1-3 (junior) residents and 54 were PGY 4-7 (senior) residents. Senior residents participated in more pectoralis major flaps (mean: 8.1, 95%-CI: 6.5-9.8) compared to SCFs (mean: 1.5, 95%-CI: 1.0-2.0, p < 0.001) and SMFs (mean: 0.7; 95%-CI: 0.4-1.0, p < 0.001). Among senior residents exposed to SCFs, SMFs and pectoralis flaps, more individuals judged pectoralis major flaps as successful or very successful (96.2%, 95%-CI: 91.1-100%), compared to SCFs (64.3%, 95%-CI: 46.5-82.0%; p < 0.001) and SMFs (63.2%, 95%-CI: 41.5-84.8%; p = 0.001). CONCLUSIONS: Senior otolaryngology residents were exposed to fewer SCFs and SMFs compared to pectoralis major flaps. Resident perception that SCFs and SMFs were not as successful as pectoralis major flaps should be investigated further.

Cross-national comparison of population density.

The unresolved difficulties associated with defining and measuring population density strictly circumscribe the scope and nature of the conclusions that can be properly derived from differentials in man:land ratios. Any conclusions about human density will have meaning only to the extent that they are based on a recognition that this density must be viewed in both static and dynamic terms and that it cannot be isolated in analysis, from either the social and cultural setting, the demographic characteristics of the population, or the broader processes of social change within the society. In and of itself, the familiar man:land ratio says more about area than it does about either the human experience of density or the relation of population to resources. This ratio is therefore essentially meaningless as an indicator of comparative conditions of life among different countries and different geographic regions. The mere fact of having a relatively low average population density thus, does not automatically entitle a nation to complacency about its ability to adjust readily to future population change, either in terms of growth in numbers or in the geographic location of its people.

Endogenous caloric sources and nitrogen balance: regulation in postoperative patients.

Twenty-three postoperative patients were divided into three groups to evaluate the peripheral vein administration of solutions containing glucose, amino acids, or glucose and amino acids. Serum insulin, glucose, and nitrogen balances were monitored in each patient. Serum insulin concentrations rose on the first postoperative day in all three groups, then fell to near preoperative levels by the third day after surgery. Negative nitrogen balance was most pronounced in patients recieving glucose only. Patients receiving only amino acids had a reduction in nitrogen balance, but some protein catabolism was present. The mean nitrogen balance in patients who received a combination of these solutions was positive on days one and two after surgery and slightly negative on the third postoperative day. These changes were not significantly better than the amino acid group. However, the combination group had 12 to 21 days of positive balance, as compared to seven of 20 days in the amino acid group. Since starvation adaptation accurs gradually, it is concluded that the simplest and safest way to reduce protein catabolism in the immediate postoperative period is by the peripheral intravenous administration of both glucose and amino acids.

Nitrogen balance in adult hospitalized patients with the use of a pediatric amino acid model.

Normalization of plasma amino acid patterns and that relationship to improved nitrogen balance was studied using a pediatric-specific amino acid solution in 21 adults requiring total parenteral nutrition therapy. There was a significantly positive correlation between improved nitrogen balance and the amino acids cystine, tyrosine, total cysteine/cystine, and ornithine. When additional cysteine was added to the solution of 11 subjects, taurine also correlated with nitrogen balance. Despite higher amounts of histidine in solution, plasma amino acid levels were not normalized. These amino acids, heretofore considered nonessential, may be required in specific molar ratios in stress. The use of a 30% branched-chain pediatric-balanced amino acid solution resulted in near normalization of plasma amino acid levels and group mean positive nitrogen balance.

Indirect calorimetry as a guide to caloric replacement during total parenteral nutrition.

Fifty patients were studied by indirect calorimetry to assess caloric needs. Seventeen patients received total parenteral nutrition (TPN) in a fixed dose of 45 +/- 3 kcal/kg. Thirty-three patients were studied after acute injury. Indirect calorimetry and the basal energy expenditure equation (BEEE) were compared. In male patients receiving TPN, indirect calorimetry more closely approximated caloric needs than did the BEEE X 1.75. In female patients, the BEEE X 1.75, indirect calorimetry value, and calories infused were more equivalent, and positive nitrogen balance was consistently achieved. In thirty-three trauma patients, indirect calorimetry and the BEEE were compared. Indirect calorimetry consistently predicted higher caloric expenditure than did the BEEE X 1.75. In assessing caloric requirements in acutely catabolic patients, the BEEE X 1.75 appears to be inadequate. The BEEE does not take into account changes in temperature or degree of illness. Indirect calorimetry is easy to perform and gives more pointed information about the patient's caloric needs.

Use of the Broviac central venous catheter for intravenous antibiotic therapy in the orthopaedic patient.

Broviac central venous catheters were placed in twenty patients who required long-term intravenous antibiotics for the treatment of osteomyelitis, septic arthritis, or an infected total joint arthroplasty. As a group, the twenty patients completed a total of 1,131 days with the catheter in place. There was only one catheter-related complication: extrusion of the Dacron cuff after removal of the catheter. Six antibiotic-related complications occurred, all of which resolved when the antibiotic was changed. No patient had sepsis related to use of the catheter, breakage of the catheter, or thrombosis. Twelve patients had part of their antibiotic treatment on an outpatient basis.

Recommendations of nutrition support team promote cost containment.

