Salvage of avascular bone from frostbite with free tissue transfer

Traditional management of frostbite injury of the hands and fingers has been to allow demarcation to occur between viable and nonviable tissues, corresponding to the level of amputation required. In this case report, phalangeal length in mummified digits was maintained with free tissue transfer followed by evidence of bony revascularization on bone scan. Rather than waiting for tissue demarcation to occur, the authors propose that consideration be given to debridement of soft tissues in the frostbitten fingers followed by free tissue transfer to salvage length and function in the digital bony skeleton.

Breastfeeding triplets: the at-home experience

The unprecedented rise in higher-order multiple (HOM) births and the subsequent increase in parents who want to breastfeed their babies presents community health nurses (CHNs) with complex challenges. The extraordinary diversity of the triplet breastfeeding experience once all infants are settled at home is illustrated through findings from a survey of nine mothers of triplets. Parents revealed how they managed the feedings over the multiples' first year: type of feedings (breast, expressed breast milk [EBM], formula); scheduled and demand feedings; adequacy of milk supply; frequency and duration of feedings; consecutive and simultaneous feedings; nighttime with three; weaning; effects of breastfeeding on their bodies and well-being; challenges and stresses; and spousal, family, and health professional attitudes and support. A number of strategies that CHNs can utilize are suggested. These include working with individual families as well as forming partnerships with parents of multiples' support groups, multiple birth associations, interested health professionals, and the community sector. It is through these actions that the accessibility, coordination, and quality of health, multiple birth education, and social support services can be strengthened and healthy public policies implemented which address the unique and enormous demands experienced by HOMs' families.

Depression and anxiety disorders during multiple pregnancy and parenthood

Depression or anxiety disorders may affect more than 25% of multiple birth parents during the perinatal period. Such parents often are uninformed, suffer in silence and fear, and are reticent to seek help. When depression, panic attacks, and obsessive-compulsive disorder are not recognized or are left untreated, parent health, parent-infants interaction, child development, and family stability may be seriously compromised. Nurses, as partners in care at the family and community levels, have a pivotal role to play in prevention-focused health, education, and social support programs; the identification of parents at risk; and the early recognition and support of women and families affected by these disorders.

Primary Health Care and Partnerships: Collaboration of a Community Agency, Health Department, and University Nursing Program

Health care reform proposals emphasize health care that is essential, practical, scientifically sound, coordinated, accessible, appropriately delivered, and affordable. One route to achievement of improved health outcomes within these parameters is the formation of partnerships. Partnerships adopting the philosophy and five principles of Primary Health Care (PHC) focus on health promotion and prevention of illness and disability, maximum community participation, accessibility to health and health services, interdisciplinary and intersectoral collaboration, and use of appropriate technologies such as resources and strategies. A community service agency serving a multicultural population initiated a partnership with a health department and a university undergraduate nursing program. The result was a preschool health fair and there were benefits for each partner-benefits which could not have been realized without the collaboration. The health fair partnership planning, implementation, and evaluation process was guided by a framework shaped by the philosophy and five principles of PHC. The educational process described can be applied to other learning experiences where the goal is to help students understand and apply the concepts of PHC, develop myriad nursing competencies, and form collaborative relationships with the community and health agencies. Community health care dilemmas and nursing education challenges can be successfully addressed when various disciplines and sectors form effective partnerships.

Analysis of microvascular changes in frostbite injury

Reported here is the characterization of the hairless mouse ear as a model system for defining the microvascular effects of minimal frostbite injury by means of gross, in vivo microscopic, histologic, and electron microscopic analysis. Initial efforts, using controlled temperatures and time of freezing, defined the minimum conditions necessary to produce consistent tissue necrosis to be -4 degrees C for 3 min. In vivo observation, after rapid thaw, showed a return of blood flow to apparent normal prefreeze rates, followed by a gradual sludging of blood 15 to 20 min post-thaw and eventually in cessation of blood flow. No vascular spasm was observed. Histologic and electron microscopic examination, unexpectedly, did not reveal evidence of early platelet or fibrin thrombi. However, marked vasodilatation and circulatory congestion began 2-3 hr after thawing. Subsequently, prominent discontinuities between damaged endothelial cells and breaks in the microvascular basement membranes were found at the light and ultrastructural level. Interstitial edema and extravasated erythrocytes occurred shortly thereafter, preceding gross tissue necrosis evident at post-freeze Day 3. We conclude that in this animal system thrombus formation is not an initial event, but rather that vascular injury in the form of endothelial cell damage predominates in early frostbite injury.

