The clinical contribution of SPECT/CT with 99mTc-HMPAO-labeled leukocyte scintigraphy in hip and knee prosthetic infections

OBJECTIVES

White blood cell scanning with ^99mTc-hexamethylpropylene amine oxime (HMPAO) has proven a sensitive and specific imaging method in the diagnosis of suspected prosthesis infection. The aim of this retrospective study was to evaluate the usefulness of SPECT/CT performed simultaneously using a hybrid imaging device of prosthesis infections.

MATERIALS AND METHODS

^99mTc-HMPAO scintigraphy was performed on 37 patients (11 men and 26 women; age range 38-84 years; mean age±SD, 65.7±5.6 years). Planar scans were acquired 2.4 and 24hour after injection. SPECT/CT was obtained 4 h after injection, using a dual-head hybrid gama camera coupled with a low-power x-ray tube. In all patients, scintigraphic results were matched with the results of surgery, cultures and clinical follow-up.

RESULTS

Seventeen (45,9%) out of 37 patients had prosthesis infection and 20 (54,1%) out of 37 patients had non-infectious prosthesis pathologies with ^99mTc-HMPAO scintigraphy and SPECT/CT. The ^99mTc-HMPAO scintigraphy was true-positive for infection in 16 of 37 patients and true-negative in 20 of 37 patients. SPECT/CT provided an accurate anatomic localization of all positive foci. With regard to the final diagnosis, SPECT/CT added a significant clinical contribution in 22 of 37 patients (59,4%). Sensitivity, specificity, negative predictive value and positive predictive values were 100%,59.1%,100%,62.5% in planar images with ^99mTc-HMPAO scintigraphy and 100%,90.1%,100%,88.2% in the planar+SPECT/CT imaging, respectively.

DISCUSSION

Our results indicate that SPECT/CT performed using a hybrid device can improve imaging with ^99mTc-HMPAO scintigraphy in patients with suspected osteomyelitis by providing accurate anatomic localization and precise definition of the extent of infection.

Updated results from the phase 3 HELIOS study of ibrutinib, bendamustine, and rituximab in relapsed chronic lymphocytic leukemia/small lymphocytic lymphoma

We report follow-up results from the randomized, placebo-controlled, phase 3 HELIOS trial of ibrutinib+bendamustine and rituximab (BR) for previously treated chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) without deletion 17p. Overall, 578 patients were randomized 1:1 to either ibrutinib (420 mg daily) or placebo, in combination with 6 cycles of BR, followed by ibrutinib or placebo alone. Median follow-up was 34.8 months (range: 0.1-45.8). Investigator-assessed median progression-free survival (PFS) was not reached for ibrutinib+BR, versus 14.3 months for placebo+BR (hazard ratio [HR] [95% CI], 0.206 [0.159-0.265]; P < 0.0001); 36-month PFS rates were 68.0% versus 13.9%, respectively. The results are consistent with the primary analysis findings (HR = 0.203, as assessed by independent review committee, with 17-month median follow-up). Median overall survival was not reached in either arm; HR (95% CI) for ibrutinib+BR versus placebo: 0.652 (0.454-0.935; P = 0.019). Minimal residual disease (MRD)-negative response rates were 26.3% for ibrutinib+BR and 6.2% for placebo+BR (P < 0.0001). Incidence of treatment-emergent adverse events (including grades 3-4) were generally consistent with the initial HELIOS report. These long-term data support improved survival outcomes and deepening responses with ibrutinib+BR compared with BR in relapsed CLL/SLL.

Local rhBMP-2 Injection after Drill-Hole Injury in Rats: Does it Have Systemic Effects?

