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Early diagnosis of crepitant gangrene caused by bacteroides maleninogenicus
ABSTRACTS
198
ANESTHESIA
AND
INHALATION
THERAPY
The Stretched Scar: A Clinical and Histological Study. B. c.
elasticity with prolonged exposure. In addition, exposure to sun rays that are longer than 3200 Angstroms, will create tanning in the skin by migration of melanin upward from the basal cell layer to the stratum corneum. In addition, the skin will be protected by a thickening of the corneous layer. In those patients who are recently operated by dermabrasion, laceration repairs, skin grafts or other plastic surgery of the face and body, it is important to prevent not only erythemal changes (burning), but also tanning. These changes can permanently alter otherwise satisfactory results. Two components of sun-blocking agents are, therefore, required to protect against the erythemal as well as the melanogenic effects of the sun. The article recommends agents containing PABA (p-Aminobenzoate) and Titanium dioxide. The first of these agents protect from rays less than 3200 Angstroms and the second of these agents protect from rays that are greater than 3200. The article reports on the preparations available containing both of these agents of which six are reviewed. There are 14 preparations that although listed as sunscreens, are not recommended by the article due to lack of ingredients. The author concludes that sunscreen and blocking preparations. should contain both PABA and Titanium dioxide.--A. B. Sokol
Sommerlad and J. M. Creosey. Br J Plast Surg 31:26-28, (January), 1978.
Pyoderma Gangrenosum: Recognition and Management.
Changes in Serum Bromide Concentration Following Halothane Anesthesia in Infants and Children. L. Pruefort.
Orvosi Hetilap, 119:957-959, 1978 The serum bromide concentration was measured in 32 infants and children before administration of Halothane anesthesia and on the first, second, fifth, and sixth postoperative day. Postoperatively the serum bromide concentration was significantly higher than before surgery. On the fifth and sixth day following surgery, there was a decrease as compared with the postoperative level on the first and second day. However, it was still elevated as compared with the preoperative level. The author draws attention to the possibility of a risk caused by the elevated serum bromide concentration in cases with an administration of high Halothane concentrations mainly in prolonged anesthesia where Halothane is used repeatedly and where further bromide containing agents (e.g., drugs) are necessary within 2-3 wk after Halothane anesthesia.-&drew Pint& INTEGUMENT
AND
CONNECTIVE
TISSUE
K. 0. Wustrack and H. A. Zarem. 62:423-428, (September), 1978.
Plast
Reconstr
Surg
A study was made of scars resulting from elliptical excisions of skin lesions. There was tension across the wound greater than normal. The skin edges were undermined for I cm before closure. One half of the wound was closed with 4/O interrupted black sutures at 0.5 cm-intervals, and used as a control for the other half which was closed at random in 1 of 4 ways. Group I: In addition to the black silk stitches, deep dermal 3/O chromic catgut was used; Group 2: 1/4” Steristrips; Group 3: 1/4” Steristrips were reapplied for a total period of 3 mo; Group 4: Continuous subcuticular 3/O nylon, removed at 3 wk.The wounds were measured and some were examined by electron microscopy. There were wide variations in the amount of stretch, the development of which occurs over a year, at a rate which is remarkably similar in all the patients. The only technique that produced a narrower scar than the controls was the use of subcuticular nylon for 3 wk. The width of the scar at 1 yr was 73% of the controls. The hypertrophy in the scars was not related to the amount of stretching. Scanning electron microscopy was used to study the architecture of the collagen. In narrow unstretched scars, it was orientated along the line of the scar. However if there is tension across the scar, especially if it lies at right angles to Langer’s lines, collagen is laid down across the scar, or randomly when the sutures are in place. If this bond is too weak after the sutures are removed, new collagen is laid down across the scar.-A. Jolleys
