Prevalence of bacterial contamination in 50% dextrose vials in varying storage conditions after multiple punctures

OBJECTIVE

To determine the risk of bacterial growth in single use 50% dextrose vials punctured multiple times and stored in various hospital environments.

MATERIALS AND METHODS

Three groups of three 50% dextrose vials were stored in our hospital intensive care unit at either ambient light or in a darkened drawer at room temperature or refrigerated at 4°C. One vial in each group was punctured either once, once weekly or once daily for 28 days and samples taken for bacterial culture every 7 days until completion of the project. A fourth group of three vials were inoculated with several species of bacteria and stored in our microbiology laboratory under the environmental conditions described above with cultures performed every 7 days for 28 days. In addition, the water activity of 50% dextrose was determined using commercial laboratory equipment.

RESULTS

Scant growth of Escherichia coli and Enterobacter agglomerans was detected in cultures performed on day 7, but not subsequent time points, from the inoculated refrigerated vials. The vial punctured once daily for 28 days and stored under refrigerated conditions showed growth of Bacillus subtilis on day 28. All remaining bottles had no bacterial growth at any time point or environmental condition. The water activity of 50% dextrose was 093 at 24°C and 092 at 4°C.

CLINICAL SIGNIFICANCE

Bacterial growth in 50% dextrose vials was uncommon even when inoculated with pathogens. Bacterial growth only occurred in refrigerated storage conditions. The water activity of 50% dextrose is not low enough to inhibit all bacterial and fungal growth.

Chloroplast and mitochondrial DNA are paternally inherited in Sequoia sempervirens D. Don Endl

Restriction fragment length polymorphisms in controlled crosses were used to infer the mode of inheritance of chloroplast DNA and mitochondrial DNA in coast redwood (Sequoia sempervirens D. Don Endl.). Chloroplast DNA was paternally inherited, as is true for all other conifers studied thus far. Surprisingly, a restriction fragment length polymorphism detected by a mitochondrial probe was paternally inherited as well. This polymorphism could not be detected in hybridizations with chloroplast probes covering the entire chloroplast genome, thus providing evidence that the mitochondrial probe had not hybridized to chloroplast DNA on the blot. We conclude that mitochondrial DNA is paternally inherited in coast redwood. To our knowledge, paternal inheritance of mitochondrial DNA in sexual crosses of a multicellular eukaryotic organism has not been previously reported.

Effect of overexpression of BCL-2 on cellular oxidative damage, nitric oxide production, antioxidant defenses, and the proteasome

Bcl-2 is a gene family involved in the suppression of apoptosis in response to a wide range of cellular insults. Multiple papers have suggested a link between Bcl-2 and oxidative damage/antioxidant protection. We therefore examined parameters of antioxidant defense and oxidative damage in two different cell lines, NT-2/D1 (NT-2) and SK-N-MC, overexpressing Bcl-2 as compared with vector-only controls. Bcl-2 transfectants of both cell lines were more resistant to H(2)O(2) and showed increases in GSH level and Cu/Zn-superoxide dismutase (SOD1) activity, but not in Mn-superoxide dismutase, glutathione peroxidase, or glutathione reductase activities. Catalase activity was increased in SK-N-MC cells. Overexpression of Bcl-2 did not significantly decrease levels of oxidative DNA damage (measured as 8-hydroxyguanine) or lipid peroxidation, but it decreased levels of 3-nitrotyrosine in both cell lines and protein carbonyls in SK-N-MC cells only. It also increased proteasome activity in both cell lines. We conclude that Bcl-2 raises cellular antioxidant defense status, but this is not necessarily reflected in decreased levels of oxidative damage to DNA and lipids. The ability of Bcl-2 overexpression to decrease 3-nitrotyrosine levels suggests that it may decrease formation of peroxynitrite or other reactive nitrogen species; this was confirmed as decreased production of NO(2)(-)/NO(3)(-) in the transfected cells and a fall in the level of nNOS protein.