The aim of this study is to investigate the histopathological findings of drill hole healing and interactions of parathyroid hormone (PTH), β-catenin and transcription factor-4 (TCF7L2/Tcf-4) after local application of recombinant human bone morphogenic protein-2 (rhBMP-2). Sprague Dawley rats were used in two groups of ‘femoral cortex hole model’. In the non-treated group, a hole was opened with a 3 mm K-wire in the distal and mid third junction of the right femur. In the treated group, local rhBMP-2 protein was injected into the similar femoral hole. Sterile 18M H2O was injected into the femoral hole at contralateral femur. There was more subperiosteal membranous bone reaction in the group treated with rhBMP-2 injection compared to the non-treated group. This was also proven immunohistochemically in both ipsilateral and contralateral femur with increased anti bone morphogenic protein-2 (anti BMP-2) expression. Moreover, there was an increased subperiosteal reaction at the contralateral femur. Also, in the treated group, PTH expression was increased in cells that form callus, and nuclear beta-catenin expression was increased in chondrocytes of periosteal ossification. Future studies should try to find whether the effects of rhBMP-2 on PTH and Wnt signaling pathway changes with different fracture models, also the systemic effects of local rhBMP-2 application should be investigated.

In-vitro Comparison of Antimicrobial Efficacy of Various Wound Dressing Materials

Many new antimicrobial dressings have been used for the treatment of or protection against wound infection since the early 1980s. There are many different wound dressings such as silver, povidone iodine, and chlorhexidine impregnated materials on the market today. Various manufacturers assert that their dressings are the most effective and therefore should be preferentially employed. However, it is difficult to find a study that clearly identifies the most effective antimicrobial wound dressing.

METHODS

Eight different commercially available wound dressing materials were compared in terms of their antimicrobial effectiveness on 18 different microorganisms via disk diffusion test (Kirby-Bauer Method) on Mueller-Hinton (MH) agar. Among the 16 bacterial and 2 yeast species grown on MH agar plates, Contreet was the most effective antimicrobial dressing tested (P <0.001).

RESULTS

A statistical difference was not found concerning efficacy against gram-positive and -negative bacteria among any of the materials except for Aquacel Ag and Inadine, the activity of which were found to be higher on gram-positive bacteria compared to gram-negative bacteria (P = 0.029, P = 0.030). In-vitro data suggest that Contreet is the most effective for topical treatment of contaminated wounds.

CONCLUSION

Further methods of assessment, including the use of infected animal models and clinical studies, will be necessary to better understand the antimicrobial efficacy of these dressings .

Poland's syndrome with rare deformities: reconstruction with latissimus dorsi muscle through a single short incision

We describe a 22-year-old man with Poland's syndrome and two other rare deformities which, to our knowledge have not been reported previously. The first deformity was a fibrotic band between the nipple-areola complex and the medial epicondyle of the humerus, and the second was a fifth digit with two phalanges. A single midaxillary vertical incision was used to harvest and then transfer the latissimus muscle for soft tissue reconstruction of the chest wall deformity. Almost complete symmetry was achieved and the scar was well hidden by the arm. The aesthetic and functional results were satisfactory.

Homozygous feature of isolated triphalangeal thumb-preaxial polydactyly linked to 7q36: no phenotypic difference between homozygotes and heterozygotes

Preaxial polydactyly is a common limb malformation in humans with variable clinical expression. Different types of triphalangeal thumb-preaxial polydactyly phenotypes were mapped to the chromosome 7q36 region. We studied a large Turkish family of 69 individuals, of whom 22 individuals were affected. In all, 11 affected family members were clinically and radiologically evaluated. All affected individuals had a triphalangeal thumb and a preaxial (hypoplastic) extra digit bilaterally, with minimal intrafamilial variation. No feet involvement was observed. Linkage and haplotype analyses using 20 informative meioses confirmed the 7q36 region contained the LIMBR1 gene. Maximum logarithm of the odds (LOD) scores were obtained with DNA markers D7S550 and D7S2423. We have further identified a novel C to T alteration at position 4909 bp in the critical zone of polarizing activity regulatory sequence (ZRS) region, in the intron 5, of the LMBR1 gene. One affected male with homozygous status and no phenotypic difference from affected family members with heterozygous status represented the first homozygote case of the triphalangeal thumb-preaxial polydactyly phenotype.

Multiple myeloma presenting as massive ascites

Ascites is a rare complication of multiple myeloma and may occur either at presentation or more often during the disease course. Most reported cases have been associated with IgA type of myeloma. When it occurs, it is usually associated with extensive liver infiltration with plasma cells, infectious peritonitis or myelomatous peritoneal infiltration. Herein, we describe a case of IgG type multiple myeloma diagnosed by further examinations due to the presence of plasma cells in ascitic fluid.

