The effect of low-molecular-weight heparin in the survival of a rabbit congested skin flap

Swelling and congestion of flaps are frequently seen postoperatively and can cause unexpected necrosis. According to previous reports, venous thrombosis seems to be a more frequent problem than arterial occlusion in both experimental and clinical surgery. Few satisfactory venous trauma models exist, and reports on experimental venous thrombosis are rare. The object of this study was to create a rabbit venous occlusion flap model and to evaluate the effect of low-molecular-weight heparin on this flap. Eight New Zealand rabbits were used in the pilot study, in which the ideal congested flap was investigated using a flap pedicle based on the central auricular artery with a skin pedicle 0, 1, 2, or 3 cm wide. The flap (3 x 6 cm) was designed on the central part of the left ear, and the central auricular vein and nerve, the former for venous return, were cut out at the base of the flap. The flaps with skin pedicles 0, 1, 2, or 3 cm wide showed mean necrosis length of 60.0, 9.3, 4.2, and 0.0 mm, respectively. The flaps with skin pedicles 0, 1, 2, or 3 cm wide showed mean necrosis of 100, 15.5, 7, and 0 percent, respectively. Therefore, the flap, based on a 1-cm-wide skin pedicle and the central auricular artery, was selected as an optimal congested flap model showing 15.5 percent necrosis. The congested flap was then elevated on the left ear of another 10 rabbits. Subcutaneous low-molecular-weight heparin (320 IU/kg) was administered immediately after surgery to five of the rabbits (the low-molecular-weight heparin group), and the remaining five were used as a control group. Fluorescein was injected 15 minutes after surgery to evaluate the circulatory territory of the flap, and the circulatory territory was measured 5 minutes after injection. The flaps were assessed 7 days after surgery by angiography, histology, and clinical findings. The circulatory territory was significantly greater in the low-molecular-weight heparin group (mean +/- SD, 39.2 +/- 3.0 mm) than the control group (mean +/- SD, 48.0 +/- 1.0 mm) (p < 0.001) assessed 7 days after surgery. The longest flap survival length in group A and group B ranged from 40 to 55 mm (mean +/- SD. 49.4 +/- 5.6 mm) and complete survival (mean +/- SD, 60.0 +/- 0.0 mm). The improvement in survival was statistically significant for group B compared with group A (p < 0.015). Histologic evaluation revealed moderate to severe venous congestion and inflammation in the control group, whereas there were minimal changes in the low-molecular-weight heparin group. Angiography of the flap revealed obvious venous occlusion in the periphery in the control group compared with the low-molecular-weight heparin group. The authors conclude that subcutaneous administration of low-molecular-weight heparin has a great potential to improve the survival length of a congested flap without major complications.     

Evaluation of performance characteristics of the medicinal leech (Hirudo medicinalis) for the treatment of venous congestion.

Medicinal leeches (Hirudo medicinalis) are a standard treatment for venous congestion, a complication that can occur after reconstructive surgery. If the cause of venous congestion cannot be surgically corrected, then medicinal leeches are used to temporarily increase perfusion levels and maintain physiologic requirements within the congested tissue. Leeches increase perfusion within congested tissue by actively drawing off blood as a bloodmeal. Furthermore, the leech bite continues to bleed and relieve congestion after detachment because of the anticoagulation effects of leech saliva left behind in the bite. In a porcine model, a 10 x 10 cm cutaneous flank flap was congested by clamping the venae comitantes. Four medicinal leeches were allowed to attach to the congested flap, and parameters of active feeding and passive bleeding after detachment were recorded. The average bloodmeal volume for the medicinal leeches was 2.45 ml. Average passive bleeding for the first 2 and 4 hours after leech detachment totaled 2.21 and 2.50 ml, respectively, with 90 percent of passive bleeding occurring within 5 hours after detachment. Laser Doppler imaging indicated that the spatial arrangement of surface perfusion increases were localized to a 1.6-cm-diameter circle around the leech head (bite) and corresponded well with the visual return of normal skin tones to the same area. This study provides a realistic and quantitative estimate of the spatial and volumetric characteristics of leech feeding and passive bleeding using a clinically relevant model of acute, severe congestion.     

