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Tissue expansion as an adjunct to reconstruction of congenital and acquired auricular deformities
J Oral Maxillofac Surg 56523-527, 1998
Abstracts Tissue Expansion as an Adjunct to Reconstruction of Congenital and Acquired Auricular Deformities. Ghana JS, Grobbeiaar AO, Gault DT. Br J Plast Surg 50:456, 1997
Acute Myocardial Infarction: Recommendations for Medical Management and Primary Angioplasty. Whisenant BK, Wolfe CL. Postgrad Med 102359, 1997
For years, tissue expansion has been used in many places throughout the head and neck. The role of tissue expansion in ear reconstruction needs met clarification. Tissue expansion for ear reconstruction is indicated in situations of skin deficiency. This study involved 16 ear reconstruction cases that involved post-traumatic, burn, and congenital defects. Previous surgery or scarring in the region of the reconstruction was not regarded as an absolute contmindication. In these types of cases reconstruction using a temporoparietal fascial flap and skin graft for cover of the cartilage framework has been considered more suitable. In this study this flap was used only as a last resort. Tissue expansion produces superior results because it avoids skin grafting on the ~te~late~l projected surface of the ear and the use of a temporoparietal fascial flap. It was proposed that tissue expansion be used as a salvage procedure provided a meticulous technique is adhered to with reference to the following factors which ensure a successful outcome: a remote incision, use of larger expanders, slow expansion with a period of maintenance at full inflation, and removal of the capsule by ~y~odissection to enhance contour definition.-Jam A. ELLIS, JR
About 1.5 million people have heart attacks (myocardial infarctions or MI) in the IJnited States each year. The early mortality incidence has recently decreased from 10% to 15% in the prethrombolytic era to 5% to 10% currently. Large, randomized clinical trials have shown mortality reductions associated with the use of aspirin, thrombolytic agents, beta-blockers, and angiotens~~onve~g enzyme (ACE) inhibitors. Additional studies have examined the use of heparin, nitrates, magnesium, and calcium channel blocking agenrs in MI patients. In this article, the authors review the mechanisms of action for the various agents, discuss recent clinic& trials, indications and contraindications, and proper a~istration of each drug. They also discuss the role of primary angioplasty as an alternative of thrombol~c therapy. Recent studies have shown that 160 mg of aspirin daily resulted in a 23% reduction in mortality whereas strrptoldnase yielded a 25% reduction. Administered together, the two drugs have additive effects, resulting in a 42% reduction in mortality. When acute MI is suspected, 160 to 325 mg of aspirin should be give11 immediately, regardless of whether immediate thrombol~ic therapy can be initiated. Other antiplatelet alternatives can be given to patients who have a hypersensitivity to aspirin. Beta-blockiig agents reduce heart rate and contractility and lower blood pressure, and may also increase coronary artery perfusion. Over 50 cliuical trials have shown a reduced mortality rate with the use of beta-blockers. The authors discuss indications and contraindications of the drug. The authors then conduct a lengthy review of thrombolydc agents, including contraindications, relative contraindications, potential side effects, and complications from their use. Meta-analysis of large trials using streptokinase and tissue plasminogen activators (TPA) have shown substantial reductions in mortality across all age groups &-eater for younger patients, less for older patients). Pre-aspirin trials with heparin showed a 17% reduction in mortality when hepazin was used. When used with a non-specific thrombolytic agent such as streptokinase, anisteplase, or urokinase, evidence suggests that routine use of heparin may not be necessary and no statistically significant benefit occurs from the use. Intravenous heparin should be reserved for patients with substantial risk for emboli, atrial fib~ation or large anterior ML A mortality benefit (about 7%) has been shown with the use of ACE inhibitors within the 1st 24 hours and appears to be a mortality benefit for the first week. Nitrates cause vasodilation, decrease oxygen consumption, and limit infarct site. Magnesium trials have had contradictory results and further trials are underway. Calcium channel blocking agents have been shown to reduce myocardial oxygen demand and dilate vessels but have failed to show any benefit in either acute MI or post-infarct patients. Their use is not recommended. Among newer drugs reviewed in the article are reteplace, TNK-TPA, glycoprotein IIb/IIIa blockers, and hirudin. Emergency angio-
Reprint rcqucsts to Dr Chana: RAFT Institute Mount Vernon Hospital, Northwood, Middlesex Kingdom.
Zidovudine ers. Ippolito
of Plastic Surgery, HA6 2RN, United
Toxicity in Uninfected Health Care WorkGM, Pure V. Am J Med 102(5B):58, 1997
Several case reports and prospective studies have clearly shown the risk of acquiring human immunodeficiency virus (HIV) infection tiler accidental exposures of infected blood or other at-risk body fluids in health care the setting is <0.5%. Zidovudine (ZDV), other nucleoside and nonnucleoside reverse transcriptase inhibitors, and the new developed protease inhibitors have been shown to have anti-HIV activity, to drastically decrease plasma HIV-l levels, and to provide clinical benefit in HIV infected patients. To evaluate the toxicity of ZDV prophylaxis in HIV exposed health care workers (HCWs), a national postexposure protocol and national registry has been established in Italy. Of 674 HCWs who received prophylaxis, 492 had at least one adverse effect ranging from gastrointestinal disturbances, to headaches, and cutaneous lesions to insomnia. Side effects were dose related, mild, reversible, and often resolved despite continuing treatment. Definitive data to assess possible longterm toxicity of ZDC postexposure prophylaxis are not available.-R.H. HAUG Reprint requests to Dott Ippolito: Cent0 di Referimento AIDSServizio di Epidemiologia dell MaIattie Infettive, Ospedale L. SpaIlanzani, Via Fortuense, 2Y2 00149, Rome, Italy.
