Samuel Lance

Hypertonic saline alters hydraulic conductivity and up-regulates mucosal/submucosal aquaporin 4 in resuscitation-induced intestinal edema

Objective:To characterize membrane conductivity by applying mathematical modeling techniques and immunohistochemistry and to localize and predict areas of the bowel where aquaporins may be associated with edema resolution/prevention associated with hypertonic saline. Intestinal edema induced by resuscitation and mesenteric venous hypertension impairs intestinal transit/contractility. Hypertonic saline decreases intestinal edema and improves transit. Aquaporins are water transport membrane proteins that may be up-regulated with edema and/or hypertonic saline. Design:Laboratory study. Setting:University research laboratory. Subjects:Male Sprague Dawley rats, weighing 270 to 330 g. Interventions:Rats were randomized to control (with and without hypertonic saline) and mesenteric venous hypertension with either 80 mL/kg normal saline (RESUS + VH + VEH) or 80 mL/kg normal saline with hypertonic saline (RESUS + VH + HTS). After 6 hrs, intestinal wet/dry ratios, urine output, peritoneal fluid, and intraluminal fluid were measured. Hydraulic conductivity was calculated from our previously known and published pressure-flow data. The cDNA microarray, Western blot, polymerase chain reaction, and immunohistochemistry studies were conducted for candidate aquaporins and distribution in intestinal edema resolution. Measurements and Main Results:Hypertonic saline decreased edema and increased urine, intraluminal, and peritoneal fluid volume. RESUS + VH favors fluid flux into the interstitium. Hypertonic saline causes increased hydraulic conductivity at the seromuscular and mucosal surfaces at the same time limiting flow into the interstitium. This is associated with increased aquaporin 4 expression in the intestinal mucosa and submucosa. Conclusions:Hypertonic saline mitigates intestinal edema development and promotes fluid redistribution secondary to increased membrane conductivity at the mucosal and seromuscular surfaces. This is associated with up-regulation of aquaporin 4 gene expression and protein. Aquaporin 4 may be a useful therapeutic target for strategies to enhance edema resolution.

Ulnar Neuropathy After Tube Thoracostomy for Pneumothorax

BACKGROUND Chest tube placement is a frequently required surgical procedure among patients in the emergency department. Although the procedure is often simple, occasionally there are known complications, including unresolved pneumothorax or hemopneumothorax, extrathoracic placement of the tube, and damage to the intercostal neurovascular bundle. OBJECTIVES We report an unusual yet noteworthy complication of ulnar neuropathy after chest tube placement for pneumothorax. Awareness of the association between acute ulnar neuropathy and chest tube placement will alert the physician to reposition the tube and prevent ongoing compression. CASE REPORT A 43-year-old man developed right-sided rib fractures (6-9 and 12) and a pneumothorax from blunt trauma to the right chest wall. Upon insertion of a 36 French chest tube, the patient reported immediate ulnar nerve distribution paresthesias of the ipsilateral arm. The tube was subsequently repositioned with improvement of symptoms. He was later discharged with occupational therapy outpatient follow-up. CONCLUSION Ulnar neuropathy is a rare, though significant, complication associated with tube thoracostomy. Management of persistent symptoms is expectant, with early upper extremity range of motion and strength exercise.

Mondor's thrombophlebitis 13 years after breast augmentation.

Patient:A 37-year-old woman presented with Mondors thrombophlebitis 13 years after augmentation mammaplasty with subpectoral saline implants. She presented complaining of 1 week of “band-like” cords and pain involving the thoracoepigastric and lateral thoracic vessels. She was evaluated and ruled out for other etiologies of her breast symptoms. Background:Mondors disease is a benign and self-limiting disease characterized by thrombophlebitis of the subcutaneous veins of the chest and abdominal wall. The inflammation causes painful superficial cords manifesting as skin retraction. Mondors disease has been described in aesthetic breast surgery literature, but most cases occur within the first few postoperative weeks. Conclusions:Mondors disease may be idiopathic, iatrogenic, or a manifestation of underlying pathology such as breast cancer. The diagnosis of iatrogenic Mondors disease can be made with high clinical certainty when following aesthetic breast surgery in the early postoperative period. However, in late presentations that are not immediately related to surgery, Mondors disease remains a diagnosis of exclusion, and other underlying pathologic etiologies must be ruled out.

