A bilateral clinical model for the study of acute and chronic pain after breast-reduction surgery

BACKGROUND

There is a need for new clinical models to investigate effectively the development of pain after surgery and the effect, if any, of pre-emptive treatment. Bilateral models are of special interest, since the patient serves as his/her own control. The objective of this preliminary study was to test a clinical model for the study of acute and chronic pain after bilateral reduction mammoplasty.

METHODS

Eight patients participated in the study where the breasts were randomized to test and control groups. In each patient, one breast was preoperatively infiltrated with lidocaine and adrenaline and the other breast infiltrated with saline and adrenaline. Assessment included visual analogue scale (VAS) pain intensity, thermal thresholds, mapping for punctate hyperalgesia and tactile sensation. Assessments were made preoperatively, postoperatively and at 6 months after surgery.

RESULTS

With regard to acute postoperative pain intensity, the model demonstrated a clear difference between lidocaine and placebo treated breasts. There was no difference between lidocaine and placebo treated breasts with regard to chronic pain, but these results are inconclusive due to small number of patients.

CONCLUSION

The model is sensitive and may be useful in studies of mechanisms of development and prevention of chronic pain after surgery.

[Skin transplantation]

Transplantation of skin was adopted as a clinical method for wound closure soon after Reverdin's introduction of skin grafts in 1869. Split-skin grafts are grafts which consist of epidermis and a portion of dermis, and full thickness skin grafts are grafts consisting of epidermis and the entire dermis including adenexal structures. Composite grafts with skin consist of cartilage and skin coverings. Skin grafts can also be grouped according to source in autograft, isograft, allograft and xenograft. Split-thickness grafts are used to close wounds that cannot be managed by suturing, full thickness-grafts or local flaps. In burn wound surgery and surgery related to necrotizing fasciitis, split-thickness skin grafting is a lifesaving treatment. In vaginal agenesis split-thickness skin graft is used to reconstruct the vagina. In the oral cavity split-thickness skin graft can be used to close wounds and cover cancelleous bone. Split-thickness skin graft can also be used to cover open abdominal wounds. Full-thickness skin grafts are used to reconstruct facial defects after removal of skin cancer. It is also used in hand surgery and for reconstruction of hypospadia. Composite graft can be used for nasal reconstruction. In this article, the indications for skin grafting, the surgical procedures and the follow-up are presented. Skin banking are presented to demonstrate the possibilities for storing skin allograft. Artificial skin or bio-engineered skin substitutes are presently undergoing clinical studies.

Cells encapsulated in alginate: a potential system for delivery of recombinant proteins to malignant brain tumours

Growth and progression of malignant brain tumours occurs in a micromilieu consisting of both tumour and normal cells. Several proteins have been identified with the potential of interfering directly with tumour cells or with the neovascularisation process, thereby inhibiting tumour growth. A continuous delivery of such inhibitory proteins to the tumour microenvironment by genetically engineered cells could theoretically be of considerable therapeutic importance. In this study we have investigated the growth characteristics of cells encapsulated in alginate, which represents a potential delivery system for recombinant proteins that may have antitumour effects. Three different cell lines, NHI 3T3, 293 and BT4C were encapsulated in alginate, which is an immuno-isolating substance extracted from brown seaweed. The encapsulated cells were observed at specific intervals during a 4-month period after in vitro propagation and as transplants into the cortex of BD-IX rats. Morphological studies showed that encapsulated cells proliferated and formed spheroids within the alginate in the in vitro cultures and after implantation into the brain. Even after 4 months in vivo a substantial amount of living cells were observed within the alginate beads. A vigorous infiltration of mononuclear cells was observed in the brain bordering the alginate beads, one week after implantation. However, there was a gradual decrease of mononuclear cells at the border zone beyond the first week of implantation. The majority of inflammatory cells were reactive microglia and invading monocytes, as verified by immunohistochemistry. The data further shows that alginate encapsulated cells can be frozen in liquid N2 and will retain their viability and proliferative capacity.

Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication

This paper addresses gastric herniation following laparoscopic fundoplication for reflux esophagitis.