523
Abstracts Tissue Expansion as an Adjunct to Reconstruction of Congenital and Acquired Auricular Deformities. Ghana JS, Grobbeiaar AO, Gault DT. Br J Plast Surg 50:456, 1997
Acute Myocardial Infarction: Recommendations for Medical Management and Primary Angioplasty. Whisenant BK, Wolfe CL. Postgrad Med 102359, 1997
For years, tissue expansion has been used in many places throughout the head and neck. The role of tissue expansion in ear reconstruction needs met clarification. Tissue expansion for ear reconstruction is indicated in situations of skin deficiency. This study involved 16 ear reconstruction cases that involved post-traumatic, burn, and congenital defects. Previous surgery or scarring in the region of the reconstruction was not regarded as an absolute contmindication. In these types of cases reconstruction using a temporoparietal fascial flap and skin graft for cover of the cartilage framework has been considered more suitable. In this study this flap was used only as a last resort. Tissue expansion produces superior results because it avoids skin grafting on the ~te~late~l projected surface of the ear and the use of a temporoparietal fascial flap. It was proposed that tissue expansion be used as a salvage procedure provided a meticulous technique is adhered to with reference to the following factors which ensure a successful outcome: a remote incision, use of larger expanders, slow expansion with a period of maintenance at full inflation, and removal of the capsule by ~y~odissection to enhance contour definition.-Jam A. ELLIS, JR
About 1.5 million people have heart attacks (myocardial infarctions or MI) in the IJnited States each year. The early mortality incidence has recently decreased from 10% to 15% in the prethrombolytic era to 5% to 10% currently. Large, randomized clinical trials have shown mortality reductions associated with the use of aspirin, thrombolytic agents, beta-blockers, and angiotens~~onve~g enzyme (ACE) inhibitors. Additional studies have examined the use of heparin, nitrates, magnesium, and calcium channel blocking agenrs in MI patients. In this article, the authors review the mechanisms of action for the various agents, discuss recent clinic& trials, indications and contraindications, and proper a~istration of each drug. They also discuss the role of primary angioplasty as an alternative of thrombol~c therapy. Recent studies have shown that 160 mg of aspirin daily resulted in a 23% reduction in mortality whereas strrptoldnase yielded a 25% reduction. Administered together, the two drugs have additive effects, resulting in a 42% reduction in mortality. When acute MI is suspected, 160 to 325 mg of aspirin should be give11 immediately, regardless of whether immediate thrombol~ic therapy can be initiated. Other antiplatelet alternatives can be given to patients who have a hypersensitivity to aspirin. Beta-blockiig agents reduce heart rate and contractility and lower blood pressure, and may also increase coronary artery perfusion. Over 50 cliuical trials have shown a reduced mortality rate with the use of beta-blockers. The authors discuss indications and contraindications of the drug. The authors then conduct a lengthy review of thrombolydc agents, including contraindications, relative contraindications, potential side effects, and complications from their use. Meta-analysis of large trials using streptokinase and tissue plasminogen activators (TPA) have shown substantial reductions in mortality across all age groups &-eater for younger patients, less for older patients). Pre-aspirin trials with heparin showed a 17% reduction in mortality when hepazin was used. When used with a non-specific thrombolytic agent such as streptokinase, anisteplase, or urokinase, evidence suggests that routine use of heparin may not be necessary and no statistically significant benefit occurs from the use. Intravenous heparin should be reserved for patients with substantial risk for emboli, atrial fib~ation or large anterior ML A mortality benefit (about 7%) has been shown with the use of ACE inhibitors within the 1st 24 hours and appears to be a mortality benefit for the first week. Nitrates cause vasodilation, decrease oxygen consumption, and limit infarct site. Magnesium trials have had contradictory results and further trials are underway. Calcium channel blocking agents have been shown to reduce myocardial oxygen demand and dilate vessels but have failed to show any benefit in either acute MI or post-infarct patients. Their use is not recommended. Among newer drugs reviewed in the article are reteplace, TNK-TPA, glycoprotein IIb/IIIa blockers, and hirudin. Emergency angio-
Reprint rcqucsts to Dr Chana: RAFT Institute Mount Vernon Hospital, Northwood, Middlesex Kingdom.
Zidovudine ers. Ippolito
of Plastic Surgery, HA6 2RN, United
Toxicity in Uninfected Health Care WorkGM, Pure V. Am J Med 102(5B):58, 1997
Several case reports and prospective studies have clearly shown the risk of acquiring human immunodeficiency virus (HIV) infection tiler accidental exposures of infected blood or other at-risk body fluids in health care the setting is <0.5%. Zidovudine (ZDV), other nucleoside and nonnucleoside reverse transcriptase inhibitors, and the new developed protease inhibitors have been shown to have anti-HIV activity, to drastically decrease plasma HIV-l levels, and to provide clinical benefit in HIV infected patients. To evaluate the toxicity of ZDV prophylaxis in HIV exposed health care workers (HCWs), a national postexposure protocol and national registry has been established in Italy. Of 674 HCWs who received prophylaxis, 492 had at least one adverse effect ranging from gastrointestinal disturbances, to headaches, and cutaneous lesions to insomnia. Side effects were dose related, mild, reversible, and often resolved despite continuing treatment. Definitive data to assess possible longterm toxicity of ZDC postexposure prophylaxis are not available.-R.H. HAUG Reprint requests to Dott Ippolito: Cent0 di Referimento AIDSServizio di Epidemiologia dell MaIattie Infettive, Ospedale L. SpaIlanzani, Via Fortuense, 2Y2 00149, Rome, Italy.
523