Barbed Suture as a Treatment Approach in Complex Degloving Injuries.

AbstractIn the late19th century, French physician Morel-Lavallée was challenged with a group of patients who sustained similar patterns of degloving injuries, which today carry his eponym. In 1853, he reported a series of cases as well as proposed strategies for the management of these complex degloving injuries. Treatment strategies have not varied significantly over the years, and these lesions continue to plague surgeons today with failure rates in excess of 50%. We present 2 case series using barbed suture in the management of these complex injuries.

Abstract: A Comparison of Intracranial Volumes in Normal Children and Patients with Metopic Craniosynostosis

PURPOSE: Non-syndromic craniosynostosis is associated with a multitude of language deficits. Early detection and prevention is essential for language remediation in these cohorts. The current standard assessment, the Bayley Scales of Infant Development (BSID), provides little predictive value for long-term development. Auditory event-related potentials (ERPs), in particular the mismatch negativity (MMN), measure passive neurological responses to speech sounds and suggest a promising avenue for analyzing infant speech development, particularly in craniosynostosis. We now provide long-term follow up neurocognitive assessment of patients with midline synostosis (sagittal and metopic) in comparison to BSID and ERP testing in infancy.

Abstract 18. A Method for Quantifying Intracranial Volume Change by Distraction Osteogenesis for Craniosynostosis

PURPOSE: Although numerous publications have described distraction osteogenesis (DO) for craniosynostosis, methods of reporting quantitative results have been inconsistent. Therefore, the efficacy of anterior DO and posterior DO in regards to volume change is not well established. We report a metric that relates volume change to distraction length and our analysis of ICV change by distraction osteogenesis.

Sustained Overcorrection After Autologous Facial Fat Grafting in the Pediatric Population: A Case Series

Introduction Autologous fat grafting is a valuable tool in the correction of facial soft tissue asymmetry and volume deficits. Pubertal growth and fluctuations in body mass present unique challenges to achieving satisfactory results after autologous fat transfer in the pediatric population. Few studies exist describing the outcomes and complications of pediatric facial fat grafting. The objective of this study is to identify the complication profile and outcomes after autologous fat grafting for the correction of facial asymmetry and volume deficits in the pediatric population. Methods Retrospective chart review was performed identifying 19 patients having undergone autologous fat grafting to the face for correction of facial volume deficits or asymmetry. Intraoperative variables were analyzed including blood loss, tumescent volume, lipoaspirate volume, graft volume transferred, donor fat processing technique, and donor site. Patient growth parameters were evaluated using body mass index (BMI) at the time of grafting and most recent follow up. Outcomes were evaluated based on adequacy of the graft, number of revisions or corrections, and complications. Results A total of 19 patients were identified. The median age at the time of primary fat graft was 17 years. The average change in BMI from preoperative to the latest recorded date was +0.60 ± 1.90. The average time from primary procedure to most recent follow up was 1.7 years. Abdomen was the most common donor site utilized. Adequate correction was achieved with an average of 1.4 graftings. Complications included contour irregularity (n = 1) and persistent overcorrection (n = 3). One patient required lipoaspiration for treatment of overcorrection. An unpaired t test demonstrated no significant difference in preoperative BMI (P = 0.58), postoperative BMI (P = 0.28), or change in BMI after grafting (P = 0.56) between adequately corrected and overcorrected patients. Conclusions Fat transfer is a safe and viable method for the correction of facial asymmetry in the pediatric population. Repeat fat grafting procedures may be required to achieve adequate correction; however, postoperative overcorrection is unlikely to resolve spontaneously in the pediatric population and is unrelated to changes in BMI. Care should be taken to minimize the degree of primary overcorrection when treating facial asymmetry in the pediatric population.