The Efficacy of Topical Negative Pressure in the Management of Infected and Non-infected Wounds 

 This study evaluates the efficacy of a vacuum-assisted closure (V.A.C.® Therapy, KCI, San Antonio, Tex) device in the comparative management of clean and infected wounds. Vacuum-assisted closure was applied to 57 wounds of 51 patients.

METHODS

Our protocol consisted of debridement of all necrotic tissue followed by vacuum-assisted closure therapy along with appropriate antibiotic administration. In 5 cases with peripheral circulation impairment, vacuum-assisted closure therapy was terminated due to a poor tissue response. In the remaining 52 wounds, healthy granulation tissue generation was observed. Wound cultures obtained from these patients prior to the start of vacuum-assisted closure proved the presence of infection in 31 wounds, while the other 21 wounds were free of infection.

RESULTS

The average sizes of the infected and non-infected wounds were 55.77 cm2 and 57.94 cm2 prior to the start of vacuum-assisted closure, respectively, while they were reduced to 48.28 cm2 and 45.70 cm2 after the last session. At the conclusion of vacuum-assisted closure therapy, 42 wounds were skin grafted and 10 wounds were covered with skin/muscle flaps.

CONCLUSION

Vacuum-assisted closure therapy is a reliable tool in the management of almost any type of wound, whether infected or not infected, unless major circulatory impairment interferes and acted as a contributory factor in wound formation. .

Incidence of pressure ulcers in intensive care unit patients at risk according to the Waterlow scale and factors influencing the development of pressure ulcers

AIMS

To determine incidence of pressure ulcers in patients at risk according to the Waterlow scale in intensive care units and to evaluate the effects of risk factors in critically ill patients.

BACKGROUND

Pressure ulcers continue to be an important health problem that increases the risk of illness and death, extends patients' length of hospital stay and increases healthcare expenses.

DESIGN

The study was conducted as a descriptive and prospective study.

METHOD

The sample consisted of 140 patients. Data were collected using a data collection form, the skin assessment instrument and the Waterlow scale.

RESULTS

The incidence of pressure ulcers in intensive care unit patients was found to be 14.3%. The majority of pressure ulcers (74%) were grade I. The mean length of time for pressure ulcer development was found to be 10.4 (SD 1.85) days. A statistically significant difference was found in the patients for pressure ulcer development according to their level of consciousness, activity, cooperation, length of stay, Waterlow scale score and C-reactive protein level. In the multiple stepwise logistic regression analysis, the most influential factors for pressure ulcer development were determined to be length of stay and activity level.

CONCLUSIONS

Extra care needs to be taken to prevent pressure ulcer development in intensive care unit patients who have an extended length of stay, are dependent for activities, have high Waterlow scores, are unconscious and are not cooperative.

RELEVANCE TO CLINICAL PRACTICE

This study determined the incidence of and factors that can affect the development of pressure ulcers in intensive care unit patients who are in a high risk group for the development of pressure ulcers and presented the importance of having Turkish nurses implement interventions directed at these factors.

Use of Tunnelled Catheters in Haematological Malignancy Patients with Neutropenia

This prospective study analysed 83 patients (age 45 ± 17 years) with haematological neoplasms, implanted with 93 tunnelled catheters, who were neutropenic or developed neutropenia during treatment. Catheters were implanted in the right ( n = 82) or left ( n = 11) jugular vein by the same surgical team using the same technique. They remained in place for 124 ± 88 days: 29% were removed due to infection; 18% due to treatment termination and 2% due to mechanical problems. Seventeen patients died with catheters in place. At 30, 60, 90, 120 and 200 days mean catheter duration rates were 82%, 75%, 65%, 60% and 35%, respectively, and freedom from catheter removal due to infection was 92%, 88%, 80%, 77% and 67%, respectively. Patient diagnosis and history of previous catheter infection did not increase catheter infection risk, but patients undergoing stem cell transplantation had an increased infection risk. Tunnelled catheters can be used in high-risk patients with neutropenia. Systemic infections can be managed in most patients without catheter removal.

