ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Traditional medical ethics is based on the relationship between the individual physician and his or her patient. Managed care organizations, particularly under capitation, threaten this relationship, raising concerns about conflicts of interest between doctor and patient. In order to reconcile the divergent political, institutional, and professional points of view regarding managed care, a model of medical ethics relying on the concept of social justice is proposed.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Thirty-eight patients with significant weight loss after vertical banded gastroplasty were studied prospectively while undergoing abdominal dermolipectomy to determine if the current intensity used during electrosurgical dissection influenced wound complication rates after this surgery. Patients were assigned randomly to one of two groups: (1) a HI group, in which the electrosurgical current intensity was set at a level that easily allowed coagulation of all vessels smaller than 0.5 mm in diameter or (2) a LO group, in which the current intensity was set at a much lower level that allowed dissection, but required that nearly all visible vessels be ligated separately. A standardized procedure was employed for all patients. The patients in the LO (N = 14) and HI (N = 24) groups were well matched for age, weight history, nutritional parameters, operative times, surgical blood loss, and postoperative hospital stay. The overall complication rates of 36% and 21%, and wound complication rates of 36% and 13% for the LO and HI groups, respectively, were not significantly different. These data indicate that using a relatively high electrosurgical. current intensity for dissection during abdominal lipectomy does not result in a higher wound complication rate.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

An incision in the axis of the ring finger is thought to be the safest for carpal tunnel release based on cadaveric studies that suggest that the palmar cutaneous nerves do not cross into this area. Despite the use of this incision, persistent postoperative scar tenderness has been reported in up to 36% of patients following standard carpal tunnel release. For this reason, an investigation was undertaken to determine the presence of palmar cutaneous nerves in this incision. Random biopsies of transversely oriented fibrous bands in the subcutaneous tissue were taken during 15 open carpal tunnel releases. In every patient, at least one biopsy was positive for peripheral nerve tissue. These findings, combined with previous cadaveric studies, suggest that a “safe” palmar incision that will avoid injury to palmar cutaneous nerves does not exist. Carpal tunnel release techniques that avoid a palmar incision may lessen postoperative morbidity by avoiding injury to these small cutaneous nerves.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Based on the relatively high incidence of complications for surgeons initially learning the technique, endoscopic carpal tunnel release is thought to have a steep learning curve. To determine if endoscopic carpal tunnel release can be safely performed by trainees, the outcomes of 84 patients who underwent endoscopic carpal tunnel release performed by a chief resident or hand fellow in a supervised setting were reviewed. All but 1 patient had uneventful procedures and complete resolution of preoperative symptoms. One patient with persistent symptoms represented the only complication. At reexploration through a standard palmar incision, the transverse carpal ligament was found to have been completely divided and fulminant tenosynovitis surrounding the nerve and flexor tendons was presumed to be the cause of his persistent symptoms. It appears that endoscopic carpal tunnel release can be safely performed by chief residents in a supervised clinical setting. Given that this procedure has a high learning curve, repeated exposure during a residency training program may offer significant advantages over the current approach of training surgeons during a single cadaveric instructional course.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Some women electing immediate bilateral postmastectomy breast reconstruction have inadequate autologous tissue to achieve an aesthetic result and also wish to avoid tissue expansion or a back scar. These patients are candidates for reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flaps and breast implants. Since November 1993, 5 women have been reconstructed bilaterally with a combination of free TRAM flaps and adjustable saline breast implants. Each patient was young (age, 29–47 years) and of slender body habitus. During the procedure, the implants were placed in a submuscular pocket formed by the pectoralis major, the serratus anterior, and the muscular portion of the TRAM flap. Careful approximation of the serratus anterior to the lateral border of the pectoralis major muscle created a reliable layer of tissue to protect the vascular pedicle of the TRAM flap from contact with the implant. The saline chambers of the implants were filled to 60% to 80% capacity at the time of surgery. TRAM flap skin was tailored to precisely replace missing breast envelope, and subcutaneous fat increased implant coverage, creating a mound with normal-appearing ptosis. There were no occurrences of microvascular thrombosis. Three patients experienced prolonged formation of serous fluid, with 2 patients requiring late aspiration of a serosa after drain removal. Although there were no documented infections, 1 patient experienced postoperative erythema of the mastectomy skin flaps and was treated empirically with antibiotics with resolution of the erythema. All breasts have remained soft and appear natural. Using free TRAM flaps and adjustable saline breast implants allows selected women to undergo immediate breast reconstruction without the need for prolonged tissue expansion or back scars. Aesthetic results are excellent and the immediate use of an implant does not appear to pose a risk to the success of the free tissue transfer.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

In a pedantic but playful way, we discuss some common errors in the use of statistical analysis that are regularly observed in our professional plastic surgical literature. The seven errors we discuss are (1) the use of parametric analysis of ordinal data; (2) the inappropriate use of parametric analysis in general; (3) the failure to consider the possibility of committing type II statistical error; (4) the use of unmodified t-tests for multiple comparisons; (5) the failure to employ analysis of covariance, multivariate regression, nonlinear regression, and logistical regression when indicated; (6) the habit of reporting standard error instead of standard deviation; and (7) the underuse or overuse of statistical consultation. Confidence and common sense are advocated as a means to balance statistical significance with clinical importance.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Immunosuppression has been known for many years to be associated with the development of skin cancer, particularly squamous cell carcinoma. The association with melanoma is less clear. This report describes 4 patients with known human immunodeficiency virus (HIV) positivity who subsequently developed malignant melanoma. The subtypes and precursors of the tumors vary. Three of 4 patients treated using accepted surgical standards remained disease free an average of 33 months postoperatively. Treatment of the melanoma as in the non-HIV infected melanoma patient is advised. Epidemiological studies remain to be done to determine the significance of this association. In the meantime, melanoma remains a surgical disease and early, aggressive, standard surgical treatment is encouraged for these patients. Despite the immunocompromised state that their HIV status implies, surgical treatment offers local and regional control of disease and possibly cure.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Vascular birthmarks are common lesions that can be divided into hemangiomas and vascular malformations (arterial, venous, capillary, and lymphatic malformations or a combination of these), according to Mulliken. Thirty-four patients with a vascular malformation were evaluated prospectively with magnetic resonance imaging (MRI) during a 6-year period in a combined study of the departments of radiology and plastic and reconstructive surgery. Hemangiomas were not part of this study, as they regress spontaneously in childhood. MRI and angiographic findings are described and the value of MRI is investigated for its usefulness in conjunction with angiography. MRI turns out to be superior as the initial diagnostic test for vascular malformations. Further investigations are not necessary in low-flow lesions. In case of high-flow and combined-flow lesions, angiography is indicated following MRI to show the exact angioarchitecture, which is essential for therapy planning. A flowchart, based on radiodiagnostic features, is proposed for diagnostic evaluation of patients with vascular birthmarks.

ISSN:0148-7043    

出版商:OVID    

年代:1996

数据来源: OVID