- Email: [email protected]
The effect of arterial reconstruction on the natural history of diabetic neuropathy
1191
CURRENT LITERATURE wounds in the pediatric and adolescent age groups but are likely to be more lethal; however, with the astounding 66,335,OOO shotguns in the United States, the trend of violent injury is expected to escalate. The lethality of these weapons is related to the dispersion of projectiles at close range with high kinetic energy imparted to the victim. For this study the authors collected data from the Pennsylvania Trauma Systems Foundation Registry for 1987 to 1994 which included age, race, sex, region, nature of injury location, length of hospital stay, organs injured, death, and discharge disposition. Over the 8 years there were 95 shotgun wounds in patients with a mean age of 14.0 + 3.7 years. Male-to-female ratio was 5.8:1. The incidence of shotgun wounds in urban areas was increased threefold during the second half of the study, but unchanged in nonurban regions. Overall, unintentional shotgun wounds were most common (48%), followed by assaults (39%), and suicides (8%). In nonurban areas shotgun wounds were usually unintentional and occurred mainly in the home. In contrast, in urban areas the majority occurred in the street as a result of assault. Overall a total of 43 cases were reported in the home, 29 in the street, 13 in the woods, 7 in unknown locations, and 3 in public areas. The majority of the injuries were localized in the thoracic region and extremities with only 5 cases involving the head and neck region and 15 causing intracranial complications. Eighteen deaths occurred with 17 of those within the first 24 hours. Operative intervention was required for 57 patients and ultimately, 67 patients were discharged to home. Unintentional wounding is the most common circumstance of injury and includes self-inflicted injuries while handling the weapon, hunting related injuries, and inadvertent discharge of the weapon. These wounds are frequently related to careless use or inappropriate access to weapons. The data from this study supports the findings that gun ownership is an independent risk factor for firearm-related death in the home. In urban areas, shotgun wounds are increasing in incidence, are related to street violence and are usually severe, morbid, and nonfatal injuries with a high percentage of muculoskeletal injury. In non-urban areas, shotgun wounds are usually unintentional, often occur in the home, and are more often lethal than shotgun wounds in urban areas. Multiple organ injury, surgery, and lengthy hospital stays are common.H. PATINO Reprint requests to Dr Sing: Department of General Surgery, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232-2861.
studied. The cox proportional hazards model for multiple events was used. For each additional year of disease duration at the time of appearance of mild NPDR, the risk for development of NV increased by a factor of 1.22. The higher Hgb Ale levels at the onset of mild NPDR were significantly associated with increased risk for development of NV, as were higher DBP levels. The blood glucose level, has a significant impact on progression of retinopathy. The lower the Hgb Ale level was, the longer the time from the onset of of mild NPDR to the onset of NV. The authors found that the majority of the participants who developed NV were postpubertal. Proteinuria had no effect on the risk for development of NV. The authors concluded that NV tends to first appear at a similar disease duration, regardless of when mild NPDR appeared.-I.E. SHAMI Reprint requests to Dr Vitale: Dana Center for Preventive Ophthalmology, Wilmer Room 131, Johns Hopkins Hospital, Baltimore, MD 21287-9019. Cyclosporin A-Induced Alterations of Dentinogenesis in Rat Molars. Ayanoglou CM, Godeau G, Lesty C, et al. Oral Path01 Med 26: 129, 1997 Cyclosporin A (CsA) can induce gingival hyperplasia and modify bone remodeling. Currently, no data exists concerning potential effects of CsA on dental hard tissues. This study provides data from long-term CsA use and the effects on rat molar dentinogenesis. Several rats were provided 19 weeks of 30 mg/kg CsA. After sacrifice, first molars were sectioned for light microscopy and morphometry. The dentin pulp interface showed a couple of findings. Osteodentin spurs were found along this interface on secondary dentin. The spurs had a homogenous appearance similar to repairatve dentin. Prominent incremental lines in dentin that correlated well with CsA administration were another feature secondary to CsA use. Globular formations were also noted within the last deposited secondary dentin. Each of these alterations appear to represent a disturbance in secondary dentinogenesis correlating with CsA administration. Effects of bone with CsA are time and dose dependent. It appears that similar conclusions can be made in rat molar dentin. The most significant findings were: 1) osteospurs, 2) prominent incremental lines, and 3) globular formations-K. BENSON Reprint requests to Dr Ayanoglou: Universite Paris V, Rue maurice Arnoux, 92120 Montrouge, France.
