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Background: A major concern in the detection and reporting of child abuse and neglect regards the phenomenon of racial bias., Objective: This research examined whether the assessment and/or decision making concerning a case of neglect by Student Guidance Center-workers (SGC) is racially biased., Participants and Setting: 238 Flemish SGC-workers participated and filled in the questionnaire., Methods: A visual vignette was used. SGC-workers were shown pictures of a neglectful situation that randomly varied with respect to whether the child in the picture was colored or white or whether the room was empty. Participants indicated (1) if this was a situation of neglect (yes/no) and (2) if they would report this situation (yes/no)., Results: The assessment was influenced by the color of the child with a moderate effect (V = 0.23). In case of a white child, 84 % of the respondents assessed the situation as neglect. In case of an empty room 71 % and in case of a colored child only 58 % assessed the situation as neglect (p = .002). Reporting of the case was not influenced by the color of the child (p = .875)., Conclusions: SGC-workers assessment of neglect appears to be racially biased. White children are considered more as neglected compared to their colored counterparts. Implementing strategies in order to decrease the racial bias is important., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis., (© 2023. The Author(s).)

Background: It is likely that the circumstances during the COVID-19-lockdown in Belgium increased the incidence and prevalence of child abuse and neglect (CAN) due to exacerbated risk factors and new COVID-19-related stressors. However, traditional reporters had less contact with children which could lead to undetected cases of CAN., Objective: Gain insight into the number and profile of CAN reports filed to the Brussels Confidential Center of Child Abuse and Neglect (CCCAN) during the COVID-19-lockdown., Participants and Setting: A dataset comprising 536 CAN reports from periods before (N = 442) and during the lockdown (N = 94)., Methods: Characteristics about the report, reporter, victim and his/her family, perpetrator(s) and the trajectory with the CCCAN were registered. The number and characteristics of reports during the lockdown were compared to those of reports before the lockdown., Results: The number of advisory questions (p = .506, d = .377) and allegations (p = .095, d = 1.206) remained unchanged. During the lockdown, the risk assessment of advisory questions was higher (p = .011, d = .280), they evolved more into social exigency investigations (p < .001, φ = .246) and were referred more often to judicial authorities (p = .010, φ = .163). Allegations were filed more often by the helpline, police and judicial authorities (p < .001, φ = .590) during the lockdown and involved more Dutch-speaking (p = .016, φ = .166) victims., Conclusions: The number of CAN reports remained the same during the lockdown but their profile changed., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

We evaluated the disposable non-invasive SpotOn™ thermometer relying on the zero-heat-flux technology. We tested the hypothesis that this technology may accurately estimate the core temperature. The primary objective was to compare cutaneous temperature measurements from this device with blood temperatures measured with the pulmonary artery catheter. Secondary objective was to compare measurements from the zero-heat-flux thermometer indirectly with other routinely used thermometers (nasopharyngeal, bladder, rectal). We included 40 patients electively scheduled for either off-pump coronary artery bypass surgery or pulmonary thromboendarterectomy. Temperatures were measured using zero-heat-flux (SpotOn™), pulmonary artery catheter, nasopharyngeal, rectal, and bladder thermometers. Agreement was assessed using the Bland and Altman random effects method for repeated measures data, and Lin's concordance correlation coefficient. Accuracy was estimated (defined as <0.5° difference with the gold standard), with a 95% confidence interval considering the multiple pairs of measurements per patient. 17 850 sets of temperature measurements were analyzed from 40 patients. The mean overall difference between zero-heat-flux and pulmonary artery catheter thermometer was -0.06 °C (95% limits of agreement of ± 0.89 °C). In addition, 14 968 sets of temperature measurements were analyzed from 34 patients with all thermometers in situ. Results from the zero-heat-flux thermometer showed better agreement with the pulmonary artery catheter than the other secondary core thermometers assessed. In conclusion, the SpotOn™ thermometer reliably assessed core temperature during cardiac surgery. It could be considered an alternative for other secondary thermometers in the assessment of core temperature during general anesthesia., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