Initial Heparin Therapy in Acute Myocardial Infarction

The administration of heparin during the first 48 hours following acute myocardial infarction is widely practised. Heparin treatment is also recommended for acute coronary insufficiency on the grounds that it may prevent development of an impending myocardial infarction. These measures had been accepted without support of a controlled clinical trial. By random selection, 101 patients hospitalized with a provisional diagnosis of acute myocardial infarction received heparin (100 mg. intravenously every eight hours for 48 hours) and 105 patients were assigned to a control group. Both groups of patients received bishydroxycoumarin (Dicumarol). The mortality in the heparin series was 30% and in the control group, 28%. A significantly large number of the heparin-treated patients developed clinical and laboratory proof of recent myocardial infarction. It is concluded that early intermittent intravenous heparin treatment does not lower the mortality in patients with acute myocardial infarction nor does it prevent impending myocardial infarction in patients with acute coronary insufficiency.     

Aeromonas, acclimation, and penicillin as complications when leeches are applied to skin flaps in rabbits

The medicinal leech, Hirudo medicinalis, has been recognized by plastic surgeons for its ability to reduce congestion and improve blood flow in grafted skin flaps by withdrawing excess blood. The leech's ability to digest blood is due to the presence of Aeromonas hydrophila in the gut of the leech. In this report we describe the occurrence of Aeromonas hydrophila septicaemia in rabbits used in a study to evaluate the efficacy of the medicinal leech on abdominal skin flap survival. In New Zealand White rabbits, twin 5 x 10 cm abdominal skin flaps were prepared and the epigastric vein was ligated to produce a model of venous congested skin. After 12 hours, a leech was applied to one of the congested abdominal flaps and skin survivability was assessed and compared with the unleeched flap. Five rabbits died acutely approximately 24 hours post-operatively. Gross necropsy, bacteriology and histopathology findings indicated that A. hydrophila was the causative agent of the septicaemia-toxaemia syndrome with an associated pneumonia and typhlitis. Review of the management and the experimental surgery protocol suggested that the two major disposing factors of Aeromonas septicaemia in these rabbits were stress and excessive prophylactic administration of penicillin.     

Comparative levels of amphotericin B in the skin and subcutaneous fatty tissue after cutaneous application of amphotericin ointment by phonophoresis and with preliminary treatment by dimethyl sulfoxide]

A comparative study of the amphotericin B contents in the skin and subcutaneous fatty tissue was performed on guinea pigs after local application of amphotericin ointment by phonophoresis and with preliminary treatment of the skin by dimethyl sulfoxide (DMSO). When the amphotericin ointment was used in combination with ultrasound the content of amphotericin B in the skin and subcutaneous fatty tissue 1, 3, 24, 48 and 72 hours after the application was much higher than that after the ointment local application without the ultrasonic treatment. When the amphotericin ointment was applied locally after the preliminary treatment with DMSO the maximum content of the antibiotic in the skin and subcutaneous fatty tissue was observed 3 hours after the application which was significantly higher than the content observed after the ointment application by phonophoresis and especially locally without the ultrasonic treatment. In 24, 48 and 72 hours the amphotericin B concentration in the skin and subcutaneous fatty tissue under any conditions lowered and in 24 hours had a tendency to level in the areas treated with ultrasound and DMSO. In 48 and 72 hours the highest concentrations of the antibiotic were in the skin and subcutaneous fatty tissue after the ointment application by phonophoresis.     

Insulin tolerance in rats.