Interval Between Onset of Mild Nonproliferative and Proliferative Retinopathy in Type I Diabetes. Vitale S, Maguire MG, Murphy RP, et al. Arch Ophthalmol 115:194, 1997
The Effect of Arterial Reconstruction on the Natural tory of Diabetic Neuropathy. Akbari CM, Gibbons Habershaw GM. Arch Surg 132:148, 1997
The objective of this longitudinal study was to describe the interval from the appearance of mild nonproliferative diabetic retinopathy (NPDR) to the appearance of neovascularization (NV) in a cohort of patients with type I diabetes. Two-hundred-sixty-nine patients had insulin-dependent diabetes were free of proliferative diabetes retinopathy in both eyes at the base line visit. Stereoscopic color fundus photographs of each eye at each study visit. The features for PDR were defined The time of the first appearance of NV was defined as NV of the disc, NV elsewhere, or panretinal photocoagulation. Mild NPDR developed in a total of 305 eyes from 175 participants during the study, of which 28 eyes (19 participants) developed NV over a period of time ranged from 10 to 21 years. Age, gender, glycosylated hemoglobin level, proteinuria, systolic and diastolic blood pressure were
Peripheral limb neuropathy in conjunction with peripheral vascular disease is an important factor in the higher rate of limb loss in diabetic patients. This study examined 55 patients with diabetes who required lower extremity arterial bypass. Twenty-one successfully treated patients were reexamined with a mean follow-up of 19.2 months. Neuropathy and tissue hypoxia levels were then compared preoperatively and postoperatively. Nonoperated opposite legs served as a control. Nerve conduction velocity was measured at the peroneal nerve of each leg using electrodes. Transcutaneous oxygen tension (TcP02) was measured preoperatively and postoperatively by electrode on the dorsum of each foot. In the leg operated on the peroneal nerve conduction velocity remained unchanged during the follow-up period but was significantly decreased in the leg not operated on over time.
HisGW,
CURRENT LITERATURE
1192 Transcutaneous oxygen tensionincreasedin all successful revascularizationsbut remainedunchangedor decreasedin the nonoperatedleg. The conclusionof this study is that reversalof tissuehypoxia in patientswith diabetesis essential in halting the progressionneuropathyfound in the lower extremitiesof diabetic patients.- J. BROKLOFF Reprint requests to Dr Veves: Deaconess/Joslin Foot Center, One Deaconess Rd, Boston, MA 02215.
Clinical Results of Therapeutic Temporomandibular Joint Arthroscopy: A Prospective Study of 34 Arthroscopieswith Prediscal Section and Retrodiscal Coagulation. Chossegros C, CheynetF, Gola R, et al. Br J Oral Max Surg 34:504, 1996 In this prospectivestudy, the authorsperformed34 therapeutic temporomandibular joint arthroscopiesandevaluated their resultbasedon subjectivesymptomimprovementpostoperatively. All patients had debilitating joint disorders (mainly discdisplacementwith or without reduction)andall had not respondedto non-invasivetreatment.Lysis and lavage were performedin all cases,prediscalsectionin 71% of cases,retrodiscalcoagulationin 85%, and disc suturein 9%. Subjective improvementof pain occurred in 71% of cases,noisein 78%, jaw openingin 88Y0,and diet in 97%. Objective measurement of jaw openingshowedan improvement in 94% of cases(mean9.24 mm). Postoperativecomplicationswerefound in 8% of cases.Two casesof preauricular hypoesthesiaand one infratemporal infection were reported.The authorsconcludethat temporomandibular joint arthroscopyis safeand indicatedin disc displacements and joint luxation if medicaltreatmenthas failed.-C.E. PEOPLES 111
Reprint requests to Dr Chossegros: Department of Oral and Maxillofacial Surgery, Centre Hospitalier et Universitaire Timone, 13385 Marseille cedex 5, France.
