Lipoma extraction via small remote incisions

We describe a technique for extraction of lipomata using gynaecological polyp forceps, via incisions placed in aesthetically better sites than directly over the lesion. Although this can also be achieved by liposuction, we have found that this alternative technique is valuable in those cases where liposuction has failed due to the fibrous nature of the lesion, or where equipment is not available.

Activation of the growth plates on three-phase bone scintigraphy: the explanation for the overgrowth of fractured femurs

Children with an uncomplicated femoral fracture, treated with superimposition of fragments and intentional shortening, usually develop overgrowth of the fractured femur and the ipsilateral tibia which may compensate for the initial shortening and enable the limb in question to reach a length similar to that on the normal side. The overgrowth is evaluated clinically and by scanography. The increased metabolic activity of the growth plates that support this overgrowth has not been documented by any laboratory method. In order to evaluate the metabolic activity of the growth plates, 18 patients (11 males, seven females; mean age 6.1 years) with fractures of the femur were studied at three different time intervals (2-5 months, 6-12 months and 18-24 months). Three-phase bone scintigraphy was performed in all patients. Ten children (five males, five females; mean age 7.5 years) who had had bone imaging for other reasons were used as the control group. Visual analysis of the flow and equilibrium phases was performed for the distal femoral and proximal tibial growth plates. Visual and semi-quantitative analyses of the delayed images were performed for the distal femoral and proximal and distal tibial growth plates. Semi-quantitative analyses yielded the following activity ratios: (a) the distal femoral growth plate of the fractured femur to the contralateral one (FR); (b) the proximal growth plate of the tibia on the side of the fractured femur to the contralateral one (TpR); (c) the distal growth plate of the tibia on the side of the fractured femur to the contralateral one (TdR); and (d) in the control group, the distal growth plates of both femora (FCG) and the proximal (TCGp) and distal (TCGd) growth plates of the tibiae. Visual analysis of the blood flow, equilibrium and delayed images showed increased activity in the distal femoral growth plates during the first and second time intervals, but not during the third. No significant activity changes were found in the proximal and distal tibial growth plates during any of the phases analysed. The mean and standard deviation for FR in the three time intervals were: FRI=1.22+/-0.27, FRII=1.17+/-0.16 and FRIII=1.09+/-0.20. FR values were significantly higher than in the control group (FCG=0.99+/-0.03) (P=0.033). The mean and standard deviation for TpR in the three time intervals were: TpRI=1.08+/-0.18, TpRII=0.94+/-0.09 and TpRIII=0.96+/-0.20. TpR values were not significantly different from those in the control group (TCGp=1.00+/-0.05). However, TpRI was significantly higher than TpRII (P=0.043). The mean and standard deviation for TdR in the three time intervals were: TdRI=1.10+/-0.41, TdRII=1.05+/-0.15 and TdRIII=1.13+/-0.36. TdR values were not significantly higher than in the control group (TCGd=1.00+/-0.04) (P=0.777). These results support the concept that three-phase bone imaging is able to quantify and determine that activation occurs in the distal femoral and proximal tibial growth plates of fractured femora. This phenomenon may explain the overgrowth observed in this injured bone structure.

Cluster and velocity effects on yields and kinetic energy distributions of Li+ desorbed from LiF

MeV N+ and N2+ ions were used to induce Li+ desorption from LiF. The contributions due to elastic atomic collisions and electronic excitation processes to the sputtering yield could be unambiguously separated. In the case of N2+ ions, a Li+ yield enhancement, i.e., Y(N2+)>2Y(N+), was found only for the electronic process. The maximum sputtering yield was observed in a projectile velocity range where the projectile electronic energy loss still increases. These results are simultaneously explained using the radial distribution of the deposited energy rather than the electronic energy loss.

Evidences of gentamicin resistance amplification in Klebsiella pneumoniae isolated from faeces of hospitalized newborns

The intestinal microbiota, a barrier to the establishment of pathogenic bacteria, is also an important reservoir of opportunistic pathogens. It plays a key role in the process of resistance-genes dissemination, commonly carried by specialized genetic elements, like plasmids, phages, and conjugative transposons. We obtained from strains of enterobacteria, isolated from faeces of newborns in a university hospital nursery, indication of phenotypical gentamicin resistance amplification (frequencies of 10(-3) to 10(-5), compatible with transposition frequencies). Southern blotting assays showed strong hybridization signals for both plasmidial and chromosomal regions in DNA extracted from variants selected at high gentamicin concentrations, using as a probe a labeled cloned insert containing aminoglycoside modifying enzyme (AME) gene sequence originated from a plasmid of a Klebsiella pneumoniae strain previously isolated in the same hospital. Further, we found indications of inactivation to other resistance genes in variants selected under similar conditions, as well as, indications of co-amplification of other AME markers (amikacin). Since the intestinal environment is a scenario of selective processes due to the therapeutic and prophylactic use of antimicrobial agents, the processes of amplification of low level antimicrobial resistance (not usually detected or sought by common methods used for antibiotic resistance surveillance) might compromise the effectiveness of antibiotic chemotherapy.

