An assessment of the US endangered species act recovery plans: using physiology to support conservation

Applying physiology to help solve conservation problems has become increasingly prominent. It is unclear, however, if the increased integration into the scientific community has translated into the application of physiological tools in conservation planning. We completed a review of the use of animal physiology in the US Fish and Wildlife Service (USFWS) and National Marine Fisheries Service (NMFS) Endangered Species Act (ESA) recovery plans released between 2005 and 2016. Over those 11 years, 135 of the 146 recovery plans mentioned physiology, with 56% including it as background information on the natural history of the species and not as part of the recovery process. Fish and bird species had the lowest proportion of recovery plans to include physiology beyond the description of the natural history. When considering multiple sub-disciplines of physiology, immunology and epidemiology were incorporated as part of the recovery process most often. Our review suggests a disconnect between available physiological tools and the potential role of physiology in developing conservation plans. We provide three suggestions to further guide conservation scientists, managers and physiologists to work synergistically to solve conservation problems: (1) the breadth of knowledge within a recovery plan writing team should be increased, for example, through increased training of federal scientists in new physiology methodologies and tools or the inclusion of authors in academia that have a background in physiology; (2) physiologists should make their research more available to conservation scientists and federal agencies by clearly linking their research to conservation and (3) communication should be enhanced between government conservation scientists and physiologists.

Parent participation in community activities and the persistence of criminality

This study assessed whether the lack of parental participation in community activities during late childhood is significantly related to the persistence of criminal activity from adolescence to adulthood. A prospective, longitudinal investigation of a representative cohort of 548 boys from a middle-sized Swedish community was employed. A pattern-oriented analysis identified five configurations of boys who showed different profiles of social and academic competence at the age of 13 years. The configurations were compared with respect to persistent criminality among the boys for parents who did, and who did not, show stable participation in a community activity when their sons were in late childhood. Fathers engaged in a community activity had sons with significantly lower rates of persistent criminality. This result was most marked for youth with low school achievement, and multiple problem profiles of social and academic disadvantage. The findings held after controlling for family socioeconomic status. Mother's participation in community activities was statistically dependent on father participation but was not related to persistent offending among multiple problem boys. Results are discussed in terms of the different impact associated with mother and father community activity participation on persistent offending, and the holistic perspective to development guiding this research.

Effect of radiation on skin expansion and skin flap viability in pigs

The aim of the present study was to investigate the effect of radiation treatment both on skin tissue expansion with the chronic inflation of subcutaneous expanders and on skin flap viability in surgically delayed and expanded skin in the pig. One flank in each of six pigs (initially weighing 17 +/- 1.8 kg) was randomly assigned for radiation treatment, and the contralateral flank served as a nonirradiated control. Three mirror-image, 8 x 10 cm, rectangular templates were marked on each flank; these templates were randomly assigned to the construction of a delayed skin flap (group A), a skin flap raised on expanded skin (group B), or a skin flap raised on expanded skin with a capsulectomy before flap surgery (group C). Radiation treatment was performed using sequential radiation with three fractions per week (810 cGy/fraction) for 2 weeks, with a total dose of 4,860 cGy. Twelve weeks after radiation treatment, skin expanders (8 x 10 cm) were installed subcutaneously in the locations assigned for skin expansion. Skin expansion by the inflation of subcutaneous skin expanders with saline twice weekly was started 8 weeks later and lasted for 3 weeks. Two weeks after surgical delay and the last skin expansion, 8 x 20 cm skin flaps were raised on the locations assigned for delayed skin flaps, expanded skin flaps, and expanded skin flaps with a capsulectomy. Skin flap viability was assessed 24 hours later using a fluorescein dye-staining technique. Skin expansion by the inflation of subcutaneous expanders with saline was slower (p < 0.05) in the radiated skin (39 +/- 6 ml/filling) than in the nonirradiated control skin (51 +/- 6 ml/filling). Radiation reduced the overall area of expanded skin by 23 percent (p < 0.05) compared with the control. Radiation treatment also reduced skin viability by 36 percent (p < 0.05) in the delayed skin flaps, 27 percent (p = 0.10) in the expanded skin flaps, and 36 percent (p < 0.05) in the expanded skin flaps with a capsulectomy when compared with their contralateral, nonirradiated controls. There were no significant differences in skin viability among these three types of skin flaps within the radiated and nonirradiated groups. Taken together, these observations indicate that radiation treatment reduced the effectiveness of the surgical delay procedure, the amount of subcutaneous skin expansion (by an increase in skin area), and skin flap viability. However, a capsulectomy alone did not affect the viability of skin flaps raised on expanded skin.