A patient with diffuse large B-cell non-Hodgkin's lymphoma and AA type amyloidosis

AA-type amyloidosis is a consequence of a long-standing systemic inflammation and is not associated with a monoclonal protein or clonal bone marrow plasma cells. Proinflammatory cytokines such as interleukin (IL)1, IL-6, and tumor necrosis factor (TNF) stimulate the synthesis of serum amyloid A during inflammation. Although the association of non-Hodgkin's lymphoma (NHL) with AL-type amyloidosis is well known and patients with Hodgkin's lymphoma with AA amyloidosis have been described, AA-type amyloidosis with NHL is extremely infrequent. We report a case of amyloidosis associated with NHL that subsided during R-CHOP chemotherapy.

Versatility of Frontal Island Flaps in the Reconstruction of Periorbital Soft Tissue Defects

The reconstruction of large soft tissue defects in the orbital and maxillomalar region is a challenging task that necessitates the consideration of both functional and aesthetic outcomes. We used the frontal island skin flap in patients with full-thickness soft tissue defects of the periorbital and malar region. In the reconstruction of full-thickness defects of this particular region, the alternatives to this flap are other regional flaps or distant free flaps. Not every pedicled regional flap can be transferred to every defect and most of the time the application of distant free flaps increases the morbidity of the procedure. The surgeon must be capable of being able to select the most useful and comprehensive flap within a range of many alternatives. We present our experience in 10 patients with complex soft tissue defects in the maxillomalar and periorbital regions whose defects were reconstructed with frontal artery island skin flaps.

The potential of microscopic sterile sponge particles to induce foreign body reaction

The sterile sponges may lose a significant amount of lint during their routine use in surgery, which is usually neglected. We designed an experimental model to evaluate the potential of sterile sponges to lose lint and to induce foreign body reaction in surgically created wounds. In 15 Wistar rats, separate subcutaneous pockets were created. Left-sided pockets were temporarily packed with sterile sponges, while the right-sided pockets remained empty. All the pockets were then irrigated with sterile saline. The presence of microscopic sponge particles was evaluated in the irrigation materials. After 4 weeks, the presence of inflammation and foreign body reaction were evaluated histologically. Microscopic sponge remnants were present in 14 of 15 samples collected from the left sides. The presence of foreign body giant cells with ingested sponge particles and formation of well-defined foreign body granulomas were observed only in samples collected from the left sides. A statistically significant difference was observed between the two sides when the intensity of inflammation was graded (P= 0.012). Cotton sponges used in surgery are shown to have a potential of losing invisible microscopic particles that have a potential to induce foreign body reaction.

Aplasia Cutis Congenita of the Scalp and Calvarium

Aplasia cutis congenita is a rare congenital disorder of skin and most commonly involves the scalp. The skull and dura underlying the defective skin may also be affected, relative to severity of the disease. The typical lesion is present at birth and ranges in size from 0.5-3 cm. The main complications of larger defects include infection, bleeding and trombosis that may be deadly. Therefore, prompt diagnosis and appropriate treatment are critical for avoiding the adverse outcomes. Controversy exists in the literature regarding the treatment of aplasia cutis congenita; both surgical and conservative treatment modalities have their proponents and opponents. We present a case of full thickness aplasia cutis congenital lesion bigger than 3 cm in diameter that healed with the application of novel wound dressing materials without any complications. The physiopathology, classification and treatment options of the disease are discussed.

An algorithm for deciding alternative grafting materials used in secondary rhinoplasty

Severe middle vault deformity with disturbed nasal form and function is one of the most challenging procedures to correct in a secondary rhinoplasty. Reconstructing the deformity with autologous septal cartilage would be the primary choice of most surgeons, if it were always available. However in certain cases the lack of a sufficient quantity of autologous cartilage has forced surgeons to explore other viable options. This paper discusses our experience with the combined use of spreader and dorsal onlay grafts from various materials in the reconstruction of severe middle vault deformity in 110 patients. In follow up, (between 6 and 42 months; mean 21 months) all patients were noted to have improved in both aesthetics and function with no major complications noted. In summary, this study proposes that any engrafting material can be used safely when the proper surgical principals and technique are employed.