Anchored reference loci in loblolly pine (Pinus taeda L.) for integrating pine genomics

Anchored reference loci provide a framework for comparative mapping. They are landmarks to denote conserved chromosomal segments, allowing the synthesis of genetic maps from multiple sources. We evaluated 90 expressed sequence tag polymorphisms (ESTPs) from loblolly pine (Pinus taeda L.) for this function. Primer sets were assayed for amplification and polymorphism in six pedigrees, representing two subgenera of Pinus and a distant member of the Pinaceae, Douglas-fir (Pseudotsuga menziesii [Mirb.] Franco). On average, 89% of primer sets amplified in four species of subgenus Pinus, 49% in one species of subgenus Strobus, and 22% in Douglas-fir. Polymorphisms were detected for 37-61% of the ESTPs within each pedigree. Comparative mapping in loblolly and slash pine (P. elliottii Englm.) revealed that ESTPs mapped to the same location. Disrupted synteny or significant disruptions in colinearity were not detected. Thirty-five ESTPs met criteria established for anchor loci. The majority of those that did not meet these criteria were excluded when map location was known in only a single species. Anchor loci provide a unifying tool for the community, facilitating the creation of a "generic" pine map and serving as a foundation for studies on genome organization and evolution.

Molecular parasites that evolve longer genomes

Molecular parasites that utilize the replication machinery of cells or of in vitro amplification reactions have previously been characterized. By and large, these parasites have been smaller than the viruses or amplicons that gave rise to them. This is likely because shorter genomes can be replicated more quickly. In contrast, we have identified and characterized parasites of an isothermal amplification reaction that are longer than their parental molecules yet replicate much more efficiently. These results raise interesting questions regarding whether the optimal size of replicators reflects a trade-off between the information encoded in a parasite and the information encoded in the machinery replicating that parasite.

Training ribozymes to switch

Ribozymes that are sensitive to cyclic nucleotides have been selected in vitro. Remarkably, the cGMP-dependent ribozymes are specifically activated by a factor of 5,000 - the largest allosteric ribozyme activation by a small molecule seen to date.

The neuronal toxicity of sulfite plus peroxynitrite is enhanced by glutathione depletion: implications for Parkinson's disease

In Parkinson's disease (PD) and incidental Lewy body disease glutathione levels in the substantia nigra are decreased by 40-50%. Both peroxynitrite (ONOO ) and alterations in the metabolism of sulfur-containing amino acids have been implicated in PD and we have previously shown that sulfite and ONOO- exert synergistic toxicity to a neuronal cell line. This article presents data to show that this synergistic toxicity of sulfite and ONOO- is greatly enhanced by 50% depletion of cellular glutathione levels. The toxicity of sulfite is also slightly enhanced. Neurones with decreased glutathione may be at increased risk from sulfite and especially from the synergistic damaging effects of ONOO- and sulfite. Because sulfite is present normally in the brain as a product of cysteine metabolism, and because increased ONOO- formation has been reported in PD, these events might contribute to neuronal cell death.

Toxic effects of sulphite in combination with peroxynitrite on neuronal cells

Sulphite is widely used as a preservative and antioxidant in foods, beverages, and pharmaceuticals. Endogenous sulphite is generated during the normal metabolism of sulphur-containing amino acids, and alterations in sulphur amino acid metabolism occur in some neurodegenerative diseases. In particular, sulphite oxidase deficiency produces severe mental retardation, seizures, spastic quadriparesis, dislocated lenses, and early death. Exposure of a neuronal cell line (rat mesencephalic cells) to high levels of sulphite induced a time-dependent decrease in viability. Peroxynitrite was also toxic to this cell line, and sulphite affected the toxicity of ONOO-. Sulphite concentrations of < or = 0.5 mM markedly potentiated cell damage induced by 200 microM ONOO-. We propose that sulphite can act as a neurotoxic agent, especially in combination with peroxynitrite. Sulphite radicals may be involved in the neurotoxic effect.

Upregulation of the anti-apoptotic protein Bcl-2 may be an early event in neurodegeneration: studies on Parkinson's and incidental Lewy body disease

Apoptosis and oxidative stress have been suggested to be involved in Parkinson's disease (PD). However, whether this is a cause or consequence of neurodegeneration is unknown. Incidental Lewy Body disease (ILBD) appears to be a presymptomatic form of Parkinson's disease where individuals are neurologically normal, but after post-mortem examination pathology similar to Parkinson's disease is present. Thus, ILBD can be used to examine the early stages of the pathological process in PD. We investigated the levels of Bcl-2, an anti-apoptotic protein known to decrease cell death induced by several mechanisms, including oxidative stress. Our data show that Bcl-2 is significantly raised in the basal ganglia regions of PD patients as compared to age-matched controls. A similar trend is also found in ILBD. We propose that Bcl-2 increases in some brain regions as an early event and that these brain regions are under a stress for perhaps many years before any symptomatic changes occur.