The measures implemented to contain the COVID-19 pandemic profoundly affected the lives of children and families all around the world, probably affecting children's psychosocial well-being. The negative consequences of lockdowns are presumed to hit even harder on vulnerable groups such as foster children who already struggle with their psychosocial well-being in normal circumstances and who face specific challenges during lockdowns such as: additional help that is no longer available or only offered digitally and physical contact with birth parents that is forbidden. Nevertheless, some scholars point to the positive side of lockdowns (e.g.: relief due to closure of schools). This study aims to asses the psychosocial well-being of Flemish foster children residing in their foster homes during the COVID-19 lockdown and the factors that are associated with the change in their psychosocial well-being. 888 foster parents reported on the psychosocial well-being of just as many foster children through the Brief Assessment Checklist for Children and Adolescents. The COVID-19 lockdown was not associated with a decreased psychosocial well-being of Flemish foster children residing in their foster homes during the lockdown. Foster parents reported a slight improvement in their relationship with their foster child during the lockdown which points to a positive consequence of the lockdown. In addition, this improvement was positively associated with an increased psychosocial well-being during adverse circumstances and should therefore be enhanced. The type and amount of contact with birth parents is significantly associated with foster children's changed psychosocial well-being during the lockdown. Foster parents who reported an increase in alternative contact (e.g., (video)calls and messages) between their foster child and his/her birth parent(s) during the lockdown, also reported an increase in their foster child's psychosocial well-being during that period., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Elsevier Ltd. All rights reserved.)

Objective: Compare different imaging scenarios in the diagnosis of uncomplicated renal colic due to urolithiasis (URCU)., Materials and Methods: A total of 206 prospectively included patients had been admitted with suspected URCU and had undergone abdominal plain film (APF), US and unenhanced CT after clinical STONE score evaluation. CT was the reference standard. We assessed sensitivity (Se), specificity (Spe) and Youden index for colic pain diagnosis, percentage of patients managed by urologic treatment with stone identified, percentage of alternative diagnoses (AD) and exposure to radiation, according to single imaging approaches, strategies driven by patient characteristics and conditional imaging strategies after APF and US., Results: One hundred (48.5%) patients had a final diagnosis of URCU and 19 underwent urologic treatment. The conditional strategy, i.e. CT in patients who had no stone identified at US, had a perfect sensitivity and specificity. This enabled diagnosis of all stones requiring urology management while decreasing the number of CT exams by 22%. The strategy whereby CT was used when there was neither direct or indirect APF + US finding of colic pain nor alternative diagnoses in patients with a STONE score ≥ 10 had a sensitivity of 0.95 and a specificity of 0.99, identified 84% of stones managed by urologic treatment and decreased the number of CT examinations by 76%., Conclusion: In patients with clinical findings consistent with URCU, the use of ultrasound as first-line imaging modality, with CT restricted to patients with negative US and a STONE score ≥ 10, led to a sensitivity and specificity of above 95%, identified 84% of stones requiring urological management and reduced the number of CT scans needed by fourfold., Key Points: • For diagnosis, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, provides both a sensitivity and specificity superior or equal to 95% and reduces the number of CT scans necessary by fourfold. • For management, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, maintains a 84% stone identification rate in urology-treated patients.

Large bowel obstruction (LBO) is associated with high morbidity and mortality due to delayed diagnosis and/or treatment. MDCT has become the standard of care to identify the site, severity, and etiology of obstruction. The goal of this review is fourfold. The first objective is to give clues to differentiate LBO from colonic pseudo-obstruction. The second objective is to describe CT features in the most common cause of LBO which is colonic cancer by illustrating classical and atypical features of colonic cancer responsible for LBO and by giving the features which must be reported when differentiating malignant from benign: presence of local lymph nodes, other colic localizations, length of involved segment, presence of diverticula, or other. The third objective is to illustrate the various causes of LBO which can mimic a colon cancer by leading to a thickening of the colonic wall: diverticulitis, ischemic colitis, endometriosis, inflammatory disease and to give tips which permit to evoke another diagnosis than a colon cancer in patient with a LBO and a thickening of the colic wall. The fourth objective is to describe the common signs of cecal and sigmoid volvulus and to give tips for a diagnosis sometimes difficult particularly for cecal volvulus: one of two transition points according to the type of volvulus and the presence of a whirl sign with a torsion of the mesenteric vessels., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Free flap reconstruction cases of the head and neck are often complex, long and have a multitude of risks. One of the greatest risks is intraoperative blood loss and need for transfusion. The purpose of this study was to examine basic patient and procedure characteristics in head and neck free flap reconstruction pre- and postoperatively that may help to predict severity of blood loss., Methods: A retrospective chart analysis of 67 free flap reconstructions for head and neck defects was performed. Patient characteristics, surgical variables, length of stay, and postoperative complications were reviewed and compared between the transfused and nontransfused patients. Characteristics between transfused and nontransfused patients were analyzed using two-tailed t tests and Fisher's exact tests., Results: Of the 67 procedures, 19 reconstructions (28.4%) required a transfusion. Transfused patients were found to have a lower preoperative hemoglobin and elevated coagulation labs. The average length of stay was also statistically longer for transfused patients. There was no statistical difference in patient characteristics, length of surgery, type of free flap, or complication rate in the transfused versus nontransfused patients., Conclusions: Our study demonstrates that head and neck microsurgical resection and reconstruction presents patients with a transfusion risk of over 28%. We found that patients with a lower preoperative hemoglobin and abnormal coagulation levels are at a higher risk for receiving a transfusion. We also have demonstrated that patients who received a transfusion had a statistically significant longer length of stay.

