A systematic review of information format and timing before scheduled adult surgery for peri-operative anxiety

We included 34 trials with 3742 participants, identified through 6 database and supplementary searches (to May 2017): 29 were randomised; 4 were quasi-randomised and 1 was cluster-randomised. Disparate measurements and outcomes precluded meta-analyses. Blinding was attempted in only 6 out of 34 (18%) trials. A multimedia format, alone or in combination with text or verbal formats, was studied in 20/34 (59%) trials: pre-operative anxiety was unaffected in 10 out of 14 trials and reduced by the multimedia format in three; postoperative anxiety was unaffected in four out of five trials in which formats were compared. Multimedia formats increased knowledge more than text, which in turn increased knowledge more than verbal formats. Other outcomes were unaffected by information format. The timing of information did not affect pre-operative anxiety, postoperative pain or length of stay. In conclusion, the effects of pre-operative information on peri-operative anxiety and other outcomes were affected little by format or timing.

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review

Difficulties with tracheal intubation commonly arise and impact patient safety. This systematic review evaluates whether videolaryngoscopes reduce intubation failure and complications compared with direct laryngoscopy in adults. We searched CENTRAL, MEDLINE, Embase and clinicaltrials.gov up to February 2015, and conducted forward and backward citation tracking. We included randomized controlled trials that compared adult patients undergoing laryngoscopy with videolaryngoscopy or Macintosh laryngoscopy. We did not primarily intend to compare individual videolaryngoscopes. Sixty-four studies (7044 participants) were included. Moderate quality evidence showed that videolaryngoscopy reduced failed intubations (Odds Ratio (OR) 0.35, 95% Confidence Interval (CI) 0.19-0.65) including in participants with anticipated difficult airways (OR 0.28, 95% CI 0.15-0.55). There was no evidence of reduction in hypoxia or mortality, but few studies reported these outcomes. Videolaryngoscopes reduced laryngeal/airway trauma (OR 0.68, 95% CI 0.48-0.96) and hoarseness (OR 0.57, 95% CI 0.36-0.88). Videolaryngoscopy increased easy laryngeal views (OR 6.77, 95% CI 4.17-10.98) and reduced difficult views (OR 0.18, 95% CI 0.13-0.27) and intubation difficulty, typically using an 'intubation difficulty score' (OR 7.13, 95% CI 3.12-16.31). Failed intubations were reduced with experienced operators (OR 0.32, 95% CI 0.13-0.75) but not with inexperienced users. We identified no difference in number of first attempts and incidence of sore throat. Heterogeneity around time for intubation data prevented meta-analysis. We found evidence of differential performance between different videolaryngoscope designs. Lack of data prevented analysis of impact of obesity or clinical location on failed intubation rates. Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a videolaryngoscope reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a videolaryngoscope affects time required for intubation.

Nitrous oxide-based vs. nitrous oxide-free general anaesthesia and accidental awareness in surgical patients: an abridged Cochrane systematic review

Accidental awareness during general anaesthesia can arise from a failure to deliver sufficient anaesthetic agent, or from a patient's resistance to an expected sufficient dose of such an agent. Awareness is 'explicit' if the patient is subsequently able to recall the event. We conducted a systematic review into the effect of nitrous oxide used as part of a general anaesthetic on the risk of accidental awareness in people over the age of five years undergoing general anaesthesia for surgery. We included 15 randomised controlled trials, 14 of which, representing a total of 3439 participants, were included in our primary analysis of the frequency of accidental awareness events. The awareness incidence rate was rare within these studies, and all were considered underpowered with respect to this outcome. The risk of bias across all studies was judged to be high, and 76% of studies failed adequately to conceal participant allocation. We considered the available evidence to be of very poor quality. There were a total of three accidental awareness events reported in two studies, one of which reported that the awareness was the result of a kink in a propofol intravenous line. There were insufficient data to conduct a meta- or sub-group analysis and there was insufficient evidence to draw outcome-related conclusions. We can, however, recommend that future studies focus on potentially high-risk groups such as obstetric or cardiac surgery patients, or those receiving neuromuscular blocking drugs or total intravenous anaesthesia.