Analysis of skin-graft loss due to infection: infection-related graft loss

This prospective study was performed to analyze the causes of infection-related skin-graft loss in a general population of plastic and reconstructive surgery patients. One hundred thirty-two patients who received either full- or split-thickness skin grafts to reconstruct soft-tissue defects were included. The tissue defects were grouped according to the cause as follows: vascular ulcers (9.2%), burns (14.5%), traumatic tissue defects (36.6%), and flap donor-site defects (39.7%). In all cases, the preoperative evaluation indicated an adequate wound-bed preparation. However, graft loss secondary to infection was recorded in 31 patients (23.5%). The microbiological cultures revealed Pseudomonas aeruginosa in 58.1% of the cases (P<0.05), followed by Staphylococcus aureus, Enterobacter, enterococci, and Acinetobacter; 58.3% of grafts in vascular ulcers, 47.4% of grafts in burns, 16.7% of grafts in traumatic-tissue defects; and 13.5% of grafts in donor-site defects were lost due to infection. Vascular ulcers and burns were more commonly associated with graft losses due to infection than other tissue defects (P<0.001). No correlation was found between the etiological cause of the defects and the microorganisms cultured. However, Pseudomonas infections were more fulminant and caused an increased reoperation rate 4.2 times (P<0.05). Full-thickness grafts were more resistant to infection than split-thickness grafts (P<0.05). Graft loss due to infection was also more common in grafts applied to the lower extremities or when performed at multiple sites. In conclusion, 23.7% of skin grafts were lost due to infection in a group of general plastic surgery patients. Infection-related graft loss was more commonly encountered in vascular ulcers and burn wounds, and the most common cause was Pseudomonas aeruginosa.

Augmentation rhinoplasty with a combination of triple cartilage grafts for secondary rhinoplasty in a middle-aged population

Because of physiologic changes with advancing age as well as previously traumatized and then healed tissues, secondary rhinoplasty for a middle-aged patient is a challenging procedure. Depending on both factors, changes in the midvault can cause a functional airway disorder, and the nose also may need a complete correction for cosmetic purposes. To achieve aesthetic and functional outcomes, augmentation rhinoplasty using a combination of triple cartilage grafts, namely, spreader, columellar, and dorsal onlays, was performed for 12 patients. Sufficient nasal airways with satisfactory appearance were achieved for 11 of 12 patients. Only one patient had improved but still insufficient nasal function with a good aesthetic result. Augmentation rhinoplasty using a combination of triple cartilage grafts for middle-aged patients could be considered an effective procedure for improving the patient's nasal airway and appearance.

The additive effects of carnitine and ascorbic acid on distally burned dorsal skin flap in rats

BACKGROUND

The purpose of this study was to determine the effects of combined use of L-carnitine and vitamin C on partially burned skin flap in an experimental rat model.

MATERIAL/METHODS

In the rat dorsal skin, a 10 x 3 cm flap was marked. The most distal 3 x 3 cm part was burned to full thickness. Twenty-four rats were randomized into four groups with 6 animals in each. Group 1 was simply followed up. Group 2 was given 0.5 mg/kg vitamin C per day for 7 days, group 3 100 mg/kg carnitine per day for 7 days, and group 4 both carnitine and vitamin C. On the eighth postoperative day, the animals were sacrificed and examined. The surviving and necrotic areas were determined by macroscopic examination and measured with a planimeter.

RESULTS

The areas of flap necrosis were measured. The median surviving areas and areas of flap necrosis, respectively, of the groups were: group 1, 16.0 cm(2) and 14.0 cm(2); group 2, 18.25 cm(2) and 11.75 cm(2); group 3, 20.0 cm(2) and 10 cm(2) ; and group 4, 23.75 cm(2) and 6.25 cm(2). The surviving areas of the groups were found to be significantly different (p=0.000).

CONCLUSIONS

The risk of ischemia-induced necrosis in flap attempts made in damaged tissues may be reduced by the combination of two promising agents, L-carnitine and vitamin C. L-carnitine appears to be the major contributing factor that reduces necrosis, and vitamin C an additive agent.

Late psychosocial effects of congenital hand anomaly

Lifetime-standing psychosocial effects of congenital hand anomalies are inevitable in patients who have not received a comprehensive treatment with appropriate timing and approach. Herein, two adult cases of untreated thumb polydactyly are presented. Both of them had hands with striking appearance and late consequent psychosocial problems.