A Review of the Use of the Neodymium YAG Laser in Oral and Maxillofacial Surgery. Bradley P. Brit J Oral Maxi110Surg 35:26, 1997 This article presentsa review of the use of neodymium:yag (Nd:Yag) laser in oral and maxillofacial surgery. The Nd:Yag laser wavelengthexhibits minimal tissueabsorption and maximal penetrationby comparisonwith the COZlaser’smaximal absorptionand minimal penetration. Thesepropertiesallow a variety of usesin maxillofacial surgery especiallynoting excellent resultsin the areasof coagulationof angiomatouslesions,hemostasis in bleeding diathesis,arthroscopictemperomandibular joint, in combination with CO2 wavelength for resection in vascular tissues such as hemiglossectomyand palliation of advancedneo-
plasms.Somedisadvantages include the beamspotential to penetrate deeply along with some peripheral scatter that may change surrounding tissues. This in contrastto the sharpcut
off of the COZbeam.This alsoleadsto morepostoperative
pain and edema.Also there is a greaterrisk of stenosisof glandularducts and nerve damage.Diode technology and the useof frequencydoublingcrystalsgives future prospects of onelaserproviding a rangeof wavelengthsfor suchpurposesassoft tissuecutting, coagulation,calcified tissuecutting, welding
and photodynamic
therapy. Lasers are likely
to have a majorrole in the comingeraof minimally invasive, minimally morbidity surgery.-J.A. ELLIS Jr. Reprint requests to Dr Bradley: Department of OMFS, The London Hospital Medical College, Turner Street, London El 2AD.
The Endo-Facelift: Basics and Options. de1Camp0AF, LucchesiR, Ley MDPC. Clin Plast Surg 24:309, 1997 It is well known that the agingprocessaffects all tissues anddoesnot occurexclusively in somethem.Thusthe surgical procedureof choice to restorethe face is the one that correctsthe alterationsat the different anatomicplanes,as well astheir structuresor traits. When soft tissuesloseconsistencyand tone, they becomevertically displaceddownwardsasa result of gravity. Thereforea “restoring” procedure should elevate the tissues in a vertical
direction.
At
present,thebasicendoscopicprocedureconsistsof a subperiostealdissectionof the foreheadand centrofacialarea,deep soft-tissuelifting by step-wisesuspension, indirect skin traction, and posteriorear rotation. Basedon the gradeof rhytidosis,the basicprocedureis performedaloneor in conjunction with neck liposuction,platysmaplasty,blepharoplasty, subcutaneousrhytidectomy, or other ancillary procedures. The foreheadlift is begunwith two 1.Ocm parasagittalincisionsin the frontal region. A broad subperiosteal dissection is performed,protecting sensorynervesand liberatingmuscle insertions.The periosteumis suspendedand then two temporalincisionsaremade.The frontal periosteumis suspendedand if scalpfolds form, the dissectionis continued until flat or the scalpis resected.The cheeksare approached through temporaland eyelid approaches.The temporal approachis through a central incision in the temporalregion. The dissectionis carriedto and aroundthe zygomatic arch. The bottom to the top approach employs additional incisions across the triangular fossa of the ear, or an intraoral buccal sulcus approach. Dissection is continued superiorly to a
lower blepharoplastyinkision. Step-wisesuspension is performed with 4-O polyglactin sutures.The neck lift is performed througha submentalincision. A liposuctionmay be performedaloneor with a centralplatysmaplasty.For a more extensiverhytidosis (gradesII, III, IV) a subperiostealdissection along the mental region and mandibularedge are performed.Plication of the superficialmusculoaponeurotic systemis then performed.Occasionallyredundantskin will require
dissection.
The eyelids
may be lifted,
and a skin
resectionperformedif necessary.Postoperativelya micropore tape dressingis placed. The endoscopicapproachreduces surgical trauma and post operative edema.-R.H.
HAUG Reprint requests to Dr de1 Campo: Urbana#155-9, Co1 Independencia, Mexico, D.F. 53830.