Pyoderma gangrenosum is a progressive necrotizing and ulcerative disease of the skin. It closely resembles, but must be differentiated from spider bites. cutaneous amebiasis. blastomycosis, and Meleney’s synergistic gangrene. Other diseases associated with the entity occur in 80% of the cases. These are ulcerative colitis. Cl disorders, rheumatoid arthritis, pulmonary diseases and hematologic disorders. These diseases can occur concomitantly or have appearance either in an earlier or a later point in time. Diagnosis is made on purely clinical grounds consisting of the acute rapid development of an ulcerating lesion that spreads rapidly and within a few days the center becomes necrotic and ulcerated. There are consistent findings of pain that may require narcotics, and a purple erythematous edge or halo. If untreated, the lesion enters a chronic phase, enlarging slowly and causing marked debilitation. The etiology appears to be due to a generalized immunologic defect. Treatment consists of local care of wet dressings with potassium permanganate. Systemic corticosteroid treatment will control the ulcer within a few days. Azulfidine has been shown to decrease the activity of skin lesions. Treatment of the underlying systemic disease is certainly a necessity. Immunosuppressive agents have also been used and are effective in a small series.-A. 6. Sokol
The Selection of Sun-Blocking Topical Agents to Protect
Early Diagnosis of Crepitant Gangrene Caused by Bacte-
the Skin. J. B. Tipton. Plast
roides Maleninogenicus. V. L. Lewis. M. B. Myers,
(August),
Reconstr
Surg
62:223-228,
1978.
With the myriad of sun-blocking agents available to the consumer today, the article brings to its readers, information that will allow the intelligent selection of an agent. Radiant energy in the ultraviolet range, from 2000 to 3000 Angstrom, will cause erythemal effects. In time this will create premature aging of the skin as thickening, wrinkling and loss of
B. H. Grifith. Plast Reconstr 1978.
Surg 62:276-279,
and (August),
Crepitant nonclostridial gangrene is a fulminant infection, frequently anaerobic. One cause of this gangrene is the anaerobe Bacteroides melaninogenicus in association with aerobic coliform organisms. A simple noninvasive technique, utilizing the Woods light. demonstrates a red fluorescence in
199
the wounds associated with B. melaninogenicus. This technique has been verified by anaerobic cultures in nine patients critically ill with crepitant gangrene. When one considers the unreliability of anaerobic cultures, the importance of this test becomes clear. The authors have listed three other organisms that emit a red fluorescence: they are Corynebacterium minutissimum, streptomyces albus, and Corynebacterium acnes. These organisms are found in wounds distinctly different than those caused by B. melaninogenicus and have other characteristic features that are described for the reader’s edification.-A. B. Sokol
Corticosteroid How Effective?-A
Treatment
of
Cutaneous
Hemangiomas:
L. E. BartosheClin Pediatr 17:625-638,
Report of 24 Children.
sky, M. Bull. and M. Feingold. (August), 1978.
Twenty-four patients with cavernous or mixed hemangiomas received corticosteroid treatment for interference with important body functions (airway compromise, feeding problems, sight and hearing, voiding, stooling, or limb function), thrombocytopenia, or a lesion with cosmetic concern to the family (I3 patients). Oral prednisone (3 mg/kg daily) was the usual treatment. Five patients (21%) had no response, I2 (50%) had a possible response, five (21%) had a probable response, and two (8%) had a definite response as defined by the authors in the text. One patient experienced marked interference with growth following 5 mo of treatment due to thrombocytopenia. The authors conclude that only about 30% of patients can be expected to improve when treated with steroids before IO mo of age. Other studies quoted had better results but not as strict criteria to grade response.Randall W. Powell
HEAD AND NECK Early
Skeletal
Release
in the
Infant
With
Craniofaciaf
J. G. McCarthy. P. J. Coccaro. F. Epstein, and J. M. Converse. Plast Reconstr Surg 62:335-346, (September), 1978. Dysostosis.