Bilateral complete avulsion of ocular globes in a Le Fort III maxillofacial fracture: a case report and review of the literature

PURPOSE

The purpose of this paper is to demonstrate a case of bilateral complete avulsion of the globes following maxillofacial trauma.

METHODS

A 23-year-old man with bilateral complete globe avulsion following a maxillofacial trauma. Both globes were luxated out of the orbit and suspended on the skin of the upper lid below the brows. No direct or indirect light reflexes or any eye movements could be noted. Computerized tomography showed complete lacerations of both optic nerves at a level just anterior to the optic canal. There were also multiple fractures corresponding to Le Fort III fracture with Le Fort II components. The brain parenchyma was normal with an exception of brain edema. As the globes were unsuitable for repositioning, both were enucleated. The maxillofacial fractures were immobilized with plates and screws. Although the patient gained consciousness with normal vital signs in the early postoperative period, he died on the ninth day due to Pseudomonas aeruginosa infection, despite invasive antibiotic treatment.

DISCUSSION

The optic nerve and the globes are very resistant to mild and moderate trauma. The avulsion of the nerve at the canalicular or more posterior level may demonstrate central nervous system complications resulting in life-threatening conditions. The most critical issue in complete globe avulsions with a transected optic nerve is to rescue the vision. In total transected optic nerves the final eyes could only have had cosmetic benefits. In spite of promising experimental research on optic nerve regeneration, there are unknowns, such as the methods to eliminate the risk of anterior segment ischemia and phthisis bulbi.

CONCLUSIONS

Globe avulsions with a complete optic nerve cut remain a challenging problem. More research is required to better understand the pathophysiology of optic nerve repair.

The relationship between patient stress and the blood levels of acute phase proteins in rhinoplasty: the report of a prospective study

OBJECTIVE

This study aims to interrogate the relationship between patient stress and the levels of acute phase proteins (APP) in rhinoplasty.

METHODS

Twenty-six primary rhinoplasty patients were asked about the most stressful step of the rhinoplasty process, which were (1) deciding on the operation, (2) waiting in the preoperative room, (3) the first few postoperative hours, and (4) withdrawing the nasal pack, in order beginning from the most stressful one, preoperatively, and then postoperatively. C-reactive protein (CRP), alfa-1-acide glycoprotein (AAG), ceruloplasmin (CER), haptoglobulin (HPT), and alfa-1-antitrypsin (AT) have been studied in blood to detect a relation between the patient stress and the levels of APP.

RESULTS

Preoperatively, the "imagined" most stressful step was Step 4 (61.53%). Postoperatively, the "declared" most stressful step was Step 3 (50%). The blood levels of APP matched with the imagined rather than the declared stress.

CONCLUSION

Patient stress could be a preoperative issue, which should be eliminated preoperatively. Detailed description of the surgery and some pharmaceutics can inhibit the negative effects of the stressors and have a contribution to patient comfort.

Enhanced Frontalis Sling With Double-Fixed, Solvent-Dehydrated Cadaveric Fascia Lata Allograft in the Management of Eye Ptosis

The article describes an enhanced frontalis sling procedure in the management of blepharoptosis with poor or no levator function. This modified method were used in the care of three patients and based on the principal of two-point fixation of the graft material that was prepared from solvent-dehydrated cadaveric fascia lata onto the frontalis muscle. After more than 1 year of follow-up, no recurrence was noted. With no extra incision over the skin, this surgical approach could be useful in the correction of difficult ptosis cases.

Giant recurrent pyogenic granuloma on the face with satellitosis responsive to systemic steroids

Pyogenic granuloma is a common benign skin tumour. However, giant recurrent pyogenic granuloma with satellitosis is relatively rare. We present a 52-year-old man who had recurrent gigantic pyogenic granuloma with satellitosis responsive to systemic steroids. Our case of recurrent pyogenic granuloma is interesting because of its clinical presentation, recurrence following surgical excision and its steroid responsiveness. Systemic steroids may be effective in treating recurrent giant pyogenic granulomas during their high-proliferation phase.