CASE HISTORY

A 46-year-old woman underwent Nissen fundoplication. Two days postoperatively she developed gastric herniation and perforation with subsequent pleural effusion and necrotizing fasciitis of the chest wall. A patent crural repair might reduce the occurrence of paraoesophageal herniation.

Small intestinal perforation and peritonitis after abdominal suction lipoplasty

Suction lipoplasty for abdominal contouring in nonoperated patients is considered a safe procedure with a low incidence of local and systemic complications. Suction lipoplasty combined with a full abdominoplasty is, however, still controversial with a higher rate of local complications. A 56-year-old woman with a history of four laparotomies and two abdominoplasties was hospitalized with abdominal pain and signs of peritonitis after an ambulatory suction lipoplasty. During laparotomy for peritonitis the abdominal wall was found to be stiff and fibrotic, with massive adhesions to the intestine. Two small intestinal perforations caused soiling into the peritoneum. The perforated intestinal segment was resected and the postoperative history was uneventful. Both recent and former laparotomies in the lower abdomen represent a possible risk when suction lipoplasty is performed. An ultrasonographic or computed tomographic scan of the abdominal wall would identify or rule out any underlying fascial defect or hernia.

Microbial colonization of large wounds

This study determines the nature of microbial wound colonization in 28 patients with large burns admitted to the Burn Centre, Haukeland University Hospital, Bergen. Altogether, 748 swabs were taken in 141 sampling procedures. A total of 414 microbial isolates were detected and their resistance patterns to a variety of systemic antimicrobial agents determined. The most frequent isolates were coagulase-negative staphylococci (21.5 per cent) and Staphylococcus aureus (14 per cent), followed by Enterococcus species (11.3 per cent), Pseudomonas aeruginosa (10.9 per cent) and Candida species (9.7 per cent). Forty-one per cent of the enterococci and 36 per cent of the coagulase-negative staphylococci were resistant to the aminoglycosides routinely given in conjunction with surgery in our ward. Only four of the 89 strains of coagulase-negative staphylococci were insensitive to methicillin, and no Staph. aureus were methicillin resistant. The time-related changes of burn wound colonization showed that on admission and during the first week, staphylococci and alpha-haemolytic streptococci were dominant. During the next weeks, these bacteria were gradually superceded by enterococci, gram-negative opportunists (mainly Pseud. aeruginosa, Acinetobacter calcoaceticus and Escherichia coli) and Candida species. The nature of microbial wound colonization and how the flora changes with time should be taken into consideration by those treating thermally injured patients.

Increased levels of circulating interleukin-8 in patients with large burns: relation to burn size and sepsis

Large burns are followed by significant trauma-induced immunomodulation, and activated neutrophils can be demonstrated in the circulation of burn patients shortly after injury. Interleukin-8 (IL-8) is a recently described molecule with neutrophil activating properties and in the present study we have measured the concentration of this cytokine in plasma from 27 patients with large burns during hospitalization using an enzyme linked immunosorbent assay (ELISA). The mean patient plasma concentration of IL-8 at admission was about 60 times higher than that of healthy controls. Furthermore, patients with total body surface area burn of more than 40% had significantly higher IL-8 concentrations in plasma than patients with smaller burns. For patients without serious infectious complications, the IL-8 concentration fell gradually after injury, whereas in patients with complicating sepsis a second peak of IL-8 was demonstrated. Thus, the increased IL-8 concentrations seem to be related to burn size and to have a role in the pathophysiology of sepsis in patients with large burns. The large amounts of circulating IL-8 following thermal injury may contribute to the strong and sustained activation of neutrophils reported earlier in patients with large burns.