Donor site morbidity following vascularized fibular grafting

We examined donor site morbidity in thirty-nine patients with avascular necrosis of the femoral head treated by curettage and transplantation of a free ipsilateral fibular graft. Utilising our donor site morbidity questionnaire, scar, functional loss, wound healing, complications, and pain were analysed. Subjective complaints and objective findings were evaluated and compared. Subjective complaints were common and included a sense of instability in 42% and a sense of weakness in 37%. However, objective findings were limited. No clinical instability could be elicited and only great toe flexion (29%) and extension (43%) were found to be mildly weak. Only one patient required reoperation for a donor site problem (2%). Eighty-nine percent were pain free at time of follow-up, and 93% felt the scar was good. Range of motion of the knee and ankle of the donor site leg was not different from the nonoperated leg. Donor site morbidity for avascular necrosis of the femoral head is low.

Leisure activities and adolescent antisocial behavior: the role of structure and social context

The goal of this study was to understand better how the structure and social context of adolescent leisure activities relates to antisocial behavior. A representative sample of 703 14-year-olds and their parents were assessed concerning adolescent involvement in community-based leisure activities, peer and adult social relations, and antisocial behavior. Results showed that participation in highly structured leisure activities was linked to low levels of antisocial behavior, while participation in activities with low structure (i.e. a youth recreation center) was associated with high levels of antisocial behavior. Overall the results were similar for boys and girls; however, the combination of involvement in a low structured activity and the absence of any highly structured participation appeared especially problematic for boys' antisocial behavior. Participants of low structured activities were also characterized by deviant peer relations, poor parent-child relations, and they received low support from their activity leader compared to adolescents engaged in more structured community activities. Findings are discussed in terms of their implication for prevention research.

School extracurricular activity participation as a moderator in the development of antisocial patterns

This research involves a longitudinal study of antecedents and moderators in the development of antisocial patterns. Participants included 695 boys and girls who were interviewed annually from childhood to the end of high school and again at ages 20 and 24. Cluster analyses identified four configurations of boys and girls that were reasonably homogeneous with respect to behavior and academic performance at the beginning of the investigation. When tracked over time, the configurations differed significantly in patterns of early school dropout and criminal arrests. Boys and girls in the "multiple risk configuration" were more likely than those in other configurations to show long-term antisocial patterns. Participation in school extracurricular activities was associated with reduced rates of early dropout and criminal arrest among high-risk boys and girls. The decline in antisocial patterns was dependent on whether the individuals' social network also participated in school extracurricular activities.

A developmental approach to prevention research: configural antecedents of early parenthood

A developmental framework emphasizing the combined impact of correlated constraints within and without the individual was applied to a prospective longitudinal study of early parenthood. The purpose was to use a person-approach to the analysis of longitudinal data to clarify risk for early parenthood and to generate hypotheses about potentially useful intervention strategies. Respondents were 475 youth who were assessed annually from seventh grade through the end of high school and, again, at ages 20 and 24. The risk patterns associated with parenthood were the same for both sexes. Individuals with a middle-school configuration of low socioeconomic status, high aggression, low academic skills, low popularity, and prior grade failure were most likely to become parents by early adulthood. Risk for early parenthood increased substantially for respondents who dropped out of school early, regardless of their initial risk status.

Treatment of osteonecrosis of the femoral head by free vascularized fibular grafting: an analysis of surgical outcome and patient health status

OBJECTIVE

To evaluate the limb-specific outcome and general health status of patients with osteonecrosis of the femoral head treated with vascularized fibular grafting.

DESIGN

A retrospective review.

SETTING

A single tertiary care centre.

PATIENTS

Fifty-five consecutive patients with osteonecrosis of the femoral head who underwent fibular grafting (8 bilaterally).

INTERVENTION

Vascularized fibular grafting.

OUTCOME MEASURES

Limb-specific scores (Harris Hip Score, St. Michael's Hospital Hip Score), general health status (Nottingham Health Profile, SF-36 health status survey) and radiographic outcome measures (Steinberg stage).

RESULTS

Patients were young (mean age 34 years, range from 18 to 52 years) and 80% had advanced osteonecrosis (Steinberg stages IV and V). Fifty-nine hips were followed up for an average of 50 months (range from 24 to 117 months) after vascularized fibular grafting. Sixteen hips (27%) were converted to total hip arthroplasty (THA). To date, 73% of hips treated with vascularized fibular grafting have required no further surgery. Preoperative and postoperative Harris Hip Scores were 57.3 and 83.6 respectively (p < 0.001). As measured by patient-oriented health status questionnaires (SF-36, Nottingham Health Profile) and compared with population controls, patients had normal mental health scores and only slight decreases in physical component scores.

CONCLUSIONS

Free vascularized fibular grafting for osteonecrosis of the femoral head provides satisfactory pain relief, functional improvement and general health status and halts the progression of symptomatic disease.