Craniofacial dysostosis is defined as premature synostosis of the cranical sutures associated with facial deformities. The importance of the cranial base sutures have been overlooked in classical neurosurgical strip craniectomies with a resulting facial deformity being neither ameliorated nor improved. The role of the sphenozygomatic suture is illuminated in this article based upon IO surgical cases. Three surgical techniques are employed in craniofacial dysostosis. If both coronal sutures are synostosed, with associated facial deformity of brachycephaly, bulging of the pterion and mild exophthalmos, a cranial facial stripping of both coronal sutures, including the sphenozygomatic suture, is performed. If, in addition to the above, there is a severe degree of exophthalmos, the Tessier type of frontal bone advancement is recommended. In addition to this, the osteotomies are extended down encompassing the sphenozygomatic sutures. Finally, in the infant with unilateral coronal synostosis and plagiocephaly, an advancement of the frontal bone on the affected side is the procedure of choice. The sphenozygomatic suture on the affected side is also opened with rongeurs.-A. B. Sokol
Congenital and Acquired Deafness in Clefting and Craniofacial Syndromes.
(July),
L. Bergstrom.
Cleft Palate
J 15:254-261,
1978.
Because craniofacial defects have a high potential for involving adjacent sensory organs, the clinician needs to know that patients may benefit from early evaluation and that evaluations have high yield. Therefore, 284 patients were reviewed whose ages ranged from 2 days to 50 yt. All underwent otolaryngologic examinations, audiometry, where possible pure tone and speech testing and acoustic bridge testing. In addition, mastoid films were taken. The author reports a congenital hearing loss occurring in 87% of patients having ocular defects, 67% in those having microcephaly, and 60% in those having cranial nerve palsy and in 50% of those having central nervous system defects. Many of these losses were sensorineural. Micrognathia had a 70% association of hearing loss and all but two were conductive in nature. Where pinna (ear) defects occurred, 75% of those affected had congenital hearing loss and nearly r/r of the 75% were conductive in nature. Palatal, facial, vertebral, and skull anomalies and posterior choanal atresia were associated with congenital hearing loss in 65 to 100%. Defects of the heart had congenital hearing loss in 72% of the cases. 83% of patients having renal defects had congenital hearing loss. However, in the study, patients with microtia/atresia had only a 5% incidence of renal anomalies. The author, therefore, concludes and recommends otologic and audiologic consultation routinely in patients having clefting and cranial facial syndromes.-A. B. Sokol Conductive
Hearing Loss in Patients
With Velopharyngeal
J. C. Heller, G. W. Gens, C. B. Croft, and D. G. Moe. Cleft Palate J 15:246-253, (July), 1978.
Insufficiency.
The literature supports the finding that in normal children, 3%lO% have a hearing loss as compared to 50%-100% in cleft palate children and 40%80% of those children with velopharyngeal insufficiency and intact palates. The study is involved with a further definition of the latter group. Seventy-seven patients with velopharyngeal insufficiency (VPI) not due to overt cleft palate were involved. This sample included 28 males and 49 females ranging in age from 4 to I6 yr. The etiology were divided into 3 groups: 17 with submucous cleft palate, 17 with palatal paresis, and 43 with palatopharyngeal disproportion. Audiologic and otologic tests were given. Audiologic evaluation revealed that 40% had hearing losses. Of these, 74% were conductive, 16% sensorineural and 10% mixed. There was an improvement in sensitivity as the subjects became older, and this finding agreed with that reported in the literature. Otologic evaluation revealed 44% had abnormalities of the tympanic membrane and 39% had significant air-borne gaps. There were no significant differences in the etiologic subgroups. This study revealed that conductive hearing loss in VP1 subjects, more closely resembled those with cleft palates than the normal population.-A. B. Sokol Early Nonsurgical Closure of Postoperative h4. D. Berkmnn.
Plast
Reconstr
Surg
Palatal Fistulae.