Activation of polymorphonuclear neutrophilic granulocytes following burn injury: alteration of Fc-receptor and complement-receptor expression and of opsonophagocytosis

Polymorphonuclear neutrophilic leukocytes (PMNLs) play a key role in host defense, and phagocyte dysfunction has been associated with increased susceptibility to infection in patients with thermal injury. We have used flow cytometric analysis (FCM) to longitudinally study PMNL expression of IgG Fc-receptor II (Fc gamma RII) and Fc-receptor III (Fc gamma RIII), as well as the complement receptors CR1 (receptor for C3b) and CR3 (receptor for C3bi) in 22 patients with large burns. Analyses of PMNL complement and immunoglobulin-mediated phagocytosis of Candida albicans were performed in parallel. Burn patient PMNL Fc gamma RIII expression was decreased to 58% of control values at admission, and remained low for the first 3 weeks. The expression of patient PMNL Fc gamma RII was not altered at admission or throughout the hospital stay. The CR1-dependent fluorescence was increased by 62% at admission, and reached a maximum at day 2, 138% greater than that of controls. The CR1 expression then gradually returned to normal at discharge. The PMNL CR3-dependent fluorescence showed an increase of 110% at admission and remained high during the first 3 weeks. The immunoglobulin-mediated phagocytosis was decreased by 12% at admission, whereas the lowest value was observed at day 10, with a reduction of 30% compared with controls. The patient PMNL complement-mediated phagocytosis of C. albicans was increased by about 160% at admission, and reached a maximum at day 2, before it gradually decreased to control levels at discharge. The expression of complement receptors correlated positively, whereas the expression of Fc gamma RIII correlated negatively, with total body surface area (TBSA) burn.(ABSTRACT TRUNCATED AT 250 WORDS)

The frequency of bacteremia and fungemia following wound cleaning and excision in patients with large burns

Twenty-eight patients with large burn injuries (mean total body surface area burned, 47.1%) who underwent 112 wound cleaning and staged early excision procedures were studied prospectively for bacteremia and fungemia induced by wound manipulation. The patients were given an aminoglycoside preoperatively, perioperatively, and postoperatively. Blood samples were obtained immediately before removal of dressings, after wound cleaning, after 30 minutes of surgery, at the end of each procedure, and 1 hour after surgery was completed. In a group of control patients blood samples were obtained immediately before the dressings were removed, after wound cleaning was completed, and 1 hour afterward. In a second group of control patients blood samples were obtained serially while the burn wounds remained undisturbed. None of the control patients received prophylactic aminoglycosides. Induced bacteremia or fungemia was documented in 50 instances of burn wound cleaning and excision; 31 cases of bacteremia or fungemia occurred after wound cleaning alone. Spontaneous bacteremia, i.e., that occurring in the absence of burn wound manipulation, was demonstrated in 3 of 18 blood culture series, whereas induced bacteremia was observed after 11 of the 17 burn wound cleaning procedures alone. The frequency of bacteremia tended to be higher for patients with inhalation injury than for those with no lung involvement. However, lung infection did not seem to account for many of the positive results of blood culture in this study. In contrast, burn wound infection contributed significantly to both spontaneous and induced bacteremia or fungemia. The micro-organisms most frequently isolated were staphylococci (50%) and enterococci (15.1%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Scalding injuries in children]

During the years 1989-91, 88 children were hospitalized in the Burn Unit. 60 children, of whom 57 were under five years of age, suffered from scalds. All of the injuries happened at home and nearly 60% of the children received immediate treatment with cold water. The causes of the scalds were hot tap water, tea, coffee or boiling water. Half of the children did not need surgery and stayed in the unit from one to 61 days. Information on burns and scalds prevention and first aid must be given to parents at the Health Care Centres, on radio and TV, and in the newspapers. In order to reduce scalds from hot tap water, legislation should be considered which would limit the temperature of such water to maximum 60 degrees C. Health personnel who meet these problems should present the above information to the politicians.

[Allogeneic transplantation--two case reports]

After a brief discussion on the transplantation of teeth, two cases of allogeneic transplantation, respectively from brother to sister, and from daughter to mother, are presented. Based on the two cases and a limited number of case histories found in dental literature, it is suggested that immunological screening of donor and recipient may help improve the prognosis of allogeneic transplantation of teeth.