Comparison of ischemic and chemical preconditioning in jejunal flaps in the rat

Jejunum is one of the most frequently used free flaps in esophagus reconstruction. However, the sensitivity of intestinal tissue to ischemia decreases the margin of safety of this donor site while increasing the risk of postoperative complications such as fistula formation and stenosis. Ischemic preconditioning can increase the tolerance of jejunal tissue to ischemia. In this study, the authors investigated the effects of chemical preconditioning with adenosine infusion on ischemia reperfusion injury in the rat jejunum, and evaluated the presence of any additive effects of adenosine administration when used together with ischemic preconditioning. Forty Sprague-Dawley rats weighting 200 to 250 mg were used in the study. Rats were randomly divided into five groups. In group I (sham-operated controls), only laparotomy was performed. In group II (ischemia-reperfusion injury), the superior mesenteric artery was clamped for 40 minutes to induce ischemia in the small bowel, followed by 60 minutes of reperfusion. In group III (ischemic preconditioning), two cycles of 5-minute ischemia and 5-minute reperfusion were performed before implementation of the ischemia-reperfusion protocol used in group II. In group IV (chemical preconditioning), adenosine (1000 microg/kg) was infused into the internal jugular vein before the group II ischemia-reperfusion schedule was implemented. In group V (adenosine-enhanced ischemic preconditioning), adenosine (1000 microg/kg) was infused into the internal jugular vein before ischemic preconditioning, followed by 40 minutes of ischemia and 60 minutes of reperfusion. At the end of the reperfusion period, samples from the jejunum were harvested and myeloperoxidase activity was determined as a measure of leukocyte accumulation. Malondialdehyde levels were measured to assess lipid peroxidation. Histopathologic sections stained with hematoxylin-eosin were evaluated for the presence of mucosal damage according to the Chiu scoring method. Immunohistochemical staining by M30 monoclonal antibodies was performed to quantify the number of ischemia-induced apoptotic cells in the intestinal mucosa. The myeloperoxidase and malondialdehyde levels were significantly lower in groups I, III, IV, and V when compared with group II. Although there were no significant differences among myeloperoxidase and malondialdehyde levels in groups III, IV, and V, group I had significantly lower levels of activity compared with the other three groups. Histological scoring reflected significantly less damage in groups I, III, IV, and V compared with group II. Similarly, the number of apoptotic cells was significantly lower in groups I, III, IV, and V when compared with group II. However, no difference was detected among these four groups with regard to either histopathological scoring or apoptosis numbers. This is the first study showing that adenosine administration is as effective as ischemic preconditioning in inducing ischemic tolerance in the rat jejunum. However, there was no enhancement of ischemic preconditioning with prior adenosine infusion.

The effects of carnitine on distally-burned dorsal skin flap: an experimental study in rats

OBJECTIVE

In ischemia and burn injuries, there are major alterations threatening tissue survival. Increased energy flow requirements are among the major problems in these disorders. Carnitine is an endogenous cofactor, which has a regulatory action on the energy flow from different oxidative sources. The purpose of this study was to determine the effects of carnitine in an experimental flap model. Biochemically, nitric oxide (NO), malondialdehyde (MDA), and acetylcholinesterase levels, and histopathologically tissue examination under light microscope were studied.

METHODS

In the rat dorsal skin, a 10 cm x 3 cm flap was marked. The most distal 3 cm x 3 cm of the flap was burned to full-thickness. The dorsal flap was elevated, and sutured back to its original site. Sixteen rats were divided into two groups (a control (1) and a study group (2)), consisting of eight rats in each. While the animals in the control group were just followed, the animals in the study group were administrated carnitine with a dose of 100 mg/kg per day for 7 days.

RESULTS

At the end of the experiment: the mean surviving areas of the flaps were 15.22 cm(2) (50.73%) in group 1, 20.53 cm(2) (68.43%) in group 2, and the difference was statistically significant (P=0.008). In the analysis of blood samples; the mean levels of NO were 22.63 and 40.78 micromol/l; of MDA were 6.74 and 3.79 ng/ml; and of acetylcholinesterase were 136.14 and 222.85 U/l in groups 1 and 2, respectively. The differences in the levels of NO (P=0.001), MDA (0.027) and acetylcholinesterase (P=0.006) were statistically significant. Histopathological examination revealed a full-thickness muscle necrosis in addition to skin tissue in the control group, while healing tissue was present with marked cellularity including mixed inflammatory cells and fibroblast proliferation with an increased vascularity in the form of capillary budding in the study group.