A biopolymer by any other name would bind as well: a comparison of the ligand-binding pockets of nucleic acids and proteins

Crystal structures have recently been reported for several in vitro selected aptamers that bind small molecules. A structural comparison of these aptamers with proteins that bind identical ligands reveals similar strategies for forming ligand-binding pockets.

Managing cancer pain: basic principles and invasive treatments

Severe pain associated with cancer continues to be a substantial problem for patients, physicians, and the health-care system. During the past 2 decades, major advances have occurred in the understanding of the pathogenesis of pain. Likewise, considerable advances have occurred in the conceptualization of and clinical approach to cancer pain. This article briefly summarizes the basic principles of the treatment of cancer pain and in particular describes the World Health Organization 3-step "analgesic ladder" for the treatment of cancer pain. In addition, several invasive approaches for managing various refractory cancer pain syndromes are discussed.

Evaluation of the antioxidant activity of melatonin in vitro

Melatonin is being increasingly promoted as a treatment for "jet lag" and insomnia and has been suggested to act as an antioxidant in vivo. The antioxidant and potential pro-oxidant activities of melatonin were investigated in vitro. Melatonin was able to scavenge hypochlorous acid (HOCl) at a rate sufficient to protect catalase against inactivation by this molecule. Melatonin could also prevent the oxidation of 5-thio-2-nitrobenzoic acid by HOCl. Melatonin decreased the peroxidation of ox-brain phospholipids with a calculated IC50 of (210 +/- 2.3) microM. In contrast, serotonin which also scavenged HOCl, was much more effective in decreasing phospholipid peroxidation (IC50 15 +/- 5 microM). Both compounds reacted with trichloromethylperoxyl radical (CCl3O2) with rate constants of (2.7 +/- 0.2) x 10(8) and (1.2 +/- 0.1) x 10(8)M-1 s- respectively. Melatonin did not scavenge superoxide radical and weakly protected DNA against damage by the ferric bleomycin system. By contrast serotonin was weakly pro-oxidant in the ferric-bleomycin system and strongly pro-oxidant in the Fe(3+)-EDTA/H2O-deoxyribose system. Solubility restrictions precluded examination of melatonin in this system. Our data show that melatonin exerts only limited direct antioxidant activities.

A mutation hotspot in the chloroplast genome of a conifer (Douglas-fir: Pseudotsuga) is caused by variability in the number of direct repeats derived from a partially duplicated tRNA gene

We determined the DNA sequence of a 2.7-kb cpDNA XbaI fragment from douglas-fir [Pseudotsuga menziesii (Mirb.) Franco]. RFLPs revealed by the 2.7-kb XbaI clone were observed to vary up to 1 kb among species within the genus Pseudotsuga and up to 200 bp among trees of P. menziesii. The polymerase chain reaction (PCR) allowed the locus of polymorphism to be identified, and the variable region was then sequenced in a second Douglas-fir tree, a single tree of a related species, Japanese Douglas-fir (P. japonica), and in a species lacking a mutation hotspot in the region, Pinus radiata (Monterey pine). The locus of polymorphism is characterized by hundreds of base pairs of imperfect, tandem direct repeats flanked by a partially duplicated and an intact trn Y-GUA gene. The duplication is direct in orientation and consists of 43 bp of the 3' end of trnY and 25 bp of its 3' flanking sequence. Tandem repeats show high sequence similarity to a 27-bp region of the trnY gene that overlaps one end of the duplication. The two trees of Douglas-fir sequenced differed by a single tandem repeat unit, whereas these trees differed from the Japanese Douglas-fir sequenced by approximately 34 repeat units. Repetitive DNA in the Pseudotsuga cpDNA hotspot was most likely generated at the time of the partial trnY gene duplication and these sequences expanded by slipped-strand mispairing and unequal crossing-over.

Accumulation of HL-60 leukemia cells in G2/M and inhibition of cytokinesis caused by two marine compounds, bistratene A and cycloxazoline