62:537-541,
(Octo-
ber), 1978. The author ative palatal
reports on the nonsurgical closure of postoperfistulae that occurred in I1 patients. The
198
ANESTHESIA
AND
INHALATION
THERAPY
The Stretched Scar: A Clinical and Histological Study. B. c.
elasticity with prolonged exposure. In addition, exposure to sun rays that are longer than 3200 Angstroms, will create tanning in the skin by migration of melanin upward from the basal cell layer to the stratum corneum. In addition, the skin will be protected by a thickening of the corneous layer. In those patients who are recently operated by dermabrasion, laceration repairs, skin grafts or other plastic surgery of the face and body, it is important to prevent not only erythemal changes (burning), but also tanning. These changes can permanently alter otherwise satisfactory results. Two components of sun-blocking agents are, therefore, required to protect against the erythemal as well as the melanogenic effects of the sun. The article recommends agents containing PABA (p-Aminobenzoate) and Titanium dioxide. The first of these agents protect from rays less than 3200 Angstroms and the second of these agents protect from rays that are greater than 3200. The article reports on the preparations available containing both of these agents of which six are reviewed. There are 14 preparations that although listed as sunscreens, are not recommended by the article due to lack of ingredients. The author concludes that sunscreen and blocking preparations. should contain both PABA and Titanium dioxide.--A. B. Sokol
Sommerlad and J. M. Creosey. Br J Plast Surg 31:26-28, (January), 1978.
Pyoderma Gangrenosum: Recognition and Management.
Changes in Serum Bromide Concentration Following Halothane Anesthesia in Infants and Children. L. Pruefort.
Orvosi Hetilap, 119:957-959, 1978 The serum bromide concentration was measured in 32 infants and children before administration of Halothane anesthesia and on the first, second, fifth, and sixth postoperative day. Postoperatively the serum bromide concentration was significantly higher than before surgery. On the fifth and sixth day following surgery, there was a decrease as compared with the postoperative level on the first and second day. However, it was still elevated as compared with the preoperative level. The author draws attention to the possibility of a risk caused by the elevated serum bromide concentration in cases with an administration of high Halothane concentrations mainly in prolonged anesthesia where Halothane is used repeatedly and where further bromide containing agents (e.g., drugs) are necessary within 2-3 wk after Halothane anesthesia.-&drew Pint& INTEGUMENT
AND
CONNECTIVE
TISSUE
K. 0. Wustrack and H. A. Zarem. 62:423-428, (September), 1978.
Plast
Reconstr
Surg
A study was made of scars resulting from elliptical excisions of skin lesions. There was tension across the wound greater than normal. The skin edges were undermined for I cm before closure. One half of the wound was closed with 4/O interrupted black sutures at 0.5 cm-intervals, and used as a control for the other half which was closed at random in 1 of 4 ways. Group I: In addition to the black silk stitches, deep dermal 3/O chromic catgut was used; Group 2: 1/4” Steristrips; Group 3: 1/4” Steristrips were reapplied for a total period of 3 mo; Group 4: Continuous subcuticular 3/O nylon, removed at 3 wk.The wounds were measured and some were examined by electron microscopy. There were wide variations in the amount of stretch, the development of which occurs over a year, at a rate which is remarkably similar in all the patients. The only technique that produced a narrower scar than the controls was the use of subcuticular nylon for 3 wk. The width of the scar at 1 yr was 73% of the controls. The hypertrophy in the scars was not related to the amount of stretching. Scanning electron microscopy was used to study the architecture of the collagen. In narrow unstretched scars, it was orientated along the line of the scar. However if there is tension across the scar, especially if it lies at right angles to Langer’s lines, collagen is laid down across the scar, or randomly when the sutures are in place. If this bond is too weak after the sutures are removed, new collagen is laid down across the scar.-A. Jolleys