A simple technique for applying local splintage to the fingers

We report a simple method of splinting the interphalangeal joints that we have employed as our standard technique without complication.

RNA content differs in slow and fast muscle fibers: implications for interpretation of changes in muscle gene expression

Quantification of a specific muscle mRNA per total RNA (e.g., by Northern blot analysis) plays a crucial role in assessment of developmental, experimental, or pathological changes in gene expression. However, total RNA content per gram of a particular fiber type may differ as well. We have tested this possibility in the distinct fiber types of adult rat skeletal muscle. Sections of single fibers were hybridized against 28S rRNA as a marker for RNA content. Quantification of the hybridization showed that the 28S rRNA content decreases in the order I>IIA>IIX>IIB, where Type I fibers show a five- to sixfold higher expression level compared to Type IIB fibers. Results were verified with an independent biochemical determination of total RNA content performed on pools of histochemically defined freeze-dried single fibers. In addition, the proportion of myosin heavy chain (MHC) mRNA per microgram of total RNA was similar in slow and fast fibers, as demonstrated by Northern blot analysis. Consequently, Type I fibers contain five- to sixfold more MHC mRNA per microgram of tissue than IIB fibers. These differences are not reflected in the total fiber protein content. This study implies that proper assessment of mRNA levels in skeletal muscle requires evaluation of total RNA levels according to fiber type composition.

Use of a vertical rectus abdominis myocutaneous flap in bilateral groin dissection for recurrent carcinoma of the penis

We present a 42-year-old man requiring bilateral groin dissection for recurrent squamous cell carcinoma of the penis. Tissue cover was obtained using a pedicled vertical rectus abdominis myocutaneous flap. This case is made interesting by the use of a unilateral flap to cover a large bilateral lower abdominal tissue defect, enabling minimal weakening of the abdominal wall, primary skin closure, and allowing early mobilization and hospital discharge.

[Newborn intestinal colonization by multidrug resistant enterobacteria in a neonatal unit]

OBJECTIVE: To evaluate the occurrence of intestinal colonization in newborns by multidrug-resistant enterobacteria strains (MDRES) during hospital stay after birth. We used selective media in an attempt to determine the relationship between isolation of these strains and some of the presumed colonization risk factors. METHOD: A sequencial inclusion study of 30 newborns was carried out in the neonatal unit of the HUPE, State University Hospital, a general 600-bed tertiary care hospital. We obtained clinical and epidemiological information from medical records and collected a fecal sample from each newborn, which was plated in gentamicin (8mg/ml) medium and potassium tellurite (25mg/ml) medium. The isolated strains were biochemically identified and also submitted to tests of antimicrobial susceptibility. Nine MDRES were submitted to an assay for plasmid conjugational transfer. RESULTS: We isolated 56 distinct MDRES from 14 among 30 newborns (46.7%). Klebsiella pneumoniae was the most common bacterial species (38/56 (68%). We found statistical association between individual MDRES isolation and presence of 3 or 4 of the following colonization risk factors considered: antimicrobial use, low weight (<2.500g), more than 6 days of hospitalization and artificial milk feeding (p< 0.02). We could detect plasmid resistance transfer by bacterial conjugation for 8 among 9 MDRES. CONCLUSION: The seletive cultura media were useful to detect the high frequence of newborns colonized by MDRES in association with well established infection risk factors. We emphasize the importance of reinforcing control rules aiming at preventing intestinal colonization viewed as a risk of nosocomial infection.

Leech-borne Serratia marcescens infection following complex hand injury

Leeches are commonly used in the postoperative course of plastic surgical operations where there is venous congestion in a pedicled or free flap. They provide a temporary relief to venous engorgement whilst venous drainage is re-established. It is known that leeches can carry Aeromonas hydrophila infection, and a second or third generation cephalosporin antibiotic has traditionally been given as prophylaxis against infection. We report a new observation that leeches can carry Serratia marcescens and give rise to clinically significant infection. The implication for prophylaxis and treatment of leech-associated cellulitis is discussed.