Salvage after severe lower-extremity trauma: are the outcomes worth the means?

Advances in reconstructive surgery have allowed for impressive salvage after severe lower-extremity trauma but not without complications when compared with immediate below-knee amputation. Several amputation index scores have been developed to help predict successful salvage as defined by a viable rather than a functional extremity. The purpose of this study was to evaluate retrospectively the predictive value of the amputation index scores and to assess prospectively overall health status and specific dysfunction in successful limb salvage and primary and secondary amputation by administering standardized generic and specific outcomes questionnaires (Medical Outcomes Study 36-Item Short-Form Health Survey, Western Ontario and MacMaster Universities Osteoarthritis Index). A retrospective chart review identified 55 severe lower-extremity injuries (Gustilo Type IIIB and IIIC) over a 12-year period (1984 to 1996). Forty-six severe open tibial fractures in 45 patients underwent attempted salvage. All required soft-tissue coverage by either local or free flap or vascular repair for leg salvage. The attempted-salvage group was subdivided into successful salvage and secondary amputation. The other nine patients underwent a primary amputation. There were no statistically significant differences in terms of patient demographics or other injuries (Injury Severity Score) in the three groups. Forty-eight of 54 patients with an average 5-year follow-up completed a validated generic and specific outcomes health questionnaire. In the attempted-salvage group, 89 percent of patients had a successful salvage and 11 percent came to a secondary amputation. The amputation index scores correctly predicted an amputation in 32 percent of patients. The magnitude of the amputation index scores did not correlate with the physical outcomes scores and were not found to add any significant value of information to the surgeon's decision making. Patients undergoing primary and secondary amputation had a worse physical outcomes score (28 versus 38) than successful salvage (p < 0.007). Even so, the SF-36 (physical component score) outcomes score for this group of injured extremities, regardless as to whether salvaged or amputated, was as low as or lower than that of many serious medical illnesses, suggesting that severe lower-extremity trauma impairs health as much as or more than being seriously ill. The mental component score in this group was comparable to that of a healthy population (49 versus 50), which implies the disability is primarily physical rather than psychological. Ninety-two percent of patients preferred their salvaged leg to an amputation at any stage of their injury, and none would have preferred a primary amputation.

The histopathological changes in irradiated vs. nonradiated tissue-expanded skin in the porcine model

This study examined the histological changes following irradiation on nonexpanded and tissue-expanded pigskin. Six Yorkshire pigs received 4860 cGy radiation to one flank with the opposite side serving as the control. A histopathological comparison of tissue expansion in irradiated tissue to nonradiated tissue showed a reduction in the thickness of the dermal and subcutaneous layers, with less prominent rete ridges and a thicker stratum spinosum (p < 0.05). Nonexpanded irradiated tissue showed a reduction of thickness in the dermis and subcutaneous layer, less prominent rete ridges, and a thicker stratum spinosum layer (p < 0.05) when compared with nonradiated tissue. Tissue-expanded irradiated tissue showed no significant differences (p > 0.05) in any of these parameters when compared with nonexpanded irradiated tissue. This study demonstrates that radiation produced a significant change in porcine skin, but tissue expansion did not further alter the histological changes associated with irradiation.

Do extracurricular activities protect against early school dropout?

This study examined the relation between involvement in school-based extracurricular activities and early school dropout. Longitudinal assessments were completed for 392 adolescents (206 girls, 186 boys) who were initially interviewed during 7th grade and followed up annually to 12th grade. A person-oriented cluster analysis based on Interpersonal Competence Scale ratings from teachers in middle schools (i.e., 7th-8th grades) identified configurations of boys and girls who differed in social-academic competence. Early school dropout was defined as failure to complete the 11th grade. Findings indicate that the school dropout rate among at-risk students was markedly lower for students who had earlier participated in extracurricular activities compared with those who did not participate (p < .001). However, extracurricular involvement was only modestly related to early school dropout among students who had been judged to be competent or highly competent during middle school.

Do extracurricular activities protect against early school dropout?

This study examined the relation between involvement in school-based extracurricular activities and early school dropout. Longitudinal assessments were completed for 392 adolescents (206 girls, 186 boys) who were initially interviewed during 7th grade and followed up annually to 12th grade. A person-oriented cluster analysis based on Interpersonal Competence Scale ratings from teachers in middle schools (i.e., 7th-8th grades) identified configurations of boys and girls who differed in social-academic competence. Early school dropout was defined as failure to complete the 11th grade. Findings indicate that the school dropout rate among at-risk students was markedly lower for students who had earlier participated in extracurricular activities compared with those who did not participate (p < .001). However, extracurricular involvement was only modestly related to early school dropout among students who had been judged to be competent or highly competent during middle school.