Altered polymorphonuclear neutrophilic granulocyte functions in patients with large burns

Multiparameter flow cytometric analyses of polymorphonuclear neutrophilic granulocyte (PMNL) functions have been performed longitudinally in ten patients with large burns. The percentage of phagocytosing PMNLs was increased at admission (within 24 hours after injury) and through the first 10 days of hospitalization. The surface binding capacity and the ingestion of Staphylococcus aureus by each PMNL was increased during the same time period, and at day 2 the number of S. aureus ingested per patient PMNL was 35% higher than in the controls. The intracellular killing of Candida albicans was reduced by about 25% at admission. The microbicidal capacity was further compromised during the first 2 weeks after injury, with a reduction of intracellular killing of about 35% 5-10 days after admission. The kinetics of patient PMNL phagolysosomal acidification was altered during the first 20 days, as the initial alkalinization of the phagolysosomes documented in control PMNLs could not be demonstrated in PMNLs from patients with burns. In addition, measurements of maximal phagolysosomal acidification showed a lower pH in patient phagolysosomes than in the controls during the first 5 days. The patient PMNL H2O2 production was reduced at admission and through the first 10 days, with an oxidative burst that was 46% lower than the controls at day 5. The intracellular degradation of S. aureus proteins and DNA was slightly but significantly reduced at day 5 and day 10 after admission. The impairment of PMNL microbicidal capacity correlated with total body surface area burn.(ABSTRACT TRUNCATED AT 250 WORDS)

Neutrophil dysfunction after thermal injury: alteration of phagolysosomal acidification in patients with large burns

The neutrophil phagolysosomal acidification during phagocytosis of Staphylococcus aureus was examined in six patients with large burns, using a flow cytometric technique allowing the simultaneous measurement of phagocytosis and phagolysosomal pH. The kinetics of neutrophil phagolysosomal acidification were altered during the first 20 days following injury, as the initial alkalinization of the phagolysosomes documented in control neutrophils could not be demonstrated in patient cells. Only at discharge and follow-up were the kinetics of phagolysosomal acidification normal. In addition, measurements of neutrophil maximal phagolysosomal acidification showed a lower pH in patient phagolysosomes than in the controls during the first 5 days of hospitalization. The changes of phagolysosomal acidification did not correlate with the alterations of neutrophil maturity or phagocytic capacity. The results demonstrate alterations of an oxygen-independent microbicidal mechanism in neutrophils from patients with large burns, which may contribute to the reduced capacity of neutrophil intracellular killing following thermal injury.

Selection of allogenic tooth graft using HLA-A, -B, -C and DR typing and the MLC test

An allotransplantation of a partly developed premolar from a 12-year-old daughter to her mother is reported. The tooth graft was selected by the use of HLA-A, -B, -C and DR typing and the MLC tests. Follow-up over a 3-year period included periodic identically taken radiographs, electric and galvanic pulp tests and tests for cytotoxic antibodies. Almost complete closure of the apex of the tooth has occurred with no sign of root resorption. The transplant has remained vital, and no production of antibodies against the graft has occurred.

Incomplete branchial arch syndromes, branchial cleft cyst and vascular hamartoma in a patient with multiple neurofibromatosis

A case report with simultaneous occurrence of neurofibromatosis, incomplete branchial arch syndromes, a branchial cleft cyst and a pseudocyst in connection with a vascular hamartoma anterior to the right ear of a 38-year-old woman is presented. A possible common pathogenesis of the vascular hamartoma and the incomplete branchial arch syndromes as well as that of the neurofibromatosis is suggested. The pseudocyst is interpreted as a branchial cleft cyst showing inflammatory changes due to a pharyngitis shortly before the preauricular tumor appeared.

[Autotransplantation of teeth: indication, technic and prognosis]

An account is given of the most important indications for tooth transplantation. The developmental stage of the tooth most suitable for transplantation and the special demands to the recipient site, are considered. Each main group of indication is illustrated with case reports. Finally, factors influencing the prognosis of the transplant are discussed.

Benign cementoblastoma

A review of 44 patients with benign cementoblastomas is presented. An additional case is reported. This patient appears to be of particular interest due to radiographic records 18 months prior to admission. In this period the tumor appeared to grow very slowly.

Lipomas of the oral cavity

The clinical and histopathologic characteristics of oral lipomas are reviewed. A series of six patients undergoing surgical treatment for oral lipomas at the University of Bergen, Department of Oral Surgery during the period 1969--1976 is presented. The characteristics of the six tumors are described and the findings compared with those of previously reported cases.