The physics of Martian weather and climate: a review

The planet Mars hosts an atmosphere that is perhaps the closest in terms of its meteorology and climate to that of the Earth. But Mars differs from Earth in its greater distance from the Sun, its smaller size, its lack of liquid oceans and its thinner atmosphere, composed mainly of CO(2). These factors give Mars a rather different climate to that of the Earth. In this article we review various aspects of the martian climate system from a physicist's viewpoint, focusing on the processes that control the martian environment and comparing these with corresponding processes on Earth. These include the radiative and thermodynamical processes that determine the surface temperature and vertical structure of the atmosphere, the fluid dynamics of its atmospheric motions, and the key cycles of mineral dust and volatile transport. In many ways, the climate of Mars is as complicated and diverse as that of the Earth, with complex nonlinear feedbacks that affect its response to variations in external forcing. Recent work has shown that the martian climate is anything but static, but is almost certainly in a continual state of transient response to slowly varying insolation associated with cyclic variations in its orbit and rotation. We conclude with a discussion of the physical processes underlying these long- term climate variations on Mars, and an overview of some of the most intriguing outstanding problems that should be a focus for future observational and theoretical studies.

Systematic review and meta-analysis of enhanced recovery programmes in surgical patients

BACKGROUND

Enhanced recovery programmes (ERPs) have been developed over the past 10 years to improve patient outcomes and to accelerate recovery after surgery. The existing literature focuses on specific specialties, mainly colorectal surgery. The aim of this review was to investigate whether the effect of ERPs on patient outcomes varies across surgical specialties or with the design of individual programmes.

METHODS

MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials were searched from inception to January 2013 for randomized or quasi-randomized trials comparing ERPs with standard care in adult elective surgical patients.

RESULTS

Thirty-eight trials were included in the review, with a total of 5099 participants. Study design and quality was poor. Meta-analyses showed that ERPs reduced the primary length of stay (standardized mean difference -1·14 (95 per cent confidence interval -1·45 to -0·85)) and reduced the risk of all complications within 30 days (risk ratio (RR) 0·71, 95 per cent c.i. 0·60 to 0·86). There was no evidence of a reduction in mortality (RR 0·69, 95 per cent c.i. 0·34 to 1·39), major complications (RR 0·95, 0·69 to 1·31) or readmission rates (RR 0·96, 0·59 to 1·58). The impact of ERPs was similar across specialties and there was no consistent evidence that elements included within ERPs affected patient outcomes.

CONCLUSION

ERPs are effective in reducing length of hospital stay and overall complication rates across surgical specialties. It was not possible to identify individual components that improved outcome. Qualitative synthesis may be more appropriate to investigate the determinants of success.

Activity of telavancin against heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) in vitro and in an in vivo mouse model of bacteraemia

OBJECTIVES

Infections caused by heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) are associated with high rates of vancomycin treatment failure. Telavancin is a bactericidal lipoglycopeptide active in vitro against Gram-positive pathogens including hVISA and vancomycin-intermediate S. aureus (VISA). This study characterizes the microbiological activity of telavancin against vancomycin-susceptible S. aureus (VSSA), hVISA and VISA strains.

METHODS

Reference strains of VSSA, hVISA and VISA were assessed for potential telavancin heteroresistance by population analysis. In addition, the efficacies of telavancin (40 mg/kg subcutaneously every 12 h for 4 days) and vancomycin (110 mg/kg subcutaneously every 12 h for 8 days) were compared in a neutropenic murine model (immunocompromised female non-Swiss albino mice) of bacteraemia caused by hVISA strain Mu3. Blood and spleen bacterial titres were quantified from cohorts of mice euthanized pre-treatment and at 24 h intervals post-treatment for 8 days.