Circulating bile is the main factor responsible for atrial natriuretic peptide release in experimental obstructive jaundice

BACKGROUND

Biliary obstruction in the rabbit causes increased release of atrial natriuretic peptide (ANP). Circulating bile, raised biliary pressure or absence of bile in the duodenum may be implicated in this hepatocardiac syndrome.

METHODS

An experimental model was developed to elucidate the mechanism linking obstructive jaundice and increased plasma ANP. Hepatic and renal function, biliary tree pressure and ANP plasma concentrations were investigated in conscious rabbits 4 and 24 h after common bile duct ligation, biliovenous shunting or external drainage via a biliary fistula.

RESULTS

Bilirubin concentration increased after bile duct ligation and creation of a biliovenous shunt. Plasma creatinine increased abruptly in rabbits with a biliovenous shunt. At 4 h, the ANP increase in animals with a biliovenous shunt was ninefold that observed after bile duct obstruction while no change was noted after external biliary diversion (mean 350 versus 45 versus 9 fmol/l; P < 0.01). Relief of biliary tree obstruction was associated with a return of ANP levels towards basal normal values.

CONCLUSION

Raised plasma ANP in obstructive jaundice is not the result of an increased biliary pressure per se or absence of bile in the proximal duodenum but of the passage of bile components to the circulation.

[Mental health and general practice in Macao]

The aim of this study was to evaluate the prevalence of mental health disturbances and similar complaints within the general practice of Macao. From 1993 to 1995, 0.5% or 2-3 in each 1000 inhabitants per year, consulted their general practitioner (GP), with at least one of these complaints or symptoms. This also means that 1% of all the enrolled people in all the health centres (P.H.C.) were observed at least once a year, with health problems of this order. At the same time, 1% of all the general practitioner's consultations had been codified (ICHPPC-2 defined) with at least one of the selected 20 codes, defining mental problems (V and VI chapter). In spite of this we consider these values lower than the reality, concerning the peoples' cultural and social environment. One of the most important reasons may be the deficient training of PHC doctors on this subject. To improve the quality of the mental health care in general practice we suggest complementary training and a continuous supervision of a consulting psychiatrist. Each health centre or each small group of health centres should have one nominated psychiatrist to answer promptly to all the mental problems and help requested by GPs.

Complications following the use of the Marchetti flexible intramedullary nail

Twenty-seven patients, with eight femoral and 20 tibial fractures, were treated with the Marchetti/Vincenzi flexible intramedullary nail between March 1993 and May 1994 in a District General Hospital. Clinical and radiological reviews were performed on all patients except for one who died. There was a high complication rate in both groups (63.5 per cent femoral and 43 per cent tibial). Particularly common was coronal mal-alignment. Other complications included non-union, external rotation, and fracture shortening with proximal migration of the nail. These data suggest that flexible intramedullary nails do not give adequate stability to either femoral or tibial fractures. We believe they should not be used in the lower limb without external support or delayed weight bearing.

Through-flow revascularization of the tongue using a radial forearm free flap

Surgery for invasive squamous cell carcinoma involving the tongue base usually necessitates a total glossectomy because complete tumour resection requires sacrifice of both lingual arteries leaving a non-viable anterior tongue. A case is presented in which both lingual arteries were sacrificed to achieve complete tumour excision and the remaining anterior two-thirds of the tongue were successfully revascularized by through-flow from a radial forearm free flap which was used for pharyngeal reconstruction. This technique offers hope of preservation of the tongue when radical surgery would otherwise lead to its removal.

Increased cardiac endocrine activity after common bile duct ligation in the rabbit. Atrial endocrine cells in obstructive jaundice

OBJECTIVE

This study investigated the pathogenesis of water and sodium metabolism derangements in obstructive jaundice.

SUMMARY BACKGROUND DATA

Obstructive jaundice is associated with hypodipsia, depletion of extracellular water, alterations of the water and sodium regulating hormones, and an increased incidence of renal failure. Plasma atrial natriuretic factor (ANF) increases after common bile duct ligation in the rabbit. The present study was designed to investigate ANF-secreting cardiac atrial cells in this animal model.

METHODS

Plasma ANF and the percentage of atrial cells staining for ANF were determined in jaundiced and sham-operated rabbits at 24 (group OJ-24, n = 11; group SO-24, n = 5) and 72 hours (group OJ-72, n = 11; group SO-72, n = 5) after surgery. The atrial ANF content was also determined.