The effects on the cell cycle of two biologically active compounds, bistratene A and cycloxazoline, from the marine ascidian Lissoclinum bistratum were studied in HL-60 human leukemia cells using flow cytometry. Both compounds were shown to cause an apparent accumulation of cells in the G2/M phase. This effect was shown to be both time- and dose-dependent. At the longer time points (30 and 48 h after addition of the compounds) polyploidy was apparent. The fate of cells labeled in the S phase with 5-bromo-2'-deoxyuridine (BrdUrd) was analysed using a bivariate BrdUrd/PI (propidium iodide) technique. Bistratene A and cycloxazoline treatment prevented the majority of BrdUrd-labeled cells from progressing through to the G1 phase. Approximately 50% of the cells were delayed at G2/M, and a significant proportion of cells appeared to be polyploid. Light and electron microscopy revealed the presence of multinucleated cells accounting for the apparent polyploidy. The progression of cells out of the G1 phase was also examined by synchronising cells with mimosine and releasing them from mimosine block in the presence of bistratene A. There was no evidence of a block at the G1/S phase transition or through the S phase since DNA synthesis was not inhibited. The mechanism by which these compounds interfere with cytokinesis is presently unknown but, in the case of bistratene A, may be linked to altered phosphorylation of cellular proteins involved in cell-cycle control.

Breast-feeding reduces maternal lower-body fat

The effect of breast-feeding on maternal anthropometric measures during the first 6 postpartum months was studied in 24 women. Mothers, who were seen in the hospital shortly after delivery and at monthly intervals thereafter, kept a record of their infant-feeding practices and provided three 24-hour dietary recalls per month. The women were placed in one of three groups according to their infant-feeding practices: breast-feeding exclusively, combination of breast- and formula-feeding, and formula-feeding only. Changes in anthropometric variables at 6 months postpartum were similar in the three groups, but mothers who breast-fed exclusively or partially had significantly larger reductions in hip circumference measurements (3.6% and 3.1%, respectively) and were less above their prepregnancy weights at 1 month postpartum (7.8% and 8.5% above prepregnancy weight, respectively) than mothers who fed formula exclusively (0.68% reduction in hip circumference and 13.7% above prepregnancy weight). Our findings indicate that a woman's choice of infant-feeding practice influences postpartum anthropometric changes, but these effects may be temporary.

Chloroplast DNA restriction fragment length polymorphism in Sequoia sempervirens D. Don Endl., Pseudotsuga menziesii (Mirb.) Franco, Calocedrus decurrens (Torr.), and Pinus taeda L

The extent and type of chloroplast DNA restriction fragment length polymorphism was determined among individual tree samples of coast redwood, Douglas fir, incense-cedar, and loblolly pine. A total of 107 trees was surveyed for three restriction enzymes (BamHI, EcoRI, HindIII) and six chloroplast DNA probes from petunia (P3, P4, P6, P8, P10, S8). The probes comprise 64% of the petunia chloroplast genome. Polymorphisms were detected in all species but loblolly pine. Coast redwood and incense-cedar had a small number of rare variants, whereas Douglas fir had one highly polymorphic region of insertions/deletions in sequences revealed by the P6 probe from petunia. The mutation hotspot is currently being studied by DNA sequence analysis.

Structure-activity relationships of the lissoclinamides: cytotoxic cyclic peptides from the ascidian Lissoclinum patella

Two new lissoclinamides (lissoclinamides 7 and 8) have been isolated from the aplousobranch ascidian Lissoclinum patella. These lissoclinamides are cyclic heptapeptides with the same structural features as lissoclinamides 4 and 5 reported earlier, containing an oxazoline ring, one proline, one valine, two phenylalanine residues, and thiazole and/or thiazoline rings. All four peptides have the same sequence of amino acids around the ring and differ from one another only in their stereochemistry or the number of thiazole and thiazoline rings. The cytotoxicities of the compounds were tested with human fibroblast and bladder carcinoma cell lines and normal lymphocytes. Slight changes in structure resulted in marked differences in the cytotoxicities of these compounds. The most potent is lissoclinamide 7, containing two thiazoline rings, which rivals didemnin B in cytotoxicity in vitro.

Hand infections in the diabetic and the diabetic renal transplant recipient

We present a series of 41 diabetic patients with severe tissue destruction and deformity secondary to hand infections. Thirty (73%) of the patients showed propagation of the infection to bone, tendons, or deep palmar spaces, and 26 of 41 (63%) required amputations. Sixty-three percent of the cultures were mixed; pure Staphylococcus aureus accounted for only 12%. Diabetics who were renal transplant recipients were at increased risk, with a 100% amputation rate and an average hospitalization of 41 days. Recommendations for management of diabetic hand infections are given to reduce the mortality and morbidity in these patients.

