Nail gun injury: a barbed problem

A case of nail gun injury is reported. Preoperative radiographs are essential to determine whether copper barbs project from the nail shaft before any attempt is made to remove the nail. Thorough exploration is required.

Use of split-skin grafting in the treatment of chronic leg ulcers

Chronic leg ulcers are a common problem for which many different forms of treatment have been used. In this study we reviewed the results of split-skin grafting of ulcers of different aetiologies; 26 patients were reviewed. The mean duration of ulceration was 27.5 months. Of the 28 ulcers, ten were due to venous disease, three arterial disease, six rheumatoid arthritis, seven traumatic, and two diabetic. Healing rates of 85% for traumatic and 67% for rheumatoid ulcers were achieved, whereas rates of only 20% and 33% were achieved for venous and arterial ulcers (P < 0.02 Fisher's exact test). We conclude that in the presence of vascular disease, split-skin grafting is not an effective treatment for chronic leg ulceration. Vascular assessment and treatment should be carried out before attempting skin grafting.

Sensory innervation of the little finger by an anomalous branch of the median nerve associated with recurrent, atypical carpal tunnel syndrome

Superficial sensory communication between the ulnar and median nerves is well recognized. In the vast majority of cases this communication is from the ulnar nerve to the median nerve. We report a case in which a communicating branch passed from the median nerve to the ulnar nerve immediately proximal to the wrist to supply sensation to the little finger. The presence of this branch correlated with the presence of symptoms which had persisted in spite of conventional open carpal release 7 years earlier. Surgical decompression of this branch led to complete resolution of those symptoms.

Multidisciplinary approach to the management of head and neck arteriovenous malformations

Arteriovenous malformations (AVM) of the head and neck are quite rare in contrast to low-flow vascular anomalies, but often present with significant haemorrhage or cosmetic defects. Treatment of these high-flow vascular anomalies is hazardous and has a predictably high incidence of recurrence if not managed correctly. Intervention is indicated for complications such as pain, haemorrhage, pressure symptoms, ischaemic ulceration and even congestive cardiac failure. A multidisciplinary team approach is required in the assessment and treatment of these lesions, and involves preoperative angiography with superselective embolisation, followed by resection of the lesion, ideally within 72 h. Recent advances in microsurgery and in therapeutic radiology have greatly improved the prognosis for patients with these malformations. We present a series of four patients who have undergone preoperative embolisation and subsequent surgical excision, with a mean follow-up of 28 months. The complication rate has remained low and there has been no re-expansion of the lesions to date.

Malignant schwannoma mistakenly diagnosed as carpal tunnel syndrome

A rare nerve sheath tumour masquerading as carpal tunnel syndrome is described. It arose in a digit, with perineural spread proximally along the median nerve.

The mortality of British Airways pilots, 1966-1989: a proportional mortality study

Of 446 deaths among serving and retired British Airways pilots between 1966 and 1989, 411 were analysed using the Proportional Mortality Ratio (PMR) technique. After removal of the predictable excess of aircraft accidents, excesses of cancer (PMR 1.31) and other accidents (1.60) were balanced by deficits in diseases of the circulatory (0.83) and respiratory (0.49) systems. While lung cancer was close to expectation (1.10), consistent excesses were shown in all analyses for malignant melanoma (6.68), cirrhosis of the liver (2.88), colon cancer (2.30) and brain/CNS cancer (2.68). Consideration of these ratios in relation to pilots' lifestyle and occupation leads to the conclusion that the brain/CNS cancer excess must be studied further.

Editorial

Images

Morphological and morphometric changes in revascularised bowel grafts reconstructing the cervical oesophagus

Revascularised grafts of jejunum and colon have been used to reconstruct the cervical oesophagus in dogs. The grafts were examined at 2 months to assess their morphological and morphometric behaviour in their new position in the oesophagus. The colonic grafts appeared to adapt completely, while the jejunal ones manifest persisting mucosal changes attributable to their new environment.

Kinetics and mechanism of electron transfer from dithionite to microsomal cytochrome b5 and to forms of the protein associated with charged and neutral vesicles

The kinetics of the dithionite reduction of calf liver microsomal cytochrome b5, both free in solution and bound to dimyristoyl phosphatidylcholine vesicles, are consistent with electron transfer between SO2- and the exposed haem edge of the protein. The vesicle membrane does not hinder the approach of SO2- to the site of electron transfer on the protein. In 0.01 M-Tris/HCl buffer, pH 8.1, ket (25 degrees C), delta H et and delta S et are estimated to be 1.44 x 10(6) M-1.s-1, 7.8 kJ.mol-1 and -92.3 J.K-1.mol-1 respectively. The cytochrome exhibits an acid dissociation, pKa 9.3 +/- 0.3, and the rate of electron transfer from dithionite to the high-pH form is about one-third of that to the neutral-pH form. The effect of ionic strength on the kinetics is consistent with a reaction between like-charged species and is discussed in terms of a number of theoretical models. In systems comprising cytochrome b5 and negatively charged vesicles, the effect of increasing the charge density of mixed dimyristoyl phosphatidylcholine/dicetyl phosphate vesicles and of increasing the concentration of dicetyl phosphate vesicles is to lower the rate of electron transfer from dithionite to the haem moiety of the cytochrome. With vesicles of high charge density, however, the kinetics are complicated by vesicle-induced conformation changes of the cytochrome.