Effect of Surgeon Volume and Craniofacial Fellowship Training on Cleft Palate Complication Rates

Background Both the general and pediatric surgical literature have evidenced an inverse relationship between surgical case volume and complications. This study seeks to ascertain the relationship between case volume and fistula rates in cleft palate patients. We also seek to determine if craniofacial fellowship training impacts fistula rates. Methods Charts were reviewed at a multidisciplinary cleft center in San Diego, CA. We performed chart review on 207 nonsyndromic patients with cleft lip and palate who had surgery at our institution from 1988 to 2010. Data were analyzed using independent samples t test, &khgr;2 test, and stepwise binary logistic regression to assess whether surgeon case volume and craniofacial fellowship training correlated with fistula repair rate. Results The surgeon with the highest volume had significantly fewer fistula repairs than lower volume surgeons (P = 0.044). Patients operated on by the craniofacial fellowship trained surgeon had significantly fewer fistulas compared with other plastic surgeons who performed cleft palate surgery (P = 0.005). Conclusions Based on our retrospective review, it does appear that both high case volume and craniofacial fellowship training are associated with fewer postoperative fistulas.

Characterization of the ocular findings in the nablus masklike facial syndrome

Nablus masklike facial syndrome (NMLFS), characterized by tight, expressionless facial features resembling a mask, was first described in 2000. Since then, 10 cases have been identified with the same phenotype and genotype. Although detailed descriptions of the facial and external ear characteristics unique to the syndrome exist, no clear description of the ocular anatomic findings and management of ocular complications has been detailed. We present a confirmed case of NMLFS with detailed descriptions of the ocular anatomy encountered in this patient and a discussion regarding the clinical significance of these findings.

Resorbable Construct for Subtotal Cranial Vault Remodeling.

IntroductionPansynostosis can result in markedly thin calvarial bone resulting in poor quality and quantity of allograft for cranial vault expansion. Such scenarios can result in large calvarial defects and poorly stabilized constructs. Additionally, the osteoinductive properties of neonatal dura and paracranium in cranial vault reconstruction suggest the possibility of reconstructing extensive calvarial defects using minimal native calvarium given the appropriate scaffold. We report a case of subtotal cranial vault remodeling involving greater than 50% of the cranial vault using a custom poly DL lactic acid (Sonic Weld) resorbable plate construct and underlay calvarial bone grafting. MethodsA 4-month-old male infant presented with a diagnosis of Cruzon syndrome and pansynostosis. Staged reconstruction was performed with the initial stage involving the posterior and middle cranial vault. Given the severity of the deformity, the native cranial bone was thinned with multiple defects such that it could not be used to provide structural integrity or sufficient surface coverage for cranial vault reconstruction. Useable bone comprised only a fraction of the surface area required to expand the posterior and midcranium. Resorbable poly DL lactic acid (Sonic Weld) plates were used to create a custom construct for reconstruction of the posterior and middle cranial vault. The construct was then seeded with usable fragments of the native calvarium and secured to the cranial base with resorbable pins. ResultsThe construct resulted in maintained cranial shape throughout the postoperative period. Postoperative computed tomography imaging demonstrated osteogenesis throughout the construct with bridging of the fragmented calvarial grafts. Examination of the construct during anterior cranial vault remodeling demonstrated near complete resorption of the construct, stable posterior cranial vault, and minimal dural adhesions to the posterior cranium. At 11 months postoperatively, the patient continues to demonstrate appropriate cranial expansion and maintenance of posterior cranial shape. ConclusionsFully resorbable constructs can provide effective structural support and a scaffold for osteogenisis in conjunction with minimal native calvarial bone grafts during reconstruction of large cranial vault defects in the infantile period.