Insulin tolerance was studied in young (8- to 10-week-old) Wistar rats: a) after the administration of mounting doses of long-acting insulin (10, 40, 160 and 320 units/kg bw.) to animals fed ad libitum on two different diets); b) after the administration of long-acting insulin (1 and 5 units/kg b.w.) to animals which had fasted for different lengths of time. In rats fed ad libitum on the two diets, graded doses of insulin induced (except for the smallest dose) hypoglycaemia of roughly the same intensity, but varying in duration in correlation to the dose. The administration of insulin to fasting rats showed differences in insulin tolerance which were correlated to the duration of the fast. A significant decrease in insulin tolerance was already found after 6 hours. During the given testing period (72 hours), the lowest insulin tolerance was found after a 12 hours' fast and the highest after 48 hours. Insulin tolerance after 24 and 72 hours' fasting was approximately the same; it was higher than after 12 hours, but lower than after 48 hours. The initial blood sugar level (before administering insulin) was not in any way correlated to insulin tolerance determined at various intervals during fasting.     

The effect of pentosan polysulphate (SP54) on the fibrinolytic enzyme system. An experimental animal study

Pentosan polysulphate (SP54) causes a transient increase in blood fibrinolysis in conscious and anaesthetized rats. Postoperative "fibrinolytic shutdown" was prevented by a dose of 2 mg/kg body weight but there appeared to be no dose-response relationship with higher doses. Fibrinolysis was also measured in conscious unstressed animals using an indwelling jugular cannula. The venous response to SP54 in these animals was substantially higher than the arterial response. Experiments with an inferior vena cava model of thrombosis suggest that a single dose of 10 mg/kg pentosan polysulphate given 90 min after thrombus formation is sufficient to achieve thrombolysis. This effect was more marked if the animals were given multiple doses over 24 to 48 hours.     

Circadian changes in anticoagulant effect of heparin infused at a constant rate.

Six patients with venous thromboembolism were treated with heparin, administered intravenously by a constant infusion pump. The initial daily dose of heparin was adjusted to keep the activated partial thromboplastin time, sampled at 0800, between 1.5 and 2.5 times the control level. Once that level was obtained, this dose was kept constant. Anticoagulation was thereafter measured, every four hours for 48 hours, by activated partial thromboplastin time, thrombin time, and coagulation factor Xa inhibition assay. The results of all three coagulation tests showed a circadian variation in the six patients. Maximum values were achieved at night and minimum values in the morning. These circadian variations were reproduced for two consecutive days. Differences between night and morning values reached almost 50% for activated partial thromboplastin time, 60% for thrombin time, and 40% for factor Xa inhibition assay. This circadian variation resulted from two rhythms, a circadian rhythm lasting 24 hours and an ultradian rhythm lasting 12 hours, which were detected by cosinor analysis for each coagulation test (p less than 0.01). A circadian rhythm was detected individually in most of the patients for each coagulation test (p less than 0.05). All patients had a nocturnal peak in activated partial thromboplastin time on both days. In four patients this peak exceeded the upper desired limit of activated partial thromboplastin time. These rhythms should be taken into account when evaluating the dosage of heparin to be administered.     

Effect of streptomycin and kanamycin on the course of experimental tularaemia in guinea-pigs

1. (1)
   Guinea-pigs weighing 250–300 g. were treated with daily doses of 10 mg. streptomycin and kanamycin for one and two weeks, starting one, four and seven days after subcutaneous infection with a dose of 10 or 100 MLD of a virulent strain ofPasteurella tularensis; 88–96% were protected from death. The adminis-tration of streptomycin 48 hours before or 24 hours after infection with a sublethal dose had a similar protective effect.     
   
   

Differential effects of venous stasis and arterial insufficiency on tissue oxygenation in myocutaneous island flaps: an experimental study in pigs.