Purpose: To determine which CT findings or combinations of CT findings could accurately identify adnexal torsion in a cohort of women admitted for abdominal pain and presenting with an adnexal mass., Materials and Methods: The local institutional review board approved this retrospective case-control study involving adults-the informed consent requirement was waived. Enhanced computed tomography (CT) findings of 32 consecutive adnexal torsion and 32 control patients admitted for abdominal pain and presenting with an adnexal mass were independently reviewed by two radiologists, with consensus by a third one, for all CT findings commonly assessed in adnexal torsion. All twisted and untwisted adnexa were confirmed by surgery. Univariate and multivariate analyses were performed for adnexal torsion prediction., Results: The median patient age was 41 years (interquartile range, 30.5-62 years). Only benign masses were encountered in the torsion group. Five CT features were significantly associated with adnexal torsion: a large ovary with a threshold at 80mm (p=0.005), median or contralateral displacement of the adnexa (p=0.00014), asymmetric wall thickening of the mass (p<0.0001), inter-utero-ovarian mass (p<0.0001) and whirlpool sign (p=0.0006). In the multivariate analysis, only the inter-utero-ovarian mass was independently associated with adnexal torsion (odds ratio=130 (CI95%: 15-infinite), p<0.0001) with an excellent overall diagnostic performance (AUC=0.89; CI95%: 0.81-0.97). It was a sensitive (Se=97%, CI95%: 84-100) and specific feature (Sp=81%, CI95%: 64-93)., Conclusion: An inter-utero-ovarian mass is an accurate and reliable CT finding for diagnosing adnexal torsion in patients with acute abdominal pain and an adnexal mass., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: Many health care facilities are navigating their way through the new antimicrobial stewardship standards and guidelines. The purpose of this article is to provide information for health care facilities to improve patient care. Summary: New regulations and guidelines surrounding antimicrobial stewardship have prompted facilities to review their process related to antimicrobial stewardship. In setting up a program, there are many factors to consider including involving key personnel, obtaining leadership support, identifying an infectious disease physician to chair or cochair the committee, and meeting agenda, metrics, and educational needs. Conclusion: Antimicrobial stewardship plays a vital role in both our hospital and community setting. Pharmacists are uniquely positioned to improve optimal patient care through rounding, review of patients' chart, and contribute to the improvement of antimicrobial stewardship by working with a multidisciplinary team. These efforts may improve the utilization of antimicrobial agents., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose To assess the rate of underestimation of atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) at magnetic resonance (MR) imaging-guided vacuum-assisted breast biopsy and to explore the imaging, demographic, and histologic characteristics associated with lesion upgrade after surgery. Materials and Methods This retrospective study had institutional review board approval, and the need to obtain informed patient consent was waived. A total of 1509 MR imaging-guided vacuum-assisted biopsy procedures were performed in nine centers. A diagnosis of ADH was obtained after biopsy in 72 cases, and a diagnosis of DCIS was obtained in 118 cases. Pearson χ 2 and Fisher tests were used to assess the association between demographic, MR imaging, and biopsy features and lesion upgrade. Univariate statistical analyses were performed, and each significant parameter was entered into a multivariate logistic regression analysis. Results Surgical excision was performed in 66 of the 72 ADH cases and in 117 of 118 DCIS cases. The ADH and DCIS underestimation rates were 25.8% (17 of 66) and 23.1% (27 of 117), respectively. Underestimation was 5.6-fold (odds ratio [OR] = 5.6; 95% confidence interval [CI]: 1.7, 18.3) and 3.6-fold (OR = 3.6; 95% CI: 1.2, 10) more likely in mass (n = 20 for ADH and n = 20 for DCIS) than in non-mass (n = 46 for ADH and n = 97 for DCIS), compared with nonunderestimation, in ADH and DCIS respectively. At multivariate analysis, the use of a 9- or 10-gauge needle versus a 7- or 8-gauge needle was also an independently associated with underestimation when a diagnosis of ADH was made at MR imaging-guided biopsy. No other parameters were associated with of ADH or DCIS upgrade at surgery. Conclusion The rates of underestimation in ADH and DCIS diagnosed at MR imaging-guided vacuum-assisted biopsy were high, at around 25%, and were significantly associated with the presence of a mass at MR imaging. © RSNA, 2016.