Limited weight losses with a gastric balloon

An evaluation of the Garren-Edwards gastric bubble in the treatment of obesity was done. Several clinical trials have compared the effects of behavior therapy with and without the bubble, but the effects of the bubble alone have not been previously evaluated. Ten obese women averaging 91% overweight received the bubble without adjunctive therapy during a 12-week treatment period. Frequent psychological and laboratory measures as well as weight were obtained during the study to explore the possible mechanisms of the bubble's effect and its side effects. Mean weight change was -2.5 kg, with a range of -8.8 to +1.6 kg. Four patients lost more than 3.5 kg, three lost less than 3.5 kg, and three gained weight. The Garren-Edwards gastric bubble alone does not appear to provide significant benefit to most obese patients.

Lithium chloride, cholecystokinin and meal patterns: evidence that cholecystokinin suppresses meal size in rats without causing malaise

Gut hormones which are proposed as natural satiety factors may act through malaise to suppress short-term feeding instead of through a normal physiological process. Evaluation of the ability of candidate satiety hormones to serve as the unconditioned stimulus in the development of a conditioned taste aversion is not adequate evidence of malaise since agents which do not produce malaise in humans are also capable of conditioning aversions. Examination of the patterns of eating behavior when drugs are given during a meal in rats may serve as a better test of the potential of an agent to produce illness. To evaluate this approach, LiCl (a known aversive agent) was infused into five rats at the start of each free-feeding meal at a dose of 1.9 mg/meal/rat for four days and at 3.8 mg/meal/rat for an additional four days. Feeding patterns during drug infusion were compared with patterns for six days when no drugs were infused. LiCl infusion produced a significant dose-dependent reduction in feeding frequency while the size and duration of meals were not changed. At the higher dose of lithium, daily meal number was reduced from a normal 13.2 +/- 1.4 to 9.9 +/- 0.5 meals/day. This pattern of behavior is significantly different from the behavior exhibited when cholecystokinin octapeptide (CCK-8) was infused using the same paradigm. CCK-8 significantly reduced meal size while meal frequency increased to compensate for the smaller meals. These findings suggest that LiCl infusion during a meal will lead to an aversion to feeding while CCK-8 is not effective at producing an aversion.(ABSTRACT TRUNCATED AT 250 WORDS)

Excision of multiple epidermal facial cysts in Gardner's syndrome

A rhytidectomy incision is recommended to excise multiple facial epidermal cysts in patients with Gardner's syndrome. The advantage of this approach is that it permits excision of excess skin over the cyst with esthetically pleasing hidden scars. The alternative to this procedure, a separate incision over each cyst, results in disfiguring and conspicuous scars.

When a patient commits suicide

Suicide is a tragic and upsetting event which sometimes occurs when a person is in some form of therapy. This paper advocates a process after a patient commits suicide which allows for a thorough and orderly working through of the event by involved treatment personnel. The primary focus of this process is neither identification of responsibility nor of cause. The primary goals are to air issues and attitudes, identify factors contributing to the suicide, and most particularly to allow for the thorough expression of residual feelings and issues by the treatment personnel affected. Therapists who utilized this process were able to deal satisfactorily with grief and guilt issues after experiencing patient suicides. A case example illustrates the use of this process.

Use of the temporalis muscule flap in blanking out orbits

We report the use of the temporalis muscle as a transposition flap to obliterate the orbit in 5 patients. In 4 of the cases we split the muscle coronally and passed the anterior part through a window in the lateral orbital wall. In two of these patients, skin grafts were put on both sides of the temporalis muscle-fascia flap, to restore nasal lining and to cover the facial surface simultaneously. In the remaining patients, the muscle was split sagittally to provide a large surface for coverage. The temporalis muscle flap is a versatile one for filling orbits after exenteration.

Xeroradiography in the diagnosis of facial fractures

Xeroradiography, because of its unique phenomenon of "edge enhancement," has some advantages for assessing facial fractures. In 17 of the 19 patients in our pilot study group, this technique was as valuable as, or more so than, plain films. The xerogram done prior to laminagraphy is a useful "map" for the radiologist to use in planning laminagraphic cuts. For the surgeon this technique offers a relatively accurate diagnostic tool, useful early after the facial injury.

Correction of the inverted nipple

The inverted nipple has been attributed to hypodevelopment of both nipple and areolomamillary musculature. A number of procedures have been devised to correct this deformity for the purposes of nursing and also for cosmesis. Excision of the entire areola, myotomy of areolomamillary bundles, and partial areolar excision in apposing quadrant triangles have all been used. An operative technique has been designed reflecting some of the older methods and an innovation utilizing areolar V-Y plasties and purse-string sutures to the nipple base for support. This method avoids excision and consequent extensive scarring of the areola. This procedure has been found to have satisfactory functional and cosmetic results in clinical trials to date.