Sternotomy infections: sternal salvage and the importance of sternal stability

OBJECTIVE

To review the management of sternal wound infection after cardiovascular surgery.

DESIGN

Retrospective case study.

SETTING

All management took place in a single tertiary-care university hospital.

PATIENTS

Twenty-one consecutive patients seen over a 3-year period who had infected median sternotomy incisions after cardiovascular surgery.

INTERVENTIONS

Surgical eradication of infection, including sternal débridement and rewiring or placement of vascularized muscle flaps, or both.

MAIN OUTCOME MEASURES

Resolution of infection and restoration of sternal stability.

RESULTS

The development of sternal wound infection was found to be associated with sternal instability. In 12 of 17 patients treated initially with sternal débridement and rewiring the infection was cured. Vascularized muscle flap transfers were required to eradicate the infection in the remaining patients.

CONCLUSIONS

Sternal débridement and rewiring is an effective initial treatment for sternal wound infections in selected patients. Some patients may require placement of muscle flaps for definitive treatment.

Lateral-arm free flap for reconstruction in the head and neck

OBJECTIVE

To describe the role of the lateral-arm free flap in reconstruction of head and neck defects following ablative oncologic surgery and to discuss the anatomy of this flap as well as indications for its use.

DESIGN

A prospective study of all patients undergoing a lateral-arm free flap was performed. Up to 3 years of follow-up was obtained.

SETTING

Tertiary referral centre.

METHOD

A total of 12 lateral-arm free flaps were utilized to reconstruct defects ranging in size from 4 x 7 to 10 x 7 cm. Maximum width of the flap was 7 cm. A mean area of 55 cm2 was harvested.

MAIN OUTCOME MEASURES

Flap survival, morbidity, speech intelligibility, and oral function and intake were assessed.

RESULTS

The vascular pedicle was reliable with vessel diameters of 1.5 mm, and length of 6 to 7 cm. All flaps survived, and minimal donor site morbidity was encountered. Nine patients maintained good speech with adequate intelligibility while 10 patients maintained adequate oral intake.

CONCLUSIONS

Functional results can be obtained with the lateral-arm free flap. A consistent pedicle of good length and size was found. It is our flap of choice in older, thinner individuals when the width of the donor site is less than 7 cm, which allows for primary closure.

Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand

High-resolution ultrasound is capable of detecting foreign bodies of practically any composition. The purpose of this study was to determine in a controlled manner the sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand. Each of 15 fresh-frozen cadaver hands was divided into 21 standardized sites for potential foreign body insertion. Foreign bodies consisted of two sizes of three different materials (wood, glass, and metal). Foreign bodies were randomly assigned to 50% of the available sites. The empty sites served as controls. All hands were scanned by a single radiologist using high-resolution ultrasound at a frequency of 10 MHz. The radiologist was unaware of which specimens contained foreign bodies. Of the 166 foreign bodies inserted in total, 156 were detected by ultrasound. Ten sites were falsely analyzed as negative, for a sensitivity of 94%. There was one false positive result and 148 true negatives. The specificity was therefore 99%. The high specificity of ultrasound allows foreign body presence to be confirmed given a positive result. A combination of ultrasound and x-ray films should allow for diagnosis and localization of virtually all foreign bodies in the hand.

Extremity arteriovenous malformations: review of a series

OBJECTIVE

To examine the diagnosis and treatment of arteriovenous malformations in adults, because of the tendency of the condition to recur.

DESIGN

Chart and literature review.

SETTING

Three tertiary-care hospitals.

PATIENTS

Twelve adults with diffuse arteriovenous malformations of the extremities.

INTERVENTIONS

Surgery of embolotherapy.

MAIN OUTCOME MEASURE

Recurrence.

RESULTS

Of the 12 cases reviewed, the arteriovenous malformations recurred in 8 patients; 2 of these were well, 6 months and 2 years after a second or third treatment. Two others were well, 2 months and 5 years after surgery or embolotherapy. One pregnant woman, whose case is described in detail, received no treatment, and her arteriovenous malformation diminished in size after her child was born. The outcome in the last patient is unknown.

CONCLUSION

Diffuse arteriovenous malformations recur after ablative treatment.

Effect of wrist position on extensor mechanism after disruption separation

A cadaveric study was performed on extensor tendon separation and excursion after extensor zone I (distal interphalangeal [DIP]) joint and III (proximal interphalangeal [PIP]) level lacerations and treatment. An average 1.5 mm tendon gap with 30 degrees lag following laceration at the DIP joint level and a 1.1 mm average tendon gap with 18 degrees (10 degrees-25 degrees) extension loss at the PIP level was demonstrated. Splinting zone I injuries with the DIP joints in 5 degrees hyperextension and zone III injuries with the PIP joint in 0 degrees extension eliminated tendon separation in all passive joint positions except when the wrist and metacarpophalangeal joints were placed in flexion. This position produced a 0.9 mm gap with a laceration at the DIP level and 1.0 and 2.0 mm gap at the PIP level, with a central slip and central slip and lateral band laceration, respectively. The tendon gaps were eliminated by placing the wrist in extension. This suggests that splinting of the wrist in neutral to mild extension and the joint underlying the tendon injury in full extension, while leaving the other joints free to move, would optimize treatment results.