RESULTS

Telavancin was active against all strains of S. aureus tested, with MIC values < or =0.5 mg/L. Population analyses revealed no evidence of subpopulations with reduced susceptibility to telavancin. In the murine bacteraemia model of hVISA infection, all animals were bacteraemic pre-treatment and mortality was 100% within 16-24 h post-infection in untreated animals. Treatment with telavancin was associated with lower spleen bacterial titres, lower rates of bacteraemia and lower overall mortality than treatment with vancomycin.

CONCLUSIONS

These in vitro and pre-clinical in vivo studies demonstrate that telavancin has the potential to be efficacious in infections caused by hVISA.

NPY-induced feeding: pharmacological characterization using selective opioid antagonists and antisense probes in rats

The ability of neuropeptide Y to potently stimulate food intake is dependent in part upon the functioning of mu and kappa opioid receptors. The combined use of selective opioid antagonists directed against mu, delta or kappa receptors and antisense probes directed against specific exons of the MOR-1, DOR-1, KOR-1 and KOR-3/ORL-1 opioid receptor genes has been successful in characterizing the precise receptor subpopulations mediating feeding elicited by opioid peptides and agonists as well as homeostatic challenges. The present study examined the dose-dependent (5-80 nmol) cerebroventricular actions of general and selective mu, delta, and kappa1 opioid receptor antagonists together with antisense probes directed against each of the four exons of the MOR-1 opioid receptor gene and each of the three exons of the DOR-1, KOR-1, and KOR-3/ORL-1 opioid receptor genes upon feeding elicited by cerebroventricular NPY (0.47 nmol, 2 ug). NPY-induced feeding was dose-dependently decreased and sometimes eliminated following pretreatment with general, mu, delta, and kappa1 opioid receptor antagonists. Moreover, NPY-induced feeding was significantly and markedly reduced by antisense probes directed against exons 1, 2, and 3 of the MOR-1 gene, exons 1 and 2 of the DOR-1 gene, exons 1, 2, and 3 of the KOR-1 gene, and exon 3 of the KOR-3/ORL-1 gene. Thus, whereas the opioid peptides, beta-endorphin and dynorphin A(1-17) elicit feeding responses that are respectively more dependent upon mu and kappa opioid receptors and their genes, the opioid mediation of NPY-induced feeding appears to involve all three major opioid receptor subtypes in a manner similar to that observed for feeding responses following glucoprivation or lipoprivation.

Effect of menstrual cycle on HIV-1 levels in the peripheral blood and genital tract. WHS 001 Study Team

OBJECTIVE

To assess the variation in HIV-1 over the menstrual cycle, including RNA levels in the female genital tract, plasma HIV-1-RNA levels, CD4 cell counts, and culturable virus.

DESIGN

A prospective analysis of 55 HIV-1-infected women.

METHODS

Blood and genital tract specimens were collected weekly over 8 weeks, spanning two complete menstrual cycles. Applying repeated-measures models that used menses as the reference level, the variation in viral RNA levels was compared in endocervical canal fluid and cells (collected by Sno-strips and cytobrush, respectively) and ectocervicovaginal lavage (CVL) fluid. Repeated-measures models were also used to assess the variation in plasma CD4 cell counts and viral load.

RESULTS

Shedding patterns differed among the three sampling methods, independent of genital tract co-infections. Genital tract HIV-1-RNA levels from CVL fluid and endocervical canal cytobrush specimens were highest during menses and lowest immediately thereafter (P = 0.001 and P = 0.04). The HIV-1-RNA level in endocervical canal fluid was highest in the week preceding menses (P = 0.003). The menstrual cycle had no effect on blood levels of RNA (P = 0.62), culturable virus (P = 0.34), or CD4 cell counts (P = 0.55). HIV-1-RNA levels were higher in endocervical canal fluid than in peripheral blood plasma during the late luteal phase (P = 0.03).

CONCLUSION

HIV-1-RNA levels vary with the menstrual cycle in the female genital tract but not the blood compartment. HIV-1-RNA levels are higher in endocervical canal fluid than in blood plasma. These findings may have important implications for sex-specific pathogenesis, heterosexual transmission, and contraceptive hormone interventions in HIV-1-infected women.