There is a significant need for basic surgical care worldwide. In recent years, modest improvement in fulfilling this demand has been achieved through international medical mission trips from various organizations. These humanitarian endeavors and global health experiences have generated increasing interest in participating in international missions from surgical residents. However, many academic institutions currently do not have the infrastructure or desire to support surgical residents participating in medical missions. This paper aims to illustrate that careful, planned integration of medical mission trips into the residency curriculum will develop and enhance resident education and experience by fulfilling all six Accreditation Council for Graduate Medical Education (ACGME) core competencies and by benefitting the native program.

Objective: The present status of global mission trips of all of the academic Plastic Surgery programs was surveyed. We aimed to provide information and guidelines for other interested programs on creating a global health elective in compliance with American Board of Plastic Surgery (ABPS) and Accreditation Council for Graduate Medical Education Residency Review Committee (ACGME/RRC) requirements., Design: A free-response survey was sent to all of the Plastic Surgery Residency program directors inquiring about their present policy on international mission trips for residents and faculty. Questions included time spent in mission, cases performed, sponsoring organizations, and whether cases are being counted in their resident Plastic Surgery Operative Logs (PSOL)., Results: Thirty-one programs responded, with 23 programs presently sponsoring international mission trips. Thirteen programs support residents going on nonprogram-sponsored trips where the majority of these programs partner with outside organizations. Many programs do not count cases performed on mission trips as part of ACGME index case requirement. Application templates for international rotations to comply with ABPS and ACGME/RRC requirements were created to facilitate the participation of interested programs., Conclusions: Many Plastic Surgery Residency programs are sponsoring international mission trips for their residents; however, there is a lack of uniformity and administrative support in pursuing these humanitarian efforts. The creation of a dynamic centralized database will help interested programs and residents seek out the global health experience they desire and ensure standardization of the educational experience they obtain during these trips.

Background: Breast implants are high-risk devices that have been at the epicenter of much debate and controversy. In light of the Poly Implant Prothèse crisis, data registries among 11 national societies around the world are cooperatively calling for the urgent need to establish robust national clinical quality registries based on international best practice within a framework of international collaboration., Methods: A survey was conducted on the historic and current status of national breast device registries. Eleven countries participated in the study, illustrating different data collection systems and registries around the world. Data collection was designed to illustrate the capabilities of current national registries, with particular focus on capture rate and outcome reporting mechanisms., Results: A study of national breast implant registries revealed that less than half of the participating countries had operational registries and that none of these had adequately high data capture to enable reliable outcome analysis. The study revealed that the two most common problems that discouraged participation are the complexity of data sets and the opt-in consent model., Conclusions: Recent implant crises have highlighted the need for robust registries. This article argues the importance of securing at least 90 percent data capture, which is achievable through the opt-out consent model. Since adopting this model, the Australian Breast Device Registry has increased data capture from 4 percent to over 97 percent. Simultaneously, it is important to foster international collaboration from the outset to avoid duplication of efforts and enable the development of effective international early warning systems.