The oxygen optode: an improved method of assessing flap blood flow and viability

The ability of a newly developed, implantable PO2 electrode to detect vascular occlusion in an isolated skin flap model was evaluated. Cutaneous groin flaps, based on the superficial epigastric artery and vein, were raised in twelve rabbits. An optochemical, oxygen-sensing electrode (Oxygen Optode--InnerSpace, Inc.), was inserted in the subcutaneous tissue of each flap. Inspired oxygen, location of the probe, ambient temperature, and temperature of the isolated, pedicled flaps were controlled. After equilibration of the electrode in the flaps at baseline oxygen levels, selective, reversible occlusion of the artery, vein, and combined vascular pedicle was carried out. The tissue PO2 in the flaps were continuously monitored over the periods of vascular compromise and subsequent reperfusion. The rates of change in tissue PO2 over time (mean +/- SEM) following arterial, venous, or combined occlusion were not statistically different. The ability to confirm vascular compromise by challenging the organism with 100% inspired oxygen was also examined. A rise in tissue PO2 levels above baseline was noted on oxygen challenge with both artery and vein patent. At no time was a rise in tissue PO2 seen during oxygen challenge with arterial or combined arteriovenous occlusion. Measurements of tissue PO2 obtained by the Oxygen Optode are felt to reliably reflect vascular occlusion of the isolated epigastric skin flap perfusion in the rabbit model.

Anatomic basis of local muscle flaps in the distal third of the leg

Soft-tissue defects of the distal third of the tibia are considered to be the realm of free-tissue transfer. We have found clinically that several local muscles can be used reliably in this area. The purposes of this study were: (1) to evaluate the potential use of the local muscles for soft-tissue coverage in the lower third of the leg and (2) to obtain numerical data that could be used preoperatively in the selection of potential local muscle flaps. All potential muscles, excluding the gastrocnemius, plantaris, and popliteus, from 10 fresh frozen legs were examined and the following details recorded: (1) the distance above the medial malleolus that the muscle bellies ended (musculotendinous junction), (2) the distance between the medial malleolus and the distal end of the transposed flaps (reach), (3) the area of tibia that could be covered, and (4) the vascular supply to these muscles. The soleus, extensor digitorum longus and peroneus tertius, extensor hallucis longus, peroneus brevis, and flexor digitorum longus were found to be the most anatomically suited muscles for local transposition to selected lower-third defects. We have worked with these muscles clinically and have found them to be useful and reliable when chosen appropriately.

Patient satisfaction with reduction mammaplasty: an early survey

There is an abundant volume of literature available on the varying techniques of reduction mammaplasty, possible complications, and long-term evaluations from the surgeon's perspective. However, there is very little to be found on the patient's perspective and personal experience with this procedure during the perioperative and early postoperative period. This article deliberately concentrates on patients' experiences and impressions during the first and second postoperative months. A prospective study was undertaken to look at patients' personal experiences and satisfaction with different aspects of their reduction mammaplasty and their overall satisfaction with the procedure. Thirty-one consecutive patients were recruited during a six-month period and evaluated one month postoperatively. Twenty-seven of these patients were evaluated again two months postoperatively. The overall satisfaction rate was high: 80.6% for the one-month survey group and 88.9% for the two-month survey group. There was a high incidence of minor complications (38%) and a significant number of the patients (32.3% of the one-month survey group and 33.3% of the two-month survey group) felt the need for more preoperative discussion.

Reconstruction of avulsed scalp after go-cart injury

Scalp avulsion is a rare injury that has significant physical and psychological consequences. It may require emergency replantation or late, challenging surgical reconstruction, or both. The authors describe two patients who had scalp avulsion. Each patient got long hair entangled in the uncovered engine of a go-cart. One underwent unsuccessful replantation without vascular repair; the other had a large segment of scalp successfully replanted with microvascular repair. Both patients required late reconstruction with tissue expansion. The final results were good. When feasible, microvascular replantation is the treatment of choice. If replantation is not possible, temporary cover by skin grafts followed by later reconstruction with tissue expansion can be effective.