Cloning of the mouse somatostatin receptor subtype 5 gene: promoter structure and function

Somatostatin is a peptide hormone whose actions are mediated by five somatostatin receptor subtypes (sstl-5). In the pituitary, somatostatin inhibits TSH release from thyrotropes and GH release from somatotropes. We have shown that sst5 transcripts and protein are induced by thyroid hormone in TtT-97 thyrotropic tumors. To map sequences responsible for promoter activity in pituitary cells, we cloned the mouse sst5 coding region of 362 amino acids and 12 kb of upstream DNA. Initial transfection studies in TtT-97 or GH3 cells mapped high levels of basal promoter activity to a 5.6-kb fragment upstream of the translational start, whereas shorter genomic fragments had low activity. To identify the transcriptional start site we used 5' RACE with TtT-97 poly A+ RNA and a sst5 antisense coding region primer. Sequence comparison between the complementary DNA and the gene revealed that the mouse sst5 gene contains 3 exons and 2 introns. The entire coding region was contained in exon 3. Two differently sized RACE products demonstrated alternate exon splicing of two untranslated exons in TtT-97 cells. A promoter fragment from -290/+48 linked to a luciferase reporter demonstrated 600- and 900-fold higher activity over a promoterless control in GH3 mammosomatotropes and TtT-97 thyrotropes, respectively, whereas a larger fragment extending to -6400 exhibited no additional promoter activity. Cloning of the sst5 gene will facilitate the mapping of basal and regulated responses at the transcriptional level.

Cigarettes, alcohol, marijuana, other risk behaviors, and American youth

Increases in adolescent marijuana and other drug use have created widespread concern. One theory argues that increased use of cigarettes and alcohol among younger adolescents leads to greater use of marijuana which, in turn, leads to subsequent use of other drugs (e.g. cocaine, heroin, hallucinogens). Detractors of this theory claim that use of these substances is a symptom of a larger set of destructive behaviors (e.g. violence, suicide, promiscuous sex), and marijuana has no independent effect on the use of other more serious drugs. The authors examined whether, for high school seniors, early use of cigarettes, alcohol and marijuana has an independent effect on more serious drug use even when other behaviors are considered. Using the 1995 Youth Risk Behavior Survey (n = 2871) and logistic analysis, after accounting for selected other behaviors, seniors using cigarettes before age 13 were 3.3 (95% C.I. 2.3,4.6) times likelier to have used marijuana than ones who never smoked; for alcohol, the odds ratio was 4.5 (2.6,7.7). Seniors using marijuana before the age of 14 were 7.4 times (4.0,13.6) likelier to have used other drugs. Though no causal effect is demonstrated, cigarette and alcohol use was associated with the likelihood of marijuana use; marijuana use was associated with the likelihood of other drug use, even after selected other risk and protective behaviors were considered.

Pit-1 and GATA-2 interact and functionally cooperate to activate the thyrotropin beta-subunit promoter

The molecular determinants governing cell-specific expression of the thyrotropin (TSH) beta-subunit gene in pituitary thyrotropes are not well understood. The P1 region of the mouse TSHbeta promoter (-133 to -88) region interacts with Pit-1 and an additional 50-kDa factor at an adjacent site that resembles a consensus GATA binding site. Northern and Western blot assays demonstrated the presence of GATA-2 transcripts and protein in TtT-97 thyrotropic tumors. In electrophoretic mobility shift assays, a comigrating complex was observed with both TtT-97 nuclear extracts and GATA-2 expressed in COS cells. The complex demonstrated binding specificity to the P1 region DNA probe and could be disrupted by a GATA-2 antibody. When both Pit-1 and GATA-2 were combined, a slower migrating complex, indicative of a ternary protein-DNA interaction was observed. Cotransfection of both Pit-1 and GATA-2 into CV-1 cells synergistically stimulated mouse TSHbeta promoter activity 8.5-fold, while each factor alone had a minimal effect. Mutations that abrogated this functional stimulatory effect mapped to the P1 region. Finally, we show that GATA-2 directly interacts with Pit-1 in solution. In summary, these data demonstrate functional synergy and physical interaction between homeobox and zinc finger factors and provide insights into the transcriptional mechanisms of thyrotrope-specific gene expression.