RESULTS

Plasma ANF was higher in jaundiced animals than in controls both at 24 (63 +/- 44 fmol/mL vs. 17 +/- 10 fmol/mL, p < 0.02) and at 72 hours (73 +/- 49 fmol/mL vs. 12 +/- 11 fmol/mL). In the two OJ groups, the percentage of positive ANF cells per 200-power field in the right atrial appendage was higher than in the SO groups both at 24 (62 +/- 11% vs. 31 +/- 12%, p < 0.003) and at 72 hours (56 +/- 18% vs. 31 +/- 12%, p < 0.01). Similar results were obtained in the right auricular wall. The percentage of positive ANF cells was significantly higher in the left atrium in which significant differences between the OJ and SO groups were also noted. The right atrial ANF content was higher in the OJ than in SO groups (437 +/- 323 pmol/mg of protein vs. 83 +/- 44 pmol/mg of protein).

CONCLUSIONS

Cardiac endocrine activity is increased in experimental obstructive jaundice. ANF may be involved in the pathogenesis of the renal and water and sodium metabolic disturbances present in this disease.

[Imaging of aortic aneurysms and dissections. Part 2. Aortic dissections]

The authors review the main imaging findings of aneurysms and dissections of the aorta. Based on the experience and imaging techniques available in their institution (Conventional Radiology, Sonography and Computed Tomography), they try to make a decision tree of radiologic procedures in ambulatory and emergency patients. Nowadays, in the majority of situations, these techniques allow the Radiologist to make the correct diagnosis, detect the complications and evaluate the patients in the pre and post-surgical phases. Other imaging techniques not available in their institution, such as Magnetic Resonance Imaging and Aortography, will be mentioned in view of their usefulness in some specific situations.

[Imaging of aneurysms and dissections of the aorta. Part 1--Aneurysms of the abdominal aorta]

The authors review the main imaging findings of aneurysms and dissections of the aorta. Based on the experience and imaging techniques available in their institution (Conventional Radiology, Sonography and Computed Tomography), they try to make a decision tree of radiologic procedures in ambulatory and emergency patients. Nowadays, in the majority of situations, these techniques allow the Radiologist to make the correct diagnosis, detect the complications and evaluate the patients in the pre and post-surgical phases. Other imaging techniques not available in their institution, such as Magnetic Resonance Imaging and Aortography, will be mentioned in view of their usefulness in some specific situations.

Use of a selective medium with potassium tellurite to follow intestinal colonization of hospitalized patients by drug-resistant Enterobacteriaceae

Nosocomial infections are a relevant factor in complicating the recovery of patients interned for even minor causes. In a attempt to determine their origin it is crucial to consider that their origin is of an endogenous nature. Looking for an accessible expression of intestinal colonization we analyzed fecal samples from 3 separate groups of hospital patients collected after different lengths of time. For practical reasons one group was studied prospectively and two other groups (patients hospitalized for up to 7 days and patients hospitalized for more than 7 days) were compared to one another. We looked for the emergence of tellurite resistance among Enterobacteriaceae using a selective medium, MacConkey potassium tellurite (MCPT). The frequency of prospectively studied patients with tellurite resistant strains was significantly greater after 7 days of hospitalization. For the two other groups, patients with more than 7 days of hospitalization showed a significant increase of bacterial species and of strains with new antimicrobial resistance markers. High molecular weight plasmids were detected in some of these strains. These data show that the MCPT medium is a useful tool for the investigation of bowel colonization in hospitalized patients by drug-resistant Enterobacteriaceae.

Treatment of gastrointestinal fistulas with Sandostatin

Pharmacological treatment of patients with enterocutaneous fistulas aims at reducing output, increasing the chance of spontaneous closure and reducing the time of fistula closure. Our initial experience with octreotide suggests that this drug effectively reduces output of established enterocutaneous fistulas when compared with a placebo in patients on parenteral nutrition. Output reduction was independent of the basal output. Likewise, this somatostatin analogue was shown to accelerate fistula closure in a series of 27 patients treated with the drug after having received parenteral nutrition for a mean of 25 days. When compared with a historical series, the rate of spontaneous fistula closure was not modified by octreotide.

[Human hydatidosis in Rio Grande do Sul (brazil): an estimate of its significance for the public health of the country]

By means of data collected through personal visits to hospitals and clinics in the 24 counties of Rio Grande do Sul held to be endemic for Echinococcus granulosus an assessment of the importance of this disease is attempted. (Barring new developments, these data reflect the situation in the country as a whole). The surgical incidence for 1990 was found to be 5.5 cases per 100 thousand inhabitants, far less than the rates for the neighboring countries. As concerns prevalence, in the absence of adequate population surveys the authors were forced to rely upon radiologic and echographic evidence available at various clinics throughout the area. The provisional prevalence rate thus adopted is 0.8 per thousand for lung cysts and 5.5 per thousand for abdominal cysts. According to the testimony of a group of local senior surgeons it appears that human hydatidosis is declining in Brazil. Such a conclusion gains further credibility on examination of the age distribution in the recent case series, as well as current investigations in veterinary medicine.