CONCLUSION

Carnitine has a positive effect in such a model, particularly in preventing the progressive effect of burn, and limiting the necrosis in the full-thickness burned part.

Versatile anterolateral thigh perforator flap: case of tailored reconstruction for a large temporal and parotidectomy defect

Perforator flaps have introduced an advance in microsurgical reconstruction, by allowing the design of flaps that are tailored for a specific defect. In this report, the reconstructive technique in a case of temporal squamous-cell carcinoma is presented as an example of this trend. Following wide resection of the skin tumor, superficial parotidectomy was performed as a part of the lymph-node dissection. An anterolateral thigh perforator flap was harvested, including a segment of the vastus lateralis muscle in connection with the skin perforators, to reconstruct both the skin defect and the parotidectomy-related soft-tissue deficit. The muscle segment was reinnervated by the greater auricular nerve to diminish atrophy. The aesthetic result was satisfactory. Minor's starch-iodine test demonstrated prevention of Frey's syndrome. The anterolateral thigh flap is a versatile donor that allows individual variations in design for custom-made flaps.

Irradiated homologous costal cartilage: versatile grafting material for rhinoplasty

For most surgeons, nasal septal cartilage is the first choice in septoplasty. However, when this source is depleted, an alloplastic implant material might be preferable over other autogenous donor sites in order to avoid additional scars, morbidity, and lengthened operating time. In the alloplastic spectrum, irradiated costal cartilage (ICC) has certain advantages. Herein, we present our results with ICC in a wide range of septorhinoplasties to show its versatility and reliability. Sixty-five patients were included in the study. There were 42 male and 23 female patients. According to the indications, there were four groups of patients: (I) secondary septorhinoplasty (n = 24), (II) traumatic deformity (n = 21), (III) primary septorhinoplasty (n = 13), (IV) deformity due to previous septal surgery (n = 7). The mean follow-up period was 33 months. No significant resorption was detected in any of the patients. Minor complications developed in four cases (6%), including deformity in the dorsal graft, excessive graft length, and erythematous nasal tips. Aesthetic and functional results were satisfactory in the remaining cases. The low incidence of major complications and the versatility of ICC make it a safe and reliable source of cartilage graft for both primary and secondary septorhinoplasties when autogenous septal cartilage is either insufficient or unsuitable.

[The need for successive free flap applications for soft-tissue reconstruction in a case with recurrent oral carcinoma]

A case of difficult oncologic oral reconstruction is illustrated, in which soft tissue deficits resulting from failure of conventional techniques were treated by successive free tissue transfers. A thirty-eight-year-old man presented with squamous cell carcinoma in the right retrotrigonal region. The tumor was resected and the defect was reconstructed with the use of a tongue flap and skin graft. However, trismus occurred following radiotherapy, which was released by the help of a radial forearm free flap. The patient developed local recurrence several months later and right hemimandibulectomy, total maxillectomy, and hemiglossectomy were performed. The resulting en bloc defect was reconstructed by a free fibula osteocutaneous flap combined with a pedicled extended pectoralis major myocutaneous flap. The pectoralis flap was complicated by partial necrosis resulting in a large orocutaneous fistula and oral commissure incompetence. As the source of either a local or regional flap was inadequate, an anterolateral thigh myocutaneous free flap was used to fill the maxillary defect. No complications were encountered associated with free tissue transfers and the patient was able to take a soft diet three weeks after the final procedure.

Unilateral brachial plexus injury occurring after reduction mammaplasty

A left neuropraxic brachial plexus injury was seen after reduction mammaplasty. The clinical signs of plexopathy were noted in the very early postoperative period. The partial axonal damage was heavy in the upper and posterior branches and moderate in the medial branch of the plexus. The hyperabduction of the upper extremity during the surgery was thought to be the main cause. With a close followup and extensive physiotherapy, in addition to B complex vitamins, a full recovery was achieved at the end of the tenth week.