Immediate insertion of silicone rubber rods in fingers with cut flexor tendons

In 7 patients with cut flexor tendons of the hand, we did an immediate quantitative bacterial analysis of the wounds. These showed fewer than 10(5) bacteria per gram of tissue, so we inserted silicone rubber rods in 10 of these fingers. All healed without infection, and this shortened the reconstruction. In retrospect, we believe it best not to insert the rods primarily in crush injuries. However, this seems to be a safe, worthwhile measure for those patients with sharp injuries of the tendons.

Salvage and reconstruction of electrical hand injuries

Electrical injury results in serious damage or amputation of the upper extremity in a significant percentage of survivors. Fourteen of sixteen patients with electrical injuries followed over a two and a half year period had major hand wounds. Careful wound assessment, management, and closure combined with appropriate reconstructive technics now available provide the greatest potential for restoration of satisfactory quality of life. Because these injuries are often of an industrial nature, occupational vigilance and prevention remain essential.

Surgical correction of nipple hypertrophy in male gynecomastia: case report

We report a case of nipple hypertrophy in male gynecomastia. By raising 4 small quadrant flaps on the areolar-nipple junction, we were able to do an appropriate core excision of the gynecomastia and hypertrophied nipple--and closure of the flaps produced a small simulated nipple.

Indications for neck dissection in carcinoma of the lip

In the past, neck dissections have been recommended only when nodes were clinically palpable or when they became so. A retrospective ten year study of thirty-seven patients with carcinoma of the lip and with an unusually high mortality has allowed reevaluation of indications for neck dissection. (1) Ten of thirty-seven patients died of this disease and nearly all of the ten died with and because of regional metastases. (2) Seven patients with nonpalpable nodes initally had nodal metastases later which, despite neck dissection at that later time, proved lethal. (3) Two patients who, despite nonpalpable nodes, had undergone neck dissections and were found to have occult bilateral nodal metastases were effectively cured with early neck dissection. This suggests that early bilateral supramohyoid neck dissections for small carcinomas of the lip and ipsilateral radical neck dissections for large primaries may yield higher cure rates than currently achieved.

Contiguous cervical and deltopectoral flaps for skin lining and replacement with en bloc resection of cancer of the head and neck

Contiguous cervical and deltopectoral flaps have several advantages in reconstruction of the head and neck after extirpation of cancer. The cervical skin provides an excellent color match for facial skin, and nonhair-bearing skin is available if lining of the oral cavity is required. The deltopectoral flap provides superior coverage for the carotid artery.

Quantitative microbiology: its application to hand injuries

Quantitative microbiologic analysis of civilian hand injuries has been accomplished in thirty-four patients. Most traumatic soft tissue injuries exhibited an insignificant level of contamination. The number of bacteria recovered from most of those wounds was comparable to that encountered in clean elective surgical hand cases. We now view most civilian hand wounds as clean wounds carrying a very low risk of infection. Our patients with traumatic hand injuries are considered candidates for immediate reconstruction, which includes vascular, bony, or neural repair as well as immediate implantation of Silastic rods in preparation for subsequent tendon grafting.

A salvage technic for extruded arteriovenous shunts

In view of the often prolonged periods of pretransplantation and chronic dialysis, every effort should be made to maintain existing arteriovenous shunts or fistulas and to salvage eroded ones when possible. The transposition of unwounded bipedicle flaps or small regional rotation advancement flaps over exposed cannulas is a surgical technic that can salvage eroded shunts and prevent their extrusion and removal.

New surgical concepts resulting from cranio-orbito-facial surgery

The authors have defined the subspecialty of craniofacial surgery and described the organization of the multi-disciplinary team required to care for such patients. Common features of the craniofacial patient have been summarized and three major categories of patients have been proposed. These are: I. Syndromes associated with hypertelorism; II. Syndromes associated with premature synostoses or growth arrests; III. Syndromes associated with primarily mid- and lower face anomalies. Growing out of an experience with 242 operations on 106 patients, the authors have listed 9 relatively new surgical "principles." Each has led to a current surgical approach that is now being employed by the craniofacial team at The University of Virginia. A number of examples are given to show ways in which the lessons learned from the craniofacial patients are now being applied, with improved results, to patients with neoplasms, traumatic injuries, or other conditions.