Carpal Tunnel Syndrome: Diagnosing and treating the most common hand disorder

Carpal tunnel syndrome is a very common hand problem usually presenting with nighttime pain, numbness, and loss of dexterity. Controversy arises over the diagnosis, treatment, and evaluation of results. Nighttime splinting will improve the symptoms in some patients. If this fails, excellent results can be achieved with surgical decompression of the median nerve in the carpal canal.

The inguinal sarcoma: a review of five cases

A review of five patients who presented during a 3-year period with sarcoma arising in the inguinal canal demonstrated that the lesion is frequently mistaken for a hernia. In three of the patients incomplete excision of the inguinal mass resulted in spread of the lesion beyond the inguinal canal. The authors suggest that neoplastic lesions discovered in the inguinal canal should be evaluated by a small incisional biopsy followed by wide resection if sarcoma is confirmed on pathological examination. Preoperative irradiation and re-excision should be considered if widespread microscopic disease remains after excisional biopsy.

A forearm free flap based on an occluded radial artery: its salvage and avoidance

The salvage of a radial forearm free flap based on an occluded radial artery is reported. Circulation to the flap was restored by resection and reconstruction of the nonpatent arterial segment within the flap. A simple test is recommended for preoperative assessment of forearm radial artery patency in which proximal pulsation is felt after distal compression of the radial artery at the wrist.

Complications and functional results after limb-salvage surgery and radiotherapy for difficult mesenchymal neoplasms: a prospective analysis

Wide resection with adjuvant radiotherapy is generally accepted as the optimal treatment for patients with extremity soft-tissue sarcomas. However, there is a subset of patients with "difficult" tumours who sustain such marked loss of function from limb-salvage procedures that amputation might offer a superior functional alternative. To evaluate this issue, the authors prospectively designated 19 of 52 patients registered in Toronto's Princess Margaret Hospital Prospective Sarcoma Database in 1986 as "difficult" cases, on the basis of tumour size and anatomical location. Complications and functional results of wide resection and adjuvant radiotherapy were documented. The most frequent complication was related to wound healing (8 of 19 patients). Functional analysis at 1 year follow-up demonstrated that all 19 patients had results superior to those that would be expected with amputation.

Variations in flap blood flow and tissue PO2: a new technique for monitoring flap viability

An implantable and disposable tissue oxygen tension (PO2) probe, useful as a clinical monitor following free-tissue transfer, is described. Experimentally, using the rabbit epigastric groin flap model, we have found it to be a sensitive indicator of arterial and venous occlusion. Oxygen can be given to verify the integrity of the monitoring technique and check any abnormal reading. Animals administered oxygen will have a rapid increase in tissue PO2 when the pedicle is intact. If compromised by arterial or venous occlusion, the low readings demonstrate no change. The application of this new technique for monitoring free flaps in 12 patients is presented. In 2 patients the tissue PO2 monitor successfully detected early vessel thrombosis, resulting in reexploration of the anastomoses and salvage of the free flaps.

Effects of adrenergic agents on colonic motility

Sympathetic hyperactivity has been implicated as an etiologic factor in postoperative ileus. The effects of methoxamine (alpha-agonist) and isoproterenol (beta-agonist) on colon contractions and blood flow were studied in nine monkeys. Phentolamine (alpha-antagonist) and propranolol (beta-antagonist) were used to block the effects of the appropriate agonist. Methoxamine caused a dose-related inhibition of colon contractions and a decrease in inferior mesenteric artery (IMA) blood flow. Isoproterenol caused a dose-related inhibition of colon contractions and an increase in IMA blood flow. The contractile and blood flow effects of methoxamine were blocked by phentolamine and those of isoproterenol by propranolol. Mechanical reduction of IMA blood flow by an amount equivalent to that observed with the highest dose of methoxamine caused no change in contractions in the segment of colon supplied by the IMA. Both alpha- and beta-agonists inhibit colon contractions and have the expected effects on IMA blood flow. The contractile and blood flow responses of the agonists can be blocked by appropriate antagonists. The blood flow changes are not responsible for the contractile changes. These results indicate that sympathetic hyperactivity may play a role in postoperative ileus.

The influence of muscle flap coverage on the repair of devascularized tibial cortex: an experimental investigation in the dog

Segments (2 cm) of canine tibial diaphyseal bone were devascularized and internally fixed with a plate. The medial cortex of the devascularized tibia was covered with skin in one experimental group (n = 7) and a local muscle flap in the other (n = 6). The animals were given intravenous fluorochrome dye and killed 42 days postoperatively. Enveloping callus formed around the cortex which was repaired by the formation of resorptive cavities on its external surface. New bone formation occurred within the resorptive cavities. Muscle flap coverage was associated with a sixfold increase in cortical porosity (p less than 0.005) and a fourfold increase in the area of enveloping callus (p less than 0.05). The area of intracortical new bone formation was greater in the cortex with muscle flap coverage (p less than 0.05). The maximum depth of intracortical new bone formation increased from 0.46 +/- 0.14 mm with skin coverage to 0.95 +/- 0.14 mm with muscle flap coverage (p less than 0.001). This study demonstrates that muscle flaps are superior to skin coverage in initiating the repair of devascularized cortical bone.