This study compared patient outcomes of a single surgeon experience between those with inferior and medial pedicle breast reductions. A cohort of 84 patients was analyzed. In all, 49 inferior pedicle reductions and 35 medial pedicle reductions were performed. The average weight of tissue removed per breast was 639 g with the inferior pedicle technique and 450 g with the medial pedicle technique. Nipple transposition distance averaged 8.6 cm for the inferior pedicle group and 6.3 cm for the medial pedicle group. Scar revision surgery within 18 months was required in 5.7% of the medial pedicle group as compared with 0% in the inferior pedicle group. The overall complication rate was higher for the inferior pedicle group (28.6%) compared with the medial pedicle group (14.3%). In this study, medial pedicle reductions resulted in lower complication rates. The amount of tissue removed was less with medial pedicle reductions. Hypertrophic scarring was reduced in the medial pedicle reduction mammoplasty.

Despite intensive public education, the incidence of melanoma in Central Texas has remained relatively constant (from 175 per 100,000 during 1981-1990 to 190 per 100,000 during 1991-2000). Although other investigators have hypothesized that the slight increase in incidence results from increased detection and reporting of early-stage (thinner) tumors, we found the average thickness was 0.99 mm from 1981 through 1990 and 1.11 mm from 1990 through 2000 (P = .30). These data suggest that despite efforts at public education, the incidence of melanoma in Central Texas is not decreasing and people are not identifying their tumors at an earlier stage.

Nipple-sparing total mastectomy remains an alternative for management of patients with high risk breast disease or patients with various types of symptomatic breast problems. In a patient with large breasts, however, achieving good cosmesis while still performing a thorough mastectomy remains a challenge. This report includes 10 patients who underwent unilateral nipple-sparing total mastectomy and 10 patients who underwent bilateral nipple-sparing total mastectomy. Tissue expansion was used as the reconstructive technique in this consecutive series done from 1985 through 1988. All expanders were placed in the submuscular position, and hyperbaric oxygen was used when intraoperative fluorescein administration identified marginally perfused areas. The average volume of breast tissue removed was 800 gm. The average permanent implant size was 767 cc. Complications included partial skin or nipple loss, infection, and problems related to the implants themselves. The complication rate, however, was not excessive, and results have been good as measured by cosmetic results, capsule grade, and lack of development of cancer in operated breasts. This reconstructive technique is recommended as an alternative in those patients undergoing nipple-sparing total mastectomy.

Tuberous sclerosis is an inherited syndrome with mental retardation, epilepsy, and acne rosacea being the classic triad of manifestations. The facial skin problems can present a cosmetic deformity or, as in the three patients presented here, can produce difficulties with hygiene and nasal breathing. Various approaches to treatment have been described over the last century, but no long-term results have been presented. Because of the full-thickness skin involvement, complete removal is not practical, and treatment should be directed toward acceptable long-term results with minimal surgical morbidity. Shaving and dermabrasion of the involved area produce very satisfactory results, but long-term follow-up of approximately 10 years reveals that there is a variable amount of recurrence and that subsequent treatment will be required.

Various expressions of nerve regeneration specificity (tissue, target, and end-organ) have been demonstrated histologically, but the influence of nerve regeneration specificity on functional outcome remains to be investigated. Specificity expression appears to be dependent, to some extent, on the distance between the proximal and distal nerve stumps. Regeneration specificity is inhibited by end-to-end alignment. This study examined the effect of gap distance repair on the return of rat hind-limb function, as measured by the sciatic function index (SFI). Sixty-four Sprague-Dawley rats were randomized into three groups: 0-mm gap (abutment), 2-mm gap, and 5-mm gap repair. The sciatic nerve was divided and secured in a Silastic conduit to maintain the gap length. The SFI was measured preoperatively and then at postoperative weeks 2, 4, 8, 12, 16, and 20. Results showed no significant difference in functional return between the abutment and the two gap groups at any time period (SFI at 20 weeks = -73.9, 0 mm; -73.5 2 mm; -75.2, 5mm; p = 0.90). This lack of difference in functional outcomes suggested an insignificant functional influence of regeneration specificity within single chamber conduits. The study also demonstrated that small gaps between nerve ends within a conduit yielded functional results equal to end-to-end repair of rat sciatic nerves.