Reconstruction of the burned palm: full-thickness versus split-thickness skin grafts--long-term follow-up

The long-term results of full-thickness (N = 11) and split-thickness (N = 14) skin grafts for reconstitution of the palmar surface following release of palmar burn scar contractures in pediatric patients are compared. Patients treated with full-thickness skin grafts required 1.2 +/- 0.4 operations (mean +/- SD). Patients treated with split-thickness skin grafts required 1.3 +/- 0.6 operations (mean +/- SD). No significant difference in the number of operative procedures was noted. No functional difference existed between the two groups. The use of split-thickness skin grafts provided comparable function without increased operative procedures and was less deforming. Increased use of split-thickness skin grafts following release of palmar burn scar contractures in pediatric patients should be considered.

Routine use of a suction drain in facial rhytidoplasty

The effectiveness of a suction drain in facial rhytidoplasty was evaluated in 46 women ranging in age from 41 to 78 years. The drain was placed on the left side of the face in 16 and on the right in 14, and no drain was used in 16 patients. The drain was removed in 24 hours regardless of the amount aspirated, which varied between 0 and 25 ml, with an average of 7.8 ml. Although none of these patients developed a hematoma while the drain was in place, a hematoma did occur in 1 patient on the drain side following its removal. Despite the variable quantities of fluid aspirated, there was no clinical difference in swelling noted around the face and neck area when the two sides were compared. Similarly, one could not distinguish this group of patients from those 16 who did not receive the drain. The routine use of continuous suction drains for patients undergoing rhytidoplasty is therefore probably unnecessary.

Restoration of the upper lip and nasolabial area by means of an intraoral approach

Superomedial repositioning of the superficial musculoaponeurotic system (SMAS) in the upper lip is accomplished by means of intraoral incisions. The procedure reestablishes the convexity of the lateral vermilion border, elevates the upper lip, and restores a more youthful appearance to the upper-lip profile. Depth of the nasolabial folds are reduced. We have performed this procedure on 14 patients. Follow-up intervals range from 6 to 20 months, averaging 14 months. All patients received concomitant rhytidectomy; usual operative time was increased by 20 minutes. Results have been rated good to excellent by patients and surgeons. There have been no recurrences of nasolabial fold deepening or upper lip depression, and there have been no complications. In selected patients, this procedure, along with rhytidectomy, may provide a more youthful appearance.

Tissue injuries associated with parenteral propylhexedrine abuse

Propylhexedrine, the active ingredient in Benzedrex Inhalers, is extracted from the wicks of the inhalers by drug abusers for intravenous injection to provide a "desirable high." Six representative cases treated over a one-year period are presented to exemplify the potential for soft tissue injury. Because the actual constituents of the injected material prepared from the inhalers were not established, solutions were prepared from Benzedrex Inhalers according to the formula provided by one of the patients. The extract was then subjected to vigorous qualitative and quantitative analyses; the presence of essentially pure propylhexedrine hydrochloride was confirmed in varying concentrations. To examine the progression of injury following injection of the prepared extract, the ears of 12 New Zealand white rabbits were injected either intra-arterially or subcutaneously. The opposite ear of each rabbit served as a control. Both clinical and pathologic observations demonstrated injury consistent with intense local vasoconstriction. Injury did not appear to relate to impurities in the solution or other embolic phenomena. Finally, the laboratory findings are discussed with regard to the clinical examples. In sum, the insult to tissue from intravascular or local injection with propylhexedrine appears to respond, although poorly, to efforts to reverse the intense pharmacologic vasoconstriction.

A circumareolar approach in surgical management of gynecomastia

Gynecomastia is a common deformity encountered among male patients. Surgery is primarily aimed at reducing the size of the breast mound and therefore should be considered aesthetic in nature. In an attempt to minimize the problems of hematoma formation, nipple necrosis, and unsightly scarring around the upper torso after the surgery, we have had the opportunity to utilize a circumareolar approach for breast tissue removal in 33 breasts (24 patients). This method, when compared with other techniques, has the advantage of leaving minimal scarring around the areolar margin while obliterating the dead space by imbricating the tissue stalk to minimize hematoma formation.