Adenocarcinoma of the esophagus

Adenocarcinoma involving the distal esophagus usually is far advanced when the patient is first seen. Adenocarcinoma differs from squamous carcinoma of the esophagus since it is relatively unresponsive to radiation therapy or chemotherapy. Adenocarcinoma of the esophagus resembles gastric cancer in its tendency to form a bulky and locally invasive tumor with early regional lymph node metastases. It differs from gastric cancer in its tendency to spread proximally in the esophagus and in the relatively infrequent early involvement of the liver by metastases. From 1979-1986, 37 patients had resection for adenocarcinoma involving the distal esophagus. Thirty-three patients were diagnosed with American Joint Committee for Cancer Stage III or IV adenocarcinoma at the time of operation. Transhiatal esophagectomy in continuity with a proximal gastrectomy was done in 27 patients. Reconstruction was accomplished by cervical esophagogastrostomy using pedicled distal stomach. There were three postoperative deaths (30-day mortality rate: 8%). Anastomotic leak occurred in nine patients and caused significant morbidity in four patients. Eleven patients required dilation of the cervical anastomosis after operation for up to 6 months. Mediastinal recurrence affected three patients treated by transhiatal esophagectomy. The survival rate (Kaplan-Meier) was 44% at 1 year and 31% at 2 years. Resection of adenocarcinoma of the esophagus can be accomplished in most patients with acceptable risks of morbidity and mortality. Resection restores ability to swallow saliva and to consume a normal diet, and is associated with an appreciable improvement in the quality of life.

Soft tissue chondromas in the hand

Benign chondromas are rare soft tissue tumors of the hand. Five cases are presented. These tumors are generally seen as a painless lump, easily removed, as shown in three cases. Two additional patients had pain and stiffness at the proximal interphalangeal (PIP) joint. They demonstrate the occasional difficulty in making an accurate preoperative diagnosis, requiring a more extensive exposure at surgery as they can extend in various directions and may involve the tendon sheath or joint.

Resolution of postoperative ileus in humans

Bipolar electrodes were placed in the ascending and descending colon of 13 patients during laparotomy. The magnitude of their operations varied from exploratory laparotomy to total gastrectomy. The magnitude and length of the operations performed did not correlate positively with the duration of postoperative ileus. Signals were recorded for up to 4 hours daily for up to 8 days after operation during periods of rest and, in some patients, after administration of epidural or parenteral morphine sulfate. Power spectrum analyses of electrical control activity (ECA) showed dominant frequencies in both lower (2-9 cpm) and higher (9-14 cpm) ranges. During postoperative recovery, the mean ECA frequencies in right and left colon were relatively constant, but a variety of dominant ECA frequency relationships were observed. The modal pattern in the right colon was a shift in the dominant frequency from the higher to the lower range as recovery progressed, while the modal pattern in the left colon was persistent dominance of ECA in the higher frequency range. Electrical response activity (ERA) initially was comprised of only random, disorganized single bursts but became progressively more complex through the initial 3 postoperative days with the appearance of more organized bursts and clusters, some of which propagated very slowly (about 5 cm/min) both orad and aborad. ERA recovery culminated, typically on the third or fourth postoperative day, with the return of long bursts of continuous ERA, some of which propagated at a higher velocity (about 80 cm/min) and exclusively in the aborad direction and which were accompanied by passage of flatus or by defecation.

Influence of soft tissue coverage on the healing of cortical defects in canine diaphyseal bone

The influence of soft tissue coverage on bone healing was investigated in dogs. A standard diaphyseal bone defect was left open, closed with skin, or closed with skin and muscle. Specimen radiography, callus morphometry, microscopy, and fluorescent microscopy were used to assess bone healing. The defects healed in all groups. Defects left open produced significantly more periosteal callus (p less than 0.01). Abscess formation was observed in the callus. The trabecular structure was abnormally oriented. Histomorphometric measurements of the rate of bone formation were the same regardless of the presence or type of soft tissue coverage. Failure to disturb the intramedullary blood supply may have minimized the differences in healing among the 3 groups. Nevertheless, soft tissue coverage was observed to prevent bone infection and to accelerate the restoration of normal cortical architecture.