The supply, consumption, and tissue tension of oxygen were studied in experimental bilateral myocutaneous island flaps in five control pigs and in eight pigs during progressive 1-hour intervals of flap ischemia. Progressive ischemia was obtained by partial to complete clamping of the artery in one flap, producing arterial insufficiency, and simultaneous clamping of the vein in the other flap, producing venous stasis. Blood flow was reduced to 50, 25, and 0 percent of baseline. In the arterial insufficiency flaps, the oxygen tension in subcutaneous tissue, muscle, and venous outflow was significantly reduced once blood flow was reduced to 50 percent of baseline. Oxygen consumption during partial vessel occlusion was lower in the venous stasis flaps than in the arterial insufficiency flaps when blood flow was reduced to 25 percent of baseline, suggesting either that cellular metabolism is reduced in the venous stasis flaps or that the oxygen which is delivered is unavailable for the cells. Increased presence of tissue fluid in the venous stasis flap inhibits the diffusion of oxygen through the interstitial tissue, and this may explain the lower oxygen consumption. During 3 hours of reperfusion, increased blood flow was observed in the arterial insufficiency flaps, whereas blood flow in the venous stasis flaps was sluggish. The arterial insufficiency flaps recovered more rapidly than the venous stasis flaps during the first hour of reperfusion, judged by the rate of increase in oxygen tension and the higher venous oxygen tension. Oxygen tension increased more rapidly in muscle than in subcutaneous tissue.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of repeated doses of MDMA ("ecstasy") on cell-mediated immune response in humans.

Cell-mediated immune response after the administration of two repeated doses of 100 mg 3,4-methylenedioxymethamphetamine (MDMA) at 4-hour and 24-hour intervals was evaluated in two randomised, double-blind and cross-over clinical trials conducted in healthy male MDMA consumers. MDMA produced a time-dependent decrease in the CD4/CD8 T-cell ratio due to a decrease in the number of CD4 T-helper cells, a decrease in the functional responsiveness of lymphocytes to mitogenic stimulation, and a simultaneous increase in natural killer cells. In case of two 100 mg MDMA doses given 4 hour apart, immune alterations produced by the first dose were strengthened by the second one. At 24 hours after treatment, statistically significant residual effects were observed for all the altered immune parameters after the administration of two MDMA doses if compared to single dose and placebo. In the second clinical trial, the second 100 mg MDMA dose given 24 hours after the first dose produced immunological changes significantly greater than those induced by the initial drug administration and which seemed to show a delayed onset. Significant residual effects were observed for all the immune parameters as late as 48 hours after the second dose. These results show that repeated administration of MDMA with both a short and a long time interval between doses extends the critical period following MDMA administration, already observed after a single dose, in which immunocompetence is severely compromised.     

Comparison of the Effects of Streptokinase and Heparin on the Early Rate of Resolution of Major Pulmonary Embolism

The extent of early resolution of major pulmonary embolism observed in 10 patients after 24 hours of treatment with heparin was compared with that seen in 17 patients after 24 hours of treatment with streptokinase. The patients in the streptokinase group also received a loading dose of heparin and were treated with heparin by continuous infusion when their thrombin time returned to normal levels. All had pulmonary hypertension. Pulmonary embolism was classified as acute in the 10 patients in the heparin group. Seven of these patients showed no angiographic change, two showed slight improvement and one showed angiographic deterioration. There was a moderate and statistically insignificant fall in mean pulmonary arterial pressure and total pulmonary resistance. Fourteen of the 17 patients who were studied before and after streptokinase were classified as acute and three as subacute progressive major pulmonary embolism. Eight showed marked angiographic improvement, four moderate and two slight angiographic improvement. There was a moderate and statistically significant fall in the mean pulmonary arterial pressure and pulmonary vascular resistance. In addition, all seven patients in whom no angiographic improvement occurred during heparin therapy showed moderate or marked angiographic improvement after a further 24 hours of treatment with streptokinase. The results strongly suggest that streptokinase therapy accelerates thrombolysis in patients with acute major pulmonary embolism.     