CURRENT LITERATURE wounds in the pediatric and adolescent age groups but are likely to be more lethal; however, with the astounding 66,335,OOO shotguns in the United States, the trend of violent injury is expected to escalate. The lethality of these weapons is related to the dispersion of projectiles at close range with high kinetic energy imparted to the victim. For this study the authors collected data from the Pennsylvania Trauma Systems Foundation Registry for 1987 to 1994 which included age, race, sex, region, nature of injury location, length of hospital stay, organs injured, death, and discharge disposition. Over the 8 years there were 95 shotgun wounds in patients with a mean age of 14.0 + 3.7 years. Male-to-female ratio was 5.8:1. The incidence of shotgun wounds in urban areas was increased threefold during the second half of the study, but unchanged in nonurban regions. Overall, unintentional shotgun wounds were most common (48%), followed by assaults (39%), and suicides (8%). In nonurban areas shotgun wounds were usually unintentional and occurred mainly in the home. In contrast, in urban areas the majority occurred in the street as a result of assault. Overall a total of 43 cases were reported in the home, 29 in the street, 13 in the woods, 7 in unknown locations, and 3 in public areas. The majority of the injuries were localized in the thoracic region and extremities with only 5 cases involving the head and neck region and 15 causing intracranial complications. Eighteen deaths occurred with 17 of those within the first 24 hours. Operative intervention was required for 57 patients and ultimately, 67 patients were discharged to home. Unintentional wounding is the most common circumstance of injury and includes self-inflicted injuries while handling the weapon, hunting related injuries, and inadvertent discharge of the weapon. These wounds are frequently related to careless use or inappropriate access to weapons. The data from this study supports the findings that gun ownership is an independent risk factor for firearm-related death in the home. In urban areas, shotgun wounds are increasing in incidence, are related to street violence and are usually severe, morbid, and nonfatal injuries with a high percentage of muculoskeletal injury. In non-urban areas, shotgun wounds are usually unintentional, often occur in the home, and are more often lethal than shotgun wounds in urban areas. Multiple organ injury, surgery, and lengthy hospital stays are common.H. PATINO Reprint requests to Dr Sing: Department of General Surgery, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232-2861.
studied. The cox proportional hazards model for multiple events was used. For each additional year of disease duration at the time of appearance of mild NPDR, the risk for development of NV increased by a factor of 1.22. The higher Hgb Ale levels at the onset of mild NPDR were significantly associated with increased risk for development of NV, as were higher DBP levels. The blood glucose level, has a significant impact on progression of retinopathy. The lower the Hgb Ale level was, the longer the time from the onset of of mild NPDR to the onset of NV. The authors found that the majority of the participants who developed NV were postpubertal. Proteinuria had no effect on the risk for development of NV. The authors concluded that NV tends to first appear at a similar disease duration, regardless of when mild NPDR appeared.-I.E. SHAMI Reprint requests to Dr Vitale: Dana Center for Preventive Ophthalmology, Wilmer Room 131, Johns Hopkins Hospital, Baltimore, MD 21287-9019. Cyclosporin A-Induced Alterations of Dentinogenesis in Rat Molars. Ayanoglou CM, Godeau G, Lesty C, et al. Oral Path01 Med 26: 129, 1997 Cyclosporin A (CsA) can induce gingival hyperplasia and modify bone remodeling. Currently, no data exists concerning potential effects of CsA on dental hard tissues. This study provides data from long-term CsA use and the effects on rat molar dentinogenesis. Several rats were provided 19 weeks of 30 mg/kg CsA. After sacrifice, first molars were sectioned for light microscopy and morphometry. The dentin pulp interface showed a couple of findings. Osteodentin spurs were found along this interface on secondary dentin. The spurs had a homogenous appearance similar to repairatve dentin. Prominent incremental lines in dentin that correlated well with CsA administration were another feature secondary to CsA use. Globular formations were also noted within the last deposited secondary dentin. Each of these alterations appear to represent a disturbance in secondary dentinogenesis correlating with CsA administration. Effects of bone with CsA are time and dose dependent. It appears that similar conclusions can be made in rat molar dentin. The most significant findings were: 1) osteospurs, 2) prominent incremental lines, and 3) globular formations-K. BENSON Reprint requests to Dr Ayanoglou: Universite Paris V, Rue maurice Arnoux, 92120 Montrouge, France.