Rapid increase in plasma levels of atrial natriuretic peptide after common bile duct ligation in the rabbit

Previous studies have shown that common bile duct ligation in the rabbit is followed by a reduction of the extracellular water compartment. To further elucidate the mechanisms leading to volume depletion in this model, water and sodium balances and changes in plasma concentrations of atrial natriuretic peptide (ANP), vasopressin (ADH), plasma renin activity (PRA) and aldosterone (Ald) were investigated during the first 4 days after common bile duct ligation (group OJ,) or sham operation (group SO). Water and chow intakes were lower in group OJ (148 +/- 30 versus 226 +/- 40 mL/4 days; p = 0.004 and 12 +/- 9 versus 171 +/- 40 g/4 days; p = 0.0001). There were no differences in urine output. Sodium urinary losses were marginally higher in group OJ (12.4 +/- 7 versus 6.7 +/- 5 mEq/4 days; p = 0.06). Water balance was lower in group OJ (-50 +/- 56 versus 101 +/- 71 mL/4 days; p = 0.0001). At 24 hours, plasma ANP (41 +/- 7 versus 10.7 +/- 1 fmol/mL, p = 0.0001), ADH (21.8 +/- 7 versus 12.3 +/- 6 pg/mL, p = 0.008) and Ald (14.5 +/- 5 versus 3.7 +/- 3 ng/dL, p = 0.001) were higher in group OJ. These alterations persisted 72 hours after bile duct ligation, when a concomitant increase in PRA (10.7 +/- 5 versus 3 +/- 1.6 ng/dL, p = 0.006) was also observed. A group of pair-fed pair-watered sham-operated controls (group SO2, n = 13) showed a metabolic profile similar to group OJ but a low ANP concentration. Multiple venous sampling in five rabbits 24 hours after bile duct ligation showed the highest plasma levels of ANP in the aorta and infrarenal vena cava. These results suggest that common bile duct ligation in the rabbit is followed by marked hypodipsia and hypophagia, possibly mediated by ANP, leading to isotonic volume depletion and secondary activation of the water and sodium retaining hormones.

Technetium-99m distribution into Klebsiella pneumoniae

Bacteria labelled with radionuclide has been the subject of much investigation and has been applied in microbiological research. Technetium-99m (99mTc) may be an alternative radionuclide for the labelling of bacteria employed in various microbiological procedures. This radionuclide is easily available, is not expensive and presents important physical and biological characteristics. 99mTc-labelled bacteria are stable and their cell viability and biological properties are not modified. Study of the distribution of radioactivity in 99mTc-labelled Klebsiella pneumoniae cultures, after homogenization and differential centrifugation of the cells fractions, showed that this radionuclide was present inside the cell, mainly in a ribosomal fraction. Treatment of these fractions with enzymes and detergent revealed a high sensitivity to pronase and Triton X-100. After phenol extraction, a large percentage of radioactivity was detected in the phenol phase. Treatment of the soluble fraction with trichloroacetic acid at different temperatures showed that the concentration of 99mTc in the precipitate was lower at 100 degrees than at 4 degrees C. These results suggest that 99mTc binds mainly to the proteins in Klebsiella pneumoniae.

Proximal toe phalanx transplantation for bony stabilization and lengthening of partially aplastic digits

In congenital malformations the lengthening of partially aplastic digits, by on-top plasty of a bone graft or the bony stabilization of finger stumps consisting of soft tissues without skeletal elements, is extremely difficult. The usual bone graft, taken from the iliac crest or the fibula, will undergo resorption and will have disappeared a few months postoperatively. Experience has shown that the proximal toe phalanx will with-stand any resorption if it is taken whole, covered by its periosteum. Another advantage is the possibility of the construction of a new joint between the metatarsophalangeal articular surface of the toe phalanx and the distal end of the recipient bone in the hand, which is usually covered by cartilage. Flexor and extensor tendons exist in most cases. Between 1976 and 1988, 69 transplantations of proximal toe phalanges were performed in 43 children. The indications were: boneless digital stumps or partial absence of digits in symbrachydactyly and ring constriction syndrome. Follow-up examinations of 40 patients with 63 transplanted phalanges at an interval of 36 months (12 to 160 months) has shown a 100% take of the bone graft provided it had not been split and the periosteum was undamaged. The earlier in life the operation was performed, the more postoperative growth was recorded. A joint construction was attempted in 46 digits with variable results; active mobility ranged from 0 degrees to 90 degrees. With the use of a tendon interposition, there is a less degree of shortening of the toes.