抗胆碱酯酶剂亚致死剂量对棉铃虫毒力的影响及对乙酰胆碱酯酶的诱导作用

辛硫磷、马拉硫磷和灭多威3种抗胆碱酯酶剂亚致死剂量（LD10）预处理棉铃虫Helicoverpa armigera 3龄幼虫24 h后,对辛硫磷、马拉硫磷、灭多威、溴氰菊酯和高效氯氰菊酯5种杀虫药剂的毒力影响有明显差异。酶动力学研究表明：在48 h内,辛硫磷亚致死剂量对棉铃虫乙酰胆碱酯酶比活力有一定的抑制作用,24 h仅为对照组的0.56倍;马拉硫磷、灭多威则可以诱导乙酰胆碱酯酶的比活力增加,诱导最大值时间分别为3 h和12 h。通过对米氏常数（K_m）值分析表明,辛硫磷诱导48 h内对乙酰胆碱酯酶与底物亲和力的影响不大,马拉硫磷、灭多威诱导48 h内乙酰胆碱酯酶对底物亲和力有所下降,其中灭多威诱导组最为明显。3种药剂亚致死剂量处理24 h后,通过蔗糖密度梯度离心表明5%蔗糖梯度层乙酰胆碱酯酶分布百分数明显高于对照组,而20%蔗糖梯度层却明显低于对照组,说明亚致死剂量处理可能引起乙酰胆碱酯酶分子型及不同分子型分布比例的变化。     

Plasma amino acid levels after carbon tetrachloride induced acute liver damage. A dose-response and time-response study in rats

Summary The aims of the present study were to assess the changes of individual plasma amino acid levels in relation (1) to the severity of liver damage and (2) to the process of liver recovery. Acute liver injury was induced by an intragastric administration of CCl₄ diluted in olive oil in doses of 2, 4 and /or 6 g of CCl₄ per kg b.w. The control rats received olive oil only. Animals were sacrificed at 16, 24, 48 and 96 hours after treatment. The severity of liver injury was assessed by histological examination, by changes in ALT and AST in the blood plasma and by changes in liver weight. Statistical analysis was carried by ANOVA, p < 0.05 was considered significant. The Spearman rank correlation coefficient was used as a measure of the degree of linear relationship between variable and dose. In the period of the development of acute liver damage, i.e. at 16 and 24 hours after treatment, an increase in blood plasma amino acid levels and positive correlations with the dose of CCl₄ were observed for most individual amino acids. The only exception was arginine which decreased in a dose dependent manner. At a phase of liver recovery, i.e. at 48 and 96 hours after CCl₄ treatment, the concentrations of some individual amino acids decreased below the control values. The negative correlation with the dose of CCl₄ occurred for taurine and isoleucine (at 48 hours) and taurine, threonine, valine, methionine, isoleucine and leucine (at 96 hours).     

X-ray semeiotics of changes in the soft tissues and bones of the lower extremities in disorders of the venous outflow

In order to improve radiodiagnosis of chronic and venous insufficiency of the lower limbs, the soft tissues and skeleton of the affected limbs were x-rayed in 120 patients with disturbed venous outflow (60 with varicosity and 60 with the post-thrombophlebitic syndrome - PTPS). The limb soft tissue changes in this disease were shown to be of one type and looked like the thickening of subcutaneous fat; obscure boundaries of the muscles with subcutaneous fat, the narrowing of intermuscular layers, the absence of differentiation of separate muscular groups, visible varices, calcifications of soft tissues and phleboliths. Bone changes appeared later than the clinical signs of disease and were as follows: regional and diffuse osteoporosis, various kinds of periostoses (scaled or partially assimilated linear, multilayer and pectiniform) and hyperostosis. Longitudinal platypodia and transverse foot flattening caused by dysfunction of the musculoligamentous apparatus and increasing venous congestion in the lower limbs were seen in most of the patients.     