Interval Between Onset of Mild Nonproliferative and Proliferative Retinopathy in Type I Diabetes. Vitale S, Maguire MG, Murphy RP, et al. Arch Ophthalmol 115:194, 1997
The Effect of Arterial Reconstruction on the Natural tory of Diabetic Neuropathy. Akbari CM, Gibbons Habershaw GM. Arch Surg 132:148, 1997
The objective of this longitudinal study was to describe the interval from the appearance of mild nonproliferative diabetic retinopathy (NPDR) to the appearance of neovascularization (NV) in a cohort of patients with type I diabetes. Two-hundred-sixty-nine patients had insulin-dependent diabetes were free of proliferative diabetes retinopathy in both eyes at the base line visit. Stereoscopic color fundus photographs of each eye at each study visit. The features for PDR were defined The time of the first appearance of NV was defined as NV of the disc, NV elsewhere, or panretinal photocoagulation. Mild NPDR developed in a total of 305 eyes from 175 participants during the study, of which 28 eyes (19 participants) developed NV over a period of time ranged from 10 to 21 years. Age, gender, glycosylated hemoglobin level, proteinuria, systolic and diastolic blood pressure were
Peripheral limb neuropathy in conjunction with peripheral vascular disease is an important factor in the higher rate of limb loss in diabetic patients. This study examined 55 patients with diabetes who required lower extremity arterial bypass. Twenty-one successfully treated patients were reexamined with a mean follow-up of 19.2 months. Neuropathy and tissue hypoxia levels were then compared preoperatively and postoperatively. Nonoperated opposite legs served as a control. Nerve conduction velocity was measured at the peroneal nerve of each leg using electrodes. Transcutaneous oxygen tension (TcP02) was measured preoperatively and postoperatively by electrode on the dorsum of each foot. In the leg operated on the peroneal nerve conduction velocity remained unchanged during the follow-up period but was significantly decreased in the leg not operated on over time.
HisGW,
CURRENT LITERATURE
1192 Transcutaneous oxygen tensionincreasedin all successful revascularizationsbut remainedunchangedor decreasedin the nonoperatedleg. The conclusionof this study is that reversalof tissuehypoxia in patientswith diabetesis essential in halting the progressionneuropathyfound in the lower extremitiesof diabetic patients.- J. BROKLOFF Reprint requests to Dr Veves: Deaconess/Joslin Foot Center, One Deaconess Rd, Boston, MA 02215.
Clinical Results of Therapeutic Temporomandibular Joint Arthroscopy: A Prospective Study of 34 Arthroscopieswith Prediscal Section and Retrodiscal Coagulation. Chossegros C, CheynetF, Gola R, et al. Br J Oral Max Surg 34:504, 1996 In this prospectivestudy, the authorsperformed34 therapeutic temporomandibular joint arthroscopiesandevaluated their resultbasedon subjectivesymptomimprovementpostoperatively. All patients had debilitating joint disorders (mainly discdisplacementwith or without reduction)andall had not respondedto non-invasivetreatment.Lysis and lavage were performedin all cases,prediscalsectionin 71% of cases,retrodiscalcoagulationin 85%, and disc suturein 9%. Subjective improvementof pain occurred in 71% of cases,noisein 78%, jaw openingin 88Y0,and diet in 97%. Objective measurement of jaw openingshowedan improvement in 94% of cases(mean9.24 mm). Postoperativecomplicationswerefound in 8% of cases.Two casesof preauricular hypoesthesiaand one infratemporal infection were reported.The authorsconcludethat temporomandibular joint arthroscopyis safeand indicatedin disc displacements and joint luxation if medicaltreatmenthas failed.-C.E. PEOPLES 111
Reprint requests to Dr Chossegros: Department of Oral and Maxillofacial Surgery, Centre Hospitalier et Universitaire Timone, 13385 Marseille cedex 5, France.