Pyoderma gangrenosum is a progressive necrotizing and ulcerative disease of the skin. It closely resembles, but must be differentiated from spider bites. cutaneous amebiasis. blastomycosis, and Meleney’s synergistic gangrene. Other diseases associated with the entity occur in 80% of the cases. These are ulcerative colitis. Cl disorders, rheumatoid arthritis, pulmonary diseases and hematologic disorders. These diseases can occur concomitantly or have appearance either in an earlier or a later point in time. Diagnosis is made on purely clinical grounds consisting of the acute rapid development of an ulcerating lesion that spreads rapidly and within a few days the center becomes necrotic and ulcerated. There are consistent findings of pain that may require narcotics, and a purple erythematous edge or halo. If untreated, the lesion enters a chronic phase, enlarging slowly and causing marked debilitation. The etiology appears to be due to a generalized immunologic defect. Treatment consists of local care of wet dressings with potassium permanganate. Systemic corticosteroid treatment will control the ulcer within a few days. Azulfidine has been shown to decrease the activity of skin lesions. Treatment of the underlying systemic disease is certainly a necessity. Immunosuppressive agents have also been used and are effective in a small series.-A. 6. Sokol
The Selection of Sun-Blocking Topical Agents to Protect
Early Diagnosis of Crepitant Gangrene Caused by Bacte-
the Skin. J. B. Tipton. Plast
roides Maleninogenicus. V. L. Lewis. M. B. Myers,
(August),
Reconstr
Surg
62:223-228,
1978.
With the myriad of sun-blocking agents available to the consumer today, the article brings to its readers, information that will allow the intelligent selection of an agent. Radiant energy in the ultraviolet range, from 2000 to 3000 Angstrom, will cause erythemal effects. In time this will create premature aging of the skin as thickening, wrinkling and loss of
B. H. Grifith. Plast Reconstr 1978.
Surg 62:276-279,
and (August),
Crepitant nonclostridial gangrene is a fulminant infection, frequently anaerobic. One cause of this gangrene is the anaerobe Bacteroides melaninogenicus in association with aerobic coliform organisms. A simple noninvasive technique, utilizing the Woods light. demonstrates a red fluorescence in
199
the wounds associated with B. melaninogenicus. This technique has been verified by anaerobic cultures in nine patients critically ill with crepitant gangrene. When one considers the unreliability of anaerobic cultures, the importance of this test becomes clear. The authors have listed three other organisms that emit a red fluorescence: they are Corynebacterium minutissimum, streptomyces albus, and Corynebacterium acnes. These organisms are found in wounds distinctly different than those caused by B. melaninogenicus and have other characteristic features that are described for the reader’s edification.-A. B. Sokol
Corticosteroid How Effective?-A
Treatment
of
Cutaneous
Hemangiomas:
L. E. BartosheClin Pediatr 17:625-638,
Report of 24 Children.
sky, M. Bull. and M. Feingold. (August), 1978.
Twenty-four patients with cavernous or mixed hemangiomas received corticosteroid treatment for interference with important body functions (airway compromise, feeding problems, sight and hearing, voiding, stooling, or limb function), thrombocytopenia, or a lesion with cosmetic concern to the family (I3 patients). Oral prednisone (3 mg/kg daily) was the usual treatment. Five patients (21%) had no response, I2 (50%) had a possible response, five (21%) had a probable response, and two (8%) had a definite response as defined by the authors in the text. One patient experienced marked interference with growth following 5 mo of treatment due to thrombocytopenia. The authors conclude that only about 30% of patients can be expected to improve when treated with steroids before IO mo of age. Other studies quoted had better results but not as strict criteria to grade response.Randall W. Powell
HEAD AND NECK Early
Skeletal
Release
in the
Infant
With
Craniofaciaf
J. G. McCarthy. P. J. Coccaro. F. Epstein, and J. M. Converse. Plast Reconstr Surg 62:335-346, (September), 1978. Dysostosis.