A histological study of the lower tarsus and the significance in the surgical management of a involutional (senile) entropion

The dimension of the lower tarsus diminishes with aging. Changes in the number and size of the meibomian glands and in the character of intermingling fibroconnective tissues are thought to be responsible. Furthermore, such alterations of the structural integrity play an important role in the pathogenesis of entropion encountered commonly in the elderly. We have advocated the use of an autogenous cartilage graft harvested from the ear to correct the deformity, especially in instances where the conventional methods of correction have failed.

Hats for the newborn infant

The efficacy of a Gamgee-lined hat in reducing the rate of fall in rectal temperature of infants during the first 30 minutes of life was studied. The trial, which included 211 infants, was randomised, prospective, and controlled. One hundred and seven infants were exposed to overhead radiantheaters. Of these, only 30 had normal deliveries, so the analysis was confined to the infants who were not subjected to radiant heat, and in this group no conclusions were drawn about the efficacy of a hat or a radiant heater. In the 104 infants not subjected to radiant heat, body weight, initial rectal temperature, the application of hat, the environmental temperature, and the duration of exposure while naked were all found to influence measureably the rate of fall in rectal temperature during the first 30 minutes. Gamgee-lined hats should be routinely used to minimise heat loss, especially in small infants exposed at birth, during surgical operations, and during investigations necessitating prolonged exposure.

Outpatient breast surgery under intercostal block anesthesia

During the past 3 years, we have performed various breast operations in 320 patients under local anesthesia, using intercostal nerve block. The amount of local anesthetic solution required has been about 20 ml 1% lidocaine for blocking both sides, and an additional 24 ml of 0.5% lidocaine during the surgery. This dosage is well within safe limits. We have found that various breast operations, ranging from augmentation mammaplasty to a staged reconstruction after mastectomy, can be done with this method of anesthesia. The complications attributable to the nerve block were nil in our series.

Burn injuries of the eyelids

Burns of the eyelid and surrounding structures are relatively uncommon in spite of a high incidence of thermal injuries involving the face. The etiologic factors, circumstances that precipitated the injury, and the anatomical features unique to the eyelid and adnexal area may conceivably account for the low incidence. The basic aims in reconstructing deformities must include primarily measures of protecting corneal exposure and relieving epiphora. Early reconstruction of other deformities such as epicanthal folds, palpebral stenosis, and missing eyebrows and eyelashes should be discouraged because of frequent recurrence of deformities due to contracting scars and scar hypertrophy.

Hand deformities in patients with snakebite

Over the past 25 years, 83 patients have been treated at our hospitals for poisonous snakebites of the hand. Prior to 1970, polyvalent antivenin was used, either alone or in conjunction with cryotherapy, steroids, or incision and suction methods. Hand deformities, due to tissue necrosis, were encountered in 15 of 22 patients (68%) treated by these methods. In contrast, excisional therapy, without the use of polyvalent antivenin, was the sole method of treatment in 61 patients seen since 1970. The incidence of hand deformity in them was 8.2%. We have concluded that early excision of the envenomated tissues will not only curtail systemic toxicity from the injected venom, but will also minimize the extent of local tissue damage.

Migration of silicone gel after the "squeeze technique" to rupture a contracted breast capsule. Case report

While the squeeze capsulotomy is a simple and effective method for managing capsular contracture around a breast implant, with extreme force the rupture of the prostheses can occur. With the concomitant use of a pressure dressing and breast massage, there was distant migration of the extravasated gel in one case, so this should be considered as a potential complication of this technique.

Ten years of experience in managing patients with burn contractures of axilla, elbow, wrist, and knee joints

An analysis of 625 patients who had sustained burns across the axillae, elbows, wrists, or knee joints indicates that the use of splints and pressure across these joints will not only greatly decrease the incidence of contractures but will also reduce the frequency and need for release operations. However, these appliances must be used for at least 6 months (longer, if possible), if substantial benefits are to be obtained.