Management of onchocerciasis. Personal observations

During a 12-month period (1977 - 1978) of employment in the river forest area of the Ivory Coast, an isolated area hyperendemic for onchocerciasis, a unique opportunity arose to study the disease in depth. Personal observations and experiences with the disease did not necessarily correlate with textbook statements. Although onchocerciasis may involve almost any area of the body it more commonly involves the skin, eyes, lymphatics and groin area. The disease does not appear to cause premature or direct death, but is often acutely and chronically disabling. Diethylcarbamazine and suramin are effective in preventing disabling complications and in diminishing or controlling the progression of complications, but are nephrotoxic. Surgery is utilized to excise microfilaria-producing nodules in order to minimize or control disease progression and for the repair of the frequently occurring complication of inguinal or femoral hernias and hydroceles. A high percentage of patients had microfilarial eye infiltrates but blindness was uncommon. The disease should therefore be known as 'river eye disease' rather than the current 'river blindness'. There is no known method of effective prevention of the disease that is acceptable on a long-term basis.

Malaria 'breakthroughs' and resistance to chloroquine in Africa. Case reports

Four cases of Plasmodium falciparum malaria are presented. These cases are typical of chloroquine resistant malaria, with their pattern of 'breakthrough' malaria despite chloroquine prophylaxis, absence of response to therapeutic doses of chloroquine and recrudescence of the malarial parasites. These cases should alert physicians in other parts of the world, who may have to treat travelers from Central and West Africa, and particularly from the Ivory Coast, to the possibility that the malaria contracted in these areas may be chloroquine-resistant. The most effective drug in these cases appears to be a combination of sulphadoxine and pyrimethamine.

Step osteotomy: a precise rotation osteotomy to correct scissoring deformities of the fingers

A scissoring deformity of the fingers frequently results from malunion of a phalangeal or metacarpal fracture. If union occurs with rotation, the injured digit will scissor with an adjacent digit on flexion of the hand. Malrotation can be corrected by a technique of step osteotomy of the metacarpal with removal of a longitudinal strip of bone. The placement of the transverse cuts of the osteotomy determines the direction of rotational correction and the width of dorsal strut determines the amount of rotational correction. Firm fixation with two interosseous wires ensures good bony union and allows early mobilization.

Onchocerciasis in expatriates on the Ivory Coast

Six cases of onchocerciasis were diagnosed in expatriates working on a hydroelectric dam project in Taabo (Ivory Coast) between 1977 and 1978. Taabo is in the forest area of the Bandama River, where onchocerciasis is hyperendemic. The six patients had lived in the area from 20 months to four years. In the early 1970s four of them had worked at the Kossou Dam, a similar project 125 miles up the Bandama River. Diagnoses were confirmed by demonstrating microfilariae in biopsy specimens taken from the skin overlying the iliac crest. A seventh case was diagnosed clinically as tropical filarial pulmonary eosinophilia. The six patients with microfilariae in the skin were treated successfully with diethylcarbamazine (Notezine, Hetrazan) and suramin (Moranyl). The patient with pulmonary involvement responded dramatically to treatment with diethylcarbamazine. The overall effects of onchocerciasis are poorly understood, though it is now one of the major tropical diseases, affecting millions of people living in central and western Africa, Yemen, and Central America. Medical treatment is successful, but few preventive measures are available for the disease; larvicides are subject to resistance, and their effects are transient.

Otogenic tetanus in Zaire

Sixty-seven patients with tetanus of otogenic origin were hospitalized at the Mama Yemo hospital, Kinshasa, Zaire over the two-year period from 1975 through 1976. The care of these patients was the same as that for all 620 tetanus cases admitted during this period. No otologic surgical procedures were performed on this group; nor were any special ear procedures utilized. The survival rate in the otogenic tetanus group was 83%. The survival rate in the 620 tetanus admissions was 79%. All 67 patients had evidence of chronic otitis media. None of these patients had evidence of otologic complications before, during or for one month after developing tetanus, other than uncomplicated otorrhea. Tetanus antitoxin of 10,000 or 50,000 IU did not appear to affect survival rates. Mortality rates were not increased in the 18% of patients who did not receive tetanus antitoxin. Sedation sufficient to eliminate muscle spasms and maintain the patient sleeping seems to be important in increasing survival rates in tetanus. The need for tracheotomies appeared to be reduced with the increased sedation. Mortality rates increased among the patients who had tracheotomies. Otologic surgical procedures do not appear to be indicated in the management of patients with otogenic tetanus.

Mass management of otitis media in Zaire

In 1976, 4,281 cases of otitis media with otorrhea were treated in the otorhinolaryngology department at Mama Yemo hospital, the 2,000-bed major medical center in Kinshasa, Zaire. Topical aluminum acetate (Burow's solution) on ear wicks of cotton was placed against the ear drum into the ear canal and changed daily as an effective method of mass control of this disease without antibiotics. The results were comparable to those from 0.3% topical gentamycin ophthalmic solution (Garamycin), but were obtained with considerably less expense in an area where economic considerations are essential.