Craniofacial dysostosis is defined as premature synostosis of the cranical sutures associated with facial deformities. The importance of the cranial base sutures have been overlooked in classical neurosurgical strip craniectomies with a resulting facial deformity being neither ameliorated nor improved. The role of the sphenozygomatic suture is illuminated in this article based upon IO surgical cases. Three surgical techniques are employed in craniofacial dysostosis. If both coronal sutures are synostosed, with associated facial deformity of brachycephaly, bulging of the pterion and mild exophthalmos, a cranial facial stripping of both coronal sutures, including the sphenozygomatic suture, is performed. If, in addition to the above, there is a severe degree of exophthalmos, the Tessier type of frontal bone advancement is recommended. In addition to this, the osteotomies are extended down encompassing the sphenozygomatic sutures. Finally, in the infant with unilateral coronal synostosis and plagiocephaly, an advancement of the frontal bone on the affected side is the procedure of choice. The sphenozygomatic suture on the affected side is also opened with rongeurs.-A. B. Sokol
Congenital and Acquired Deafness in Clefting and Craniofacial Syndromes.
(July),
L. Bergstrom.
Cleft Palate
J 15:254-261,
1978.
Because craniofacial defects have a high potential for involving adjacent sensory organs, the clinician needs to know that patients may benefit from early evaluation and that evaluations have high yield. Therefore, 284 patients were reviewed whose ages ranged from 2 days to 50 yt. All underwent otolaryngologic examinations, audiometry, where possible pure tone and speech testing and acoustic bridge testing. In addition, mastoid films were taken. The author reports a congenital hearing loss occurring in 87% of patients having ocular defects, 67% in those having microcephaly, and 60% in those having cranial nerve palsy and in 50% of those having central nervous system defects. Many of these losses were sensorineural. Micrognathia had a 70% association of hearing loss and all but two were conductive in nature. Where pinna (ear) defects occurred, 75% of those affected had congenital hearing loss and nearly r/r of the 75% were conductive in nature. Palatal, facial, vertebral, and skull anomalies and posterior choanal atresia were associated with congenital hearing loss in 65 to 100%. Defects of the heart had congenital hearing loss in 72% of the cases. 83% of patients having renal defects had congenital hearing loss. However, in the study, patients with microtia/atresia had only a 5% incidence of renal anomalies. The author, therefore, concludes and recommends otologic and audiologic consultation routinely in patients having clefting and cranial facial syndromes.-A. B. Sokol Conductive
Hearing Loss in Patients
With Velopharyngeal
J. C. Heller, G. W. Gens, C. B. Croft, and D. G. Moe. Cleft Palate J 15:246-253, (July), 1978.
Insufficiency.
The literature supports the finding that in normal children, 3%lO% have a hearing loss as compared to 50%-100% in cleft palate children and 40%80% of those children with velopharyngeal insufficiency and intact palates. The study is involved with a further definition of the latter group. Seventy-seven patients with velopharyngeal insufficiency (VPI) not due to overt cleft palate were involved. This sample included 28 males and 49 females ranging in age from 4 to I6 yr. The etiology were divided into 3 groups: 17 with submucous cleft palate, 17 with palatal paresis, and 43 with palatopharyngeal disproportion. Audiologic and otologic tests were given. Audiologic evaluation revealed that 40% had hearing losses. Of these, 74% were conductive, 16% sensorineural and 10% mixed. There was an improvement in sensitivity as the subjects became older, and this finding agreed with that reported in the literature. Otologic evaluation revealed 44% had abnormalities of the tympanic membrane and 39% had significant air-borne gaps. There were no significant differences in the etiologic subgroups. This study revealed that conductive hearing loss in VP1 subjects, more closely resembled those with cleft palates than the normal population.-A. B. Sokol Early Nonsurgical Closure of Postoperative h4. D. Berkmnn.
Plast
Reconstr
Surg
Palatal Fistulae.
62:537-541,
(Octo-
ber), 1978. The author ative palatal
reports on the nonsurgical closure of postoperfistulae that occurred in I1 patients. The