Burn alopecia

Our experience in managing 117 patients with burn alopecia are presented. Most often we used staged excisions of the scarred scalp areas, and by this means we could cover up to 15 percent of the scalp. When the alopecia involved the anterior portion of the scalp, however, a rotational scalp flap was needed to restore the anterior hairline and/or sideburns. For those with burn alopecia of more than 60 percent of the scalp surface, no surgical treatment was effective; the women would often cover their scalps with hairpieces, but the men in our series preferred not to do so.

Retrobulbar hemorrhage

Retrobulbar hemorrhage is a rare complication of orbital trauma or surgery. Although the process is usually self-limiting, infrequently visual impairment may result. Various methods for relieving the associated intraocular hypertension (caused by the extraocular compression posteriorly) have been suggested. The effectiveness of some remains questionable. To reassess the effectiveness of conservative management of this problem, we reviewed the medical records of all 10 patients who had had retrobulbar hemorrhage at our institution during the past 8 years. Additionally, we did an experimental study on rabbits to evaluate the visual effects of a transient but abnormally high intraorbital pressure. The results are reported.

Reconstruction of eyelids and eyebrows in burned patients

The records of 283 consecutive patients treated for facial burns were reviewed. Eighteen percent of these patients had significant deformities of the eyelids or adnexal structures and underwent surgical correction. Our experience in managing these patients is presented and discussed.

Relative hypoxemia during rhytidoplasty

The results of blood gas analyses in 24 patients who had a rhytidoplasty under local anesthesia indicated that a moderate degree of hypoxemia can be elicited in these patients when they have had standard doses of the usual sedatives. While the acid-base abnormalities were generally corrected spontaneously, the extent of the hypoxemia can be aggravated further by the additional use of diazepam during the operation. Therefore, over-sedation of such a patient during the operation, without a secured airway, must be avoided. Additionally, we recommend deep breathing at frequent intervals, with or without supplemental oxygen through a high flow system.

Thumb reconstruction in the severely burned hand

The standard techniques have generally been adequate for thumb reconstruction in the severely burned hand. The basic principles of preservation of length, prevention of malposition and contracture by appropriate splinting, early motion, and early skin coverage are all applicable. The nature of the tissue changes wrought by the burn wound, however, frequently necessitates certain modifications in the approach to surgical reconstruction. We have described these and our methods used in handling 9 specific cases.

Prevention and management of contractures in patients with burns of the neck

Two hundred patients with neck burns were analyzed to determine the incidence of contractures. It was found that only 8 per cent of patients with second degree burns had contractures, all of which were mild. Both the overall incidence of cervical contractures in patients with third degree neck burns and their severity can be decreased by the use of a custom-formed isoprene splint. Splinting should begin as soon as possible after the burn and continue until scar maturation is complete.

Burned hands

Hand involvement is common in patients with severe burns. Our experience indicates that almost one-third of the patients admitted to the Shriner's Burns Institute and The University of Texas Medical Branch Hospitals with burns exceeding 30 per cent of the body surface had concomitant burns of the hand. Our approach in managing the burned hand during the acute phase of unjury, as well as during secondary reconstruction of the deformities, is presented and discussed.

The use of excisional therapy in the management of snakebite

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Lack of temperature control in infants with abnormalities of central nervous system

The temperature control of 11 infants with severe abnormalities of the central nervous system has been investigated. 4 were normothermic and 7 poikilothermic. Necropsy of the latter showed that either the hypothalamus was absent or disorganized, or the long tracts through the brainstem were unidentifiable, or in one case interrupted by a cervical myelocele. The lateral horn cells, sympathetic nervous system, and brown fat appeared normal. Where the normal reflex responses to warm and cool stimuli were absent, direct stimulation of the effector organs was attempted. Noradrenaline both stimulated heat production and constricted the peripheral skin vessels. Surprisingly, local application of pilocarpine or acetyl choline failed to stimulate the sweat glands which appeared normal at necropsy.