Traditionally, Nutrition Support Teams (NST) have been employed in an advisory capacity to recommend the most beneficial type of total nutritional support. Frequently, this form of therapy is also the most economical, particularly when enteral nutrition can replace parenteral nutrition. In a retrospective study, we reviewed the files of 31 patients who had received total nutritional support and compared the nutritional therapy initiated by their attending physicians to the therapy recommended by the NST. Based on guidelines established by the NST, we evaluated patient records for appropriateness of therapy and potential monetary savings had the NST's recommendations been followed. In the majority of cases in which compliance with the NST's recommendations was not accepted, the NST had encouraged the use of enteral nutritional support rather than parenteral nutrition. In the 14 noncompliant cases (representing 280 days of nutritional support) the potential savings to these patients was estimated at $70,200 (more than $5,000 per patient).

Safety and efficacy of glycerol and amino acids in combination with lipid emulsion for peripheral parenteral nutrition support.

The safety and efficacy of administering lipid emulsion with ProcalAmine, a glycerol-based parenteral nutrition solution, for peripheral nutrition has not been previously studied. Thirty-four patients recovering from major trauma or surgery were studied while receiving a peripheral parenteral nutrition regimen of either ProcalAmine with 10% lipid emulsion (group 1) or ProcalAmine with 20% lipid emulsion (group 2) for up to 5 days postinjury. Daily dose was 45 mL/kg ProcalAmine, providing 1.35 g of amino acids/kg and 1.35 g of glycero/kg, and 500 mL/day lipid emulsion. The mean daily nitrogen balance was -0.3 g/day in group 1 and -4.1 g/day in group 2. There was no progressive accumulation of circulating glycerol, and urinary glycerol excretion was minimal (less than 0.2 g/day), indicating effective utilization of glycerol as an energy substrate. Our finding that nitrogen balance was better with 10% fat emulsion suggests a limitation in fat utilization in this setting. Both regimens were well tolerated; there were no adverse clinical reactions and no occurrences of phlebitis in either group.

Indirect calorimetry in postoperative patients with acute renal failure.

Oxygen consumption was measured and caloric expenditure calculated (indirect calorimetry) in ten adult patients with acute renal failure (ARF) following surgery. Eight patients recovered from ARF and six were discharged from the hospital. Caloric expenditure averaged 47 Kcal/kg/24 hours during the period of AFR. Attempts were made to match caloric replacement with expenditure based on indirect calorimetry, but was achieved in only one patient. Indirect calorimetry appears to be a practical method for guiding caloric replacement in these patients. Postoperative patients in ARF must undergo healing of incisions and bowel anastomoses, and contain infection. Since these patients are severely catabolic, it seems reasonable to treat them with adequate protein and calories and to use dialysis to control azotemia and water metabolism.

The efficacy of a 20 per cent fat emulsion as a peripherally administered substrate.

Physicians and industrial biochemists involved in the development and trial of disease specific amino acid formulations and adjustments in nonprotein calorie to nitrogen ratios consistently emphasize the need for discriminate clinical use of variations from standard formulations and ratios of substrates. The decision to manipulate substrate content must be based upon the metabolic state of each individual patient. Despite these recommendations, there appears to be a tendency to try innovative therapy in patients not fully meeting the criteria for disease specific TPN. A standard mix of postoperative patients commonly found on surgical services were entered into this protocol. Three randomly assigned variations in nonprotein calorie to nitrogen ratios were secondarily tested under carefully controlled conditions. The results indicate that 20 per cent lipid solution is a useful adjunct in TPN regimens, since twice the number of calories can be delivered in one-half the fluid volume. Fat solutions alone or in combination with isotonic concentrations of dextrose did not consistently produce positive nitrogen balance when given with significantly different nonprotein calorie to nitrogen ratios.

Penicillamine in rheumatoid disease: a long-term study.

Eighty-five patients with rheumatoid disease were treated with penicillamine, and 69 completed more than one year's treatment. The main reason for discontinuing penicillamine in the 16 patients who withdrew was adverse reaction. The number of adverse reactions, however, declined when patients were given lower maintenance doses of penicillamine. In those who tolerated the drug the results of treatment were good. To prevent side effects the drug should be introduced gradually and maintenance doses should be the lowest which produce a satisfactory response. Urine should be monitored for protein and blood for changes in platelet and white cell counts at frequent intervals throughout treatment.

Effect of penicillamine on the kidney.

Twenty patients with rheumatoid arthritis developing proteinuria when being treated with penicillamine have been studied. In 5 the proteinuria was mild and resolved rapidly. Eleven of the remaining patients have undergone renal biopsy. One was found to have amyloidosis, and in the other 10 there was evidence of an immune complex type of injury, manifested by a granular immunoglobulin deposition within glomerular capillary walls associated with subepithelial deposits, found on electron microscopy. The proteinuria associated with this was mild (mean 2.6 g per 24 h) and occurred on average some eight months after commencing therapy (range 6 weeks to 60 months).

Maintenance dose of penicillamine in rheumatoid arthritis: a comparison between a standard and a response-related flexible regimen.

There is much individual variation in the response of rheumatoid arthritis (RA) to penicillamine, some patients deriving benefit from very small doses. A dose of 750 mg daily is widely regarded as standard, and, while their RA commonly responds, many patients discontinue treatment because of adverse reactions to penicillamine. A more flexible prescribing policy might be more successful in the long term and was tested in 1 group of 20 patients, another receiving a 'standard' regimen, each beginning treatment at a low dose level. Of those who were given increases of dose only if response was poor 17 completed 1 year of treatment on an average maintenance dose of 308 mg daily, but only 11 of the other group on an average dose 613 mg daily. Proteinuria, which was found only in the latter group accounted for 6 withdrawals, all at doses of 625 mg daily or above. The reduction in rheumatoid activity appeared to be of about the same degree among the members of both groups who completed 12 months of treatment. Penicillamine should be given initially in a low dose and this should be raised only if there is lack of response after at least 4 weeks.