Early intravenous unfractionated heparin and outcome in acute lung injury and acute respiratory distress syndrome -- a retrospective propensity matched cohort study

ABSTRACT: BACKGROUND: Acute lung injury (ALI) is characterized by a pro-coagulant state. Heparin is an anticoagulant with anti-inflammatory properties. Unfractionated heparin has been found to be protective in experimental models of ALI. We hypothesized that an intravenous therapeutic dose of unfractionated heparin would favorably influence outcome of critically ill patients diagnosed with ALI. METHODS: Patients admitted to the Intensive Care Unit (ICU) of a tertiary referral center in the Netherlands between November 2004 and October 2007 were screened. Patients who developed ALI (consensus definition) were included. In this cohort, the impact of heparin use on mortality was assessed by logistic regression analysis in a propensity matched case--control design. RESULTS: Of 5,561 admitted patients, 2,138 patients had a length of stay > 48 hours, of whom 723 were diagnosed with ALI (34 %), of whom 164 received intravenous heparin. In a propensity score adjusted logistic regression analysis, heparin use did not influence 28-day mortality (odds ratio 1.23 [confidence interval 95 % 0.80--1.89], nor did it affect ICU length of stay. CONCLUSIONS: Administration of therapeutic doses of intravenous unfractionated heparin was not associated with reduced mortality in critically ill patients diagnosed with ALI. Heparin treatment did not increase transfusion requirements. These results may help in the design of prospective trials evaluating the use of heparin as adjunctive treatment for ALI.     

Comparison of transthecal digital block and traditional digital block for anesthesia of the finger

A randomized, double-blind study was performed in 50 patients to compare the transthecal and traditional subcutaneous infiltration techniques of digital block anesthesia regarding the onset of time to achieve anesthesia and pain during the infiltration. All the patients had sustained injury involving two or four fingers of the hand. Each patient served as his or her own control, having one finger infiltrated with the transthecal technique and the other with the subcutaneous infiltration technique. Time to loss of pinprick sensation and pain (at the time of the infiltration and 24 hours postoperatively) were assessed using a visual analogue scale and verbal response score. A total of 104 blocks (52 transthecal and 52 subcutaneous infiltration) were performed. All of these blocks were successful. Mean time to achieve anesthesia with the transthecal block was 165 seconds, compared with 100 seconds for the subcutaneous infiltration block. The mean analogue pain score was higher for transthecal blocks than for subcutaneous infiltration blocks (3.2 +/- 0.19 versus 1.6 +/- 0.14). Twenty-four hours postoperatively, 24 patients who had the transthecal block experienced pain at the injection site of the digit. However, none of the patients who received the subcutaneous infiltration block complained of pain at the digit. The technique of anesthesia preferred by patients for their finger was the subcutaneous infiltration block, because it causes less pain. Our results confirm the efficacy of the transthecal block for achieving anesthesia of the finger; however, because it is a more painful procedure, it is not recommended.     

Salvage of a failing microvascular free muscle flap by direct continuous intravascular infusion of heparin: a case report

A free gracilis muscle transfer with skin graft was performed for reconstruction of a type IIIB lower extremity traumatic wound with acute exposure of the distal tibia fracture site and an extensive soft-tissue wound. The free muscle flap failed from a venous thrombosis that was recognized 12 hours postoperatively, and reexploration revealed extensive venous thrombosis throughout the lower leg. The flap was salvaged by direct catheter administration of heparin into the vena comitans of the gracilis artery, which bathed the newly repaired venous anastomosis with an anticoagulating dose of heparin without systemic elevation of the patient's PTT. Ultimate full flap survival and wound healing ensued.     

Subcutaneous injections and intravenous infusion of sodium salt of heparin in the treatment of thrombosis of deep veins of the lower extremities

Ninety-four patients with deep vein thrombosis of inferior limbs were randomly allocated to receive sodium heparin either by subcutaneous injections or by continuous intravenous infusion for six days. No significant difference was observed in the therapeutic efficiency as judged by phlebographic examinations and in rate of symptomatic pulmonary embolism between the two groups. There was one instance of major bleeding in the subcutaneous group. Minor bleedings occurred in 10 of the 48 patients treated with subcutaneous heparin and in 13 of the 46 patients receiving intravenous heparin. The results showed that subcutaneous injections of sodium heparin are as effective and safe as continuous intravenous infusion of this drug in the treatment of deep vein thrombosis.