A Review of the Use of the Neodymium YAG Laser in Oral and Maxillofacial Surgery. Bradley P. Brit J Oral Maxi110Surg 35:26, 1997 This article presentsa review of the use of neodymium:yag (Nd:Yag) laser in oral and maxillofacial surgery. The Nd:Yag laser wavelengthexhibits minimal tissueabsorption and maximal penetrationby comparisonwith the COZlaser’smaximal absorptionand minimal penetration. Thesepropertiesallow a variety of usesin maxillofacial surgery especiallynoting excellent resultsin the areasof coagulationof angiomatouslesions,hemostasis in bleeding diathesis,arthroscopictemperomandibular joint, in combination with CO2 wavelength for resection in vascular tissues such as hemiglossectomyand palliation of advancedneo-
plasms.Somedisadvantages include the beamspotential to penetrate deeply along with some peripheral scatter that may change surrounding tissues. This in contrastto the sharpcut
off of the COZbeam.This alsoleadsto morepostoperative
pain and edema.Also there is a greaterrisk of stenosisof glandularducts and nerve damage.Diode technology and the useof frequencydoublingcrystalsgives future prospects of onelaserproviding a rangeof wavelengthsfor suchpurposesassoft tissuecutting, coagulation,calcified tissuecutting, welding
and photodynamic
therapy. Lasers are likely
to have a majorrole in the comingeraof minimally invasive, minimally morbidity surgery.-J.A. ELLIS Jr. Reprint requests to Dr Bradley: Department of OMFS, The London Hospital Medical College, Turner Street, London El 2AD.
The Endo-Facelift: Basics and Options. de1Camp0AF, LucchesiR, Ley MDPC. Clin Plast Surg 24:309, 1997 It is well known that the agingprocessaffects all tissues anddoesnot occurexclusively in somethem.Thusthe surgical procedureof choice to restorethe face is the one that correctsthe alterationsat the different anatomicplanes,as well astheir structuresor traits. When soft tissuesloseconsistencyand tone, they becomevertically displaceddownwardsasa result of gravity. Thereforea “restoring” procedure should elevate the tissues in a vertical
direction.
At
present,thebasicendoscopicprocedureconsistsof a subperiostealdissectionof the foreheadand centrofacialarea,deep soft-tissuelifting by step-wisesuspension, indirect skin traction, and posteriorear rotation. Basedon the gradeof rhytidosis,the basicprocedureis performedaloneor in conjunction with neck liposuction,platysmaplasty,blepharoplasty, subcutaneousrhytidectomy, or other ancillary procedures. The foreheadlift is begunwith two 1.Ocm parasagittalincisionsin the frontal region. A broad subperiosteal dissection is performed,protecting sensorynervesand liberatingmuscle insertions.The periosteumis suspendedand then two temporalincisionsaremade.The frontal periosteumis suspendedand if scalpfolds form, the dissectionis continued until flat or the scalpis resected.The cheeksare approached through temporaland eyelid approaches.The temporal approachis through a central incision in the temporalregion. The dissectionis carriedto and aroundthe zygomatic arch. The bottom to the top approach employs additional incisions across the triangular fossa of the ear, or an intraoral buccal sulcus approach. Dissection is continued superiorly to a
lower blepharoplastyinkision. Step-wisesuspension is performed with 4-O polyglactin sutures.The neck lift is performed througha submentalincision. A liposuctionmay be performedaloneor with a centralplatysmaplasty.For a more extensiverhytidosis (gradesII, III, IV) a subperiostealdissection along the mental region and mandibularedge are performed.Plication of the superficialmusculoaponeurotic systemis then performed.Occasionallyredundantskin will require
dissection.
The eyelids
may be lifted,
and a skin
resectionperformedif necessary.Postoperativelya micropore tape dressingis placed. The endoscopicapproachreduces surgical trauma and post operative edema.-R.H.
HAUG Reprint requests to Dr de1 Campo: Urbana#155-9, Co1 Independencia, Mexico, D.F. 53830.