The development of a rat/human skin flap served by a defined and accessible vasculature on a congenitally athymic (nude) rat

Experience in microvascular surgery on rats and availability of athymic (nude) rats led us to believe that a long-term functional rat/human skin sandwich flap could be generated on a defined and experimentally accessible vasculature on nude rats. Such a system has been developed and validated. Microvasculature has been assessed. The volume of blood to the flap ranges from 1 to 2 ml/min, collateral circulation to the flap exists, but is negligible, and there is little change in the capillary blood flow as the flap ages. The flap can be utilized to study absorption of compounds from a half-cell diffusion chamber or from direct deposition on the skin, and can be utilized to study various parameters of percutaneous absorption, e.g., the effect of hydration on the stratum corneum. Transdermal flux can be determined. Altering the microcirculation directly affects the percutaneous absorption of compounds that are rapidly absorbed. The absorption of benzoic acid through an experimentally vasoconstricted area (iontophoresis of phenylephrine) significantly alters the time to peak absorption, with values being 14 times that of the control site. The system has been utilized to assess metabolic activity of skin in situ using [3H]adenine arabinoside and studying the appearance of its major metabolite, [3H]Ara-H, in flap blood, as well as the back diffusion of this compound into the donor chamber. Recently the human/rat skin sandwich flap component has been developed. With this system, it has been demonstrated that benzoic acid, when applied to the human skin component of the flap has an absorption profile which is quite different from that when benzoic acid is applied to rat skin, peak flux occurred 2 hr after application. This contrasts with 10 min to peak flux when the same experiment is carried out on the rat/rat skin sandwich flap. To our knowledge, the human/rat skin sandwich flap is the first example of a viable, functional human organ that is chronically maintained by a biologic support system which has the added distinction of being on an independent but accessible vasculature. The validation experiments strongly suggest that this system will be important in gaining insights into the more sophisticated in vivo components of skin, relative to toxicology and pharmacology.

Sagittal fractures of the maxilla and palate

Sagittal fractures of the maxilla and palate are infrequent and can demonstrate significant instability with conventional methods of treatment. They require that rigid, horizontal stability of the dentition be obtained, as well as restoration of midface projection and height. The most effective and precise management has utilized a combination of open reduction and internal fixation at the piriform aperture and zygomatic buttress and posterior palate, use of a maxillary arch bar as a tension band, and utilization of a palatal splint.

Chemical burns: effect of prompt first aid

Chemical burns account for a relatively small proportion of the patients treated within a burn center; however, certain characteristics of these injuries, particularly in the initial stages of treatment, justify their separate consideration and review. Thirty-five patients were treated in the Baltimore Regional Burn Center from July 1976 through June 1980, with 14 different agents involved. The majority of injuries were work related; however, 20% were the result of assault. All patients received copious water lavage as primary therapy. In approximately one half of the patients this was begun as a first-aid measure at the scene of the accident. Compared to the group which did not receive lavage until admission to the hospital, the patients receiving appropriate first aid showed significantly less full-thickness injury and more than twofold shorter hospital stay, indicating the importance of public and industrial medical awareness of the role of immediate copious lavage. The problems of systemic toxicity with and specific therapy for certain agents is discussed with particular attention given to an unusual case involving cutaneous absorption of dichromate.

Adjunctive use of intravenous fluorescein in the tangential excision of burns of the hand

The use of fluorescein as an aid to the differentiation of viable from nonviable tissue facilitates early tangential excision of hand burns. This technique, applied as part of an overall treatment program that includes immediate autografting with unexpanded meshed grafts and early mobilization, has resulted in excellent functional recovery from a potentially devastating injury.

Craniofacial coverage using the latissimus dorsi myocutaneous island flap

The latissimus dorsi myocutaneous island flap adds a new dimension to head and neck reconstruction. With it, massive defects of the neck, face, and cranium can be covered in a single-stage procedure.