The implantable cardioverter-defibrillator is a mechanical device developed to manage patients with life-threatening arrhythmias when pharmacologic control has failed or produced unacceptable side effects. It is a significant amount of foreign material with a generator pack (volume 113 to 145 cc, weight 197 to 235 gm) and two or three leads and patches that are inserted into or placed on the heart. Although it has worked very well in preventing premature death, there have been complications associated with the device itself. The most significant of these has been exposure and/or infection. We present three patients who have experienced this problem. Improved coverage has been accomplished by burying the implant beneath the rectus abdominis muscle in situations where skin and subcutaneous tissue alone have proved inadequate. By dividing one or two tendinous inscriptions and the anterior limb of the internal oblique fascia, a musculofascial pocket is created to contain the generator and lead wires. This provided satisfactory coverage in two of our three patients. The single failure resulted from external trauma to the abdominal wall.

Although the internal cardioverter defibrillator has prevented many premature deaths from lethal ventricular arrhythmias, some complications have occurred with its use. We present a patient who developed a fistula between the left ventricle and a bronchus, caused by erosion of the ventricular patch. The patient's presenting symptom was hemoptysis. Physicians caring for patients with these devices should be aware of this potential problem.

Chronic alcoholization by ethyl-alcohol inhalation was used to study the properties of a spin-trapping agent on different alcohol manifestations in rat. The spin-trapping agent, i.e. N-tert-butyl-alpha-phenylnitrone (PBN), was given at the dose of 32 mg/kg twice a day during the whole alcoholization procedure. The blood alcohol level, the hypermotility which accompanied the ethanol withdrawal, the behavioral dependence as estimated by a free-choice program and the hypervascularization which is developed after a chronic pulmonary alcoholization were quantified. The rats treated with PBN differ from the control rats only by their higher blood alcohol level at the end of the chronic alcoholization while the other quantified alcohol-induced manifestations remained unchanged.

The rat sciatic nerve serves as a good model of nerve regeneration and, as such, is often used in investigations of nerve repair. After transection of the sciatic nerve, rodents frequently scratch and bite their anesthetic foot, resulting in amputation of one or more toes. This is termed autotomy or autophagy. When these rats are part of a study using the sciatic functional index (SFI), autotomy results in unusable data, since necessary foot landmarks have been removed. It would be helpful, therefore, to be familiar with the phenomenon of autotomy and to know which rats are least likely to mutilate themselves. In our experiment involving 64 rats in which the sciatic nerve was transected and repaired, we found that female Sprague-Dawley rats were significantly less likely to perform autotomy than males (33% vs. 65%, P = .04). In addition, we noted that two-thirds of the autotomies that occurred did so by postoperative week 4 and that tabasco sauce did not decrease this activity. We present our experience and a survey of the literature on autotomy and the SFI.

Current management of wounds in the diabetic foot is detailed. A thorough initial clinical examination and non-invasive tests can give baseline values and provide valuable information about limb and foot circulation. The approach detailed involves limited amputation and preservation of as much of the weight-bearing surface as possible.

The use of a drain trochar with a length of attached silicone drain is described for passing wires through the face into the mouth in fixation of complex facial fractures.

In 1833 Dupuytren described what he referred to as an "affectation" of the palmar aponeurosis. This disorder continues to bear his name a century and a half later despite the fact that Dupuytren was not the first to describe it. The author contemplates the contributions of Felix Platter, Henry Cline, and Sir Astley Cooper in the management of this "maladie."

The elderly patient with a chronic wound displays many characteristics peculiar to the age group that must be considered by the treating physician. This article describes a variety of specific age-related influences on wound healing, and incorporates several illustrative case reports.

Residual splenic tissue can occasionally be responsible for recurrent idiopathic thrombocytopenic purpura after splenectomy. Although this is an uncommon phenomenon, we have identified six such patients at the Mayo Clinic in the last 40 years, and a review of the literature revealed nine others. Only 4 of the 15 patients with sufficient follow-up were significantly improved after splenectomy, 1 requiring less medication to control his thrombocytopenia. The presence of residual splenic material is suggested by the absence of Howell-Jolly bodies in the peripheral smear and confirmed by technetium-99m scanning. Accessory splenectomy should be considered as an adjunct to the control of idiopathic thrombocytopenic purpura in previously splenectomized patients but with the realization that remission or improvement in the clinical course may occur in only about one-half of such patients.