The innervated trapezius flap in facial paralysis

The use of an innervated lateral trapezius flap to allow movement of the paralysed face is described. Five cases are presented, all of whom achieved some facial movement postoperatively. The place of this technique in the armamentarium of procedures for facial reanimation is discussed.

Interaction of cytochrome b5 with surfactant vesicles

Changes in the u.v.-visible absorption spectrum of cytochrome b5 which occur upon addition of dicetyl phosphate, dimyristoyl phosphatidic acid (DMPA), or mixed DMPA/dimyristoyl phosphatidylcholine vesicles are consistent with haem transfer from the cytochrome to the membrane via an intermediate haemoprotein species. The effects of vesicle charge and concentration on the kinetics of haem transfer are discussed.

A method of phalloplasty using the deep inferior epigastric flap

Penile reconstruction remains a difficult surgical problem. To produce a phallus capable of erection and with a water-tight urethra to the tip has not been solved satisfactorily even by the introduction of free flap transfers. We present a method used in four cases, three transsexuals and one pseudohermaphrodite, in which a phallus was successfully constructed using the deep inferior epigastric flap.

Phalloplasty using the free radial forearm flap

Our experience of phalloplasty using the radial forearm flap in five transsexual cases is reported. The results are disappointing due to the high incidence of complications. We had partial success in two cases, both complicated by a fistula, and complete failure in three cases due to vascular thrombosis.

Doppler waveforms in the fetal aorta and umbilical artery in patients with hypertension in pregnancy

Pulsed Doppler ultrasound assessment of blood flow was performed in the fetal aorta and umbilical arteries of 41 patients with hypertension in pregnancy. Patients were grouped according to severity of the hypertension and the presence or absence of chronic hypertension. Doppler abnormalities were seen in two patients with chronic hypertension, both of whom delivered small for gestational age infants. Only one patient with mild to moderate preeclampsia had abnormal aortic Doppler assessment and was also delivered of a small for gestational age infant. The highest number of abnormal Doppler waveforms in both fetal aorta and umbilical artery were found in patients with severe preeclampsia. Abnormalities were detected more frequently in the fetal aorta than in the umbilical artery. Doppler assessment was often abnormal before a nonstress test or biophysical profile. The number of abnormal Doppler values correlated with perinatal outcome in patients with severe preeclampsia.

The functional recovery of revascularised colon and jejunum replacing the cervical oesophagus

An experimental animal model was set up to study the comparative behaviour of revascularised transplants of colon and jejunum used to reconstruct the cervical oesophagus. Age, sex and size matched greyhound dogs were used in the study. An investigation of the physiological behaviour of the graft mucosa was carried out at 8 weeks using the mucosal specific activity of the enzyme Na+K+ATPase. The findings demonstrate a clear depression in the functional behaviour of the jejunal graft mucosa, while the colonic graft mucosa remained biochemically unchanged. The significance of these findings is discussed, and the conclusion drawn that they support the hypothesis that colon makes a more stable and functionally superior free graft than jejunum when replacement of the cervical oesophagus is required.

Jejunum versus colon for free oesophageal reconstruction: an experimental radiological assessment

The reconstruction of the cervical oesophagus and the hypopharynx by revascularised bowel grafts has become a frequently described treatment option. Problems with the standard jejunal grafts have led us to suggest that the colon provides a suitable alternative. Experimental work in dogs demonstrates clear functional differences between colon and jejunum as free oesophageal grafts, and shows how structurally and functionally the colon integrates into the new position in the oesophagus better than the jejunum.

Experimental assessment of free jejunal and colonic grafts of the esophagus

The reconstruction of the cervical esophagus and the hypopharynx by revascularized bowel grafts has become a well-recognized treatment option and often is the method of first choice. Problems described by several protagonists of the standard revascularized jejunal graft have caused us to hypothesize that the colon provides both a suitable alternative and a solution to these problems. Experimental work in dogs demonstrates clear functional differences between colon and jejunum as free esophageal grafts. Video-fluoroscopic and manometric assessment of the two types of graft show that structurally and functionally the colon integrates into the new position in the esophagus better than does the jejunum.