Breath testing for intra-abdominal infection: appendicitis, a preliminary study.

In the current pilot study we aimed to determine whether breath analysis could be used to help recognise intra-abdominal infection, using acute appendicitis as an exemplar condition. Our study included 53 patients (aged 18-88 years) divided into three groups: appendix group, 26 (13 male) patients suffering from acute appendicitis; control group 20 (seven male) patients undergoing elective abdominal surgery; normal group, seven patients who were clinically diagnosed with appendicitis, but whose appendix was normal on histological examination. Samples of breath were analysed using ion molecule reaction mass spectroscopy measuring the concentration of volatile compounds (VCs) with molecular masses 27-123. Intraperitoneal gas samples were collected from a subset of 23 patients (nine diagnosed with acute appendicitis). Statistically significant differences in the concentration of VCs in breath were found between the three groups. Acetone, isopropanol, propanol, butyric acid, and further unassigned VCs with molecular mass/charge ratio (m/z) 56, 61 and 87 were all identified with significant endogenous contributions. Principle component analysis was able to separate the control and appendicitis groups for seven variables: m/z = 56, 58, 59, 60, 61, 87 and 88. Comparing breath and intraperitoneal samples showed significant relationships for acetone and the VC with m/z = 61. Our data suggest that it may be possible to help diagnose acute appendicitis by breath analysis; however, factors such as length of starvation remain to be properly accounted for and the management or mitigation of background levels needs to be properly addressed, and larger studies relating breath VCs to the causative organisms may help to highlight the relative importance of individual VCs.

Measurement of breath acetone in patients referred for an oral glucose tolerance test.

Breath acetone concentrations were measured in 141 subjects (aged 19-91 years, mean = 59.11 years, standard deviation = 12.99 years), male and female, undergoing an oral glucose tolerance test (OGTT), having been referred to clinic on suspicion of type 2 diabetes. Breath samples were measured using an ion-molecule-reaction mass spectrometer, at the commencement of the OGTT, and after 1 and 2 h. Subjects were asked to observe the normal routine before and during the OGTT, which includes an overnight fast and ingestion of 75 g glucose at the beginning of the routine. Several groups of diagnosis were identified: type 2 diabetes mellitus positive (T2DM), n = 22; impaired glucose intolerance (IGT), n = 33; impaired fasting glucose, n = 14; and reactive hypoglycaemia, n = 5. The subjects with no diagnosis (i.e. normoglycaemia) were used as a control group, n = 67. Distributions of breath acetone are presented for the different groups. There was no evidence of a direct relationship between blood glucose (BG) and acetone measurements at any time during the study (0 h: p = 0.4482; 1 h: p = 0.6854; and 2 h: p = 0.1858). Nor were there significant differences between the measurements of breath acetone for the control group and the T2DM group (0 h: p = 0.1759; 1 h: p = 0.4521; and 2 h: p = 0.7343). However, the ratio of breath acetone at 1 h to the initial breath acetone was found to be significantly different for the T2DM group compared to both the control and IGT groups (p = 0.0189 and 0.011, respectively). The T2DM group was also found to be different in terms of ratio of breath acetone after 1 h to that at 2 h during the OGTT. And was distinctive in that it showed a significant dependence upon the level of BG at 2 h (p = 0.0146). We conclude that single measurements of the concentrations of breath acetone cannot be used as a potential screening diagnostic for T2DM diabetes in this cohort, but monitoring the evolution of breath acetone could open a non-invasive window to aid in the diagnosis of metabolic conditions.

How well do neurosurgeons care for trauma patients? A survey of the membership of the American Association for the Surgery of Trauma.

OBJECTIVE: To quantify the trauma community's perceptions about neurosurgeons' involvement in trauma. METHODS: Mail survey of the membership of the American Association for the Surgery of Trauma. RESULTS: The response rate was 33.6% (280 of 833 mailings). Eighty-four percent of respondents practiced in an academic setting, and 51% reported that neurosurgery residents were available in their hospitals at night and on weekends. Approximately 60% reported that neurosurgeons were in charge of the care of adults with isolated head injuries (HIs) who had been operated on. A similar percentage thought that neurosurgeons should be in charge of such patients' care. Only 31.5% indicated that neurosurgeons were in charge if no operation had been performed (P < 0.001 versus patients who had been operated on), but 42.1% thought that neurosurgeons should be in charge of patients who had not been operated on (P < 0.001 versus neurosurgeons who actually were in charge of such patients). The same question was asked with regard to adults with both HIs and systemic injuries and with regard to children with HIs with and without systemic injuries. In general, the actuality of a leadership role for neurosurgeons depended on whether a craniotomy had been performed, and it was believed that more neurosurgeons should be in charge than actually were in charge of patients with HIs. Reluctance to insert intracranial pressure monitors was the most commonly reported problem (44.8% of respondents) with regard to neurosurgeons' care of patients with HIs. All problems were reported to be significantly more common when in-house neurosurgery residents were not available. More than 40% of respondents indicated that non-neurosurgeons should be allowed to insert intracranial pressure monitors, and 14% thought that non-neurosurgeons should be allowed to perform trauma craniotomies. These opinions were strongly associated with the reporting of problems in neurosurgeons' performance in these areas (P < 0.001 and P = 0.001, respectively). CONCLUSION: Neurosurgeons frequently yield responsibility for managing patients with HIs to other specialists, but more frequent leadership of neurosurgeons in this area would be welcome. Reported problems with neurosurgical care of trauma patients may be related to a lack of immediate availability of neurosurgeons, such as the absence of in-house neurosurgery residents at night. Failure of neurosurgeons to address perceived deficiencies in their care of trauma patients may lead to serious erosion of the central role of neurosurgeons in managing patients with HIs.

Arytenoid adduction combined with Gore-Tex medialization thyroplasty.

OBJECTIVE: To describe the technique of combined Gore-Tex medialization thyroplasty with arytenoid adduction and to determine the long-term vocal outcome of patients treated for unilateral vocal cord paralysis with this procedure. STUDY DESIGN: A retrospective chart review and patient reevaluation for patients treated at The University of Iowa Hospitals and Clinics between May 1995 and June 1999. METHODS: The review addressed patient demographics, perioperative and long-term complications, and voice outcomes. Details of the surgical technique are provided within the manuscript. RESULTS: Seventy-two Gore-Tex medialization procedures were completed. Arytenoid adduction was included in 22 of these procedures. This subset of patients was compared with the patients treated with Gore-Tex alone. No major postoperative complications occurred in either group. Preoperative and postoperative voice and videostroboscopy data were available for 19 arytenoid adduction patients and 25 Gore-Tex alone patients. On a seven-point scale (6 [severely abnormal] --> 0 [normal voice]), the average patient rating of voice dysfunction improved from 4.2 to 1.6 (arytenoid adduction) and 4.5 to 2.8 (Gore-Tex alone). Maximum phonation time improved from 6.9 seconds to 16.7 seconds in the arytenoid adduction group. Subjective voice assessment employing the four-point GRBAS scale (3 [severely abnormal] --> 0 [normal]) identified average improvement from an overall grade of 2.1 to 0.8 arytenoid adduction and 2.2 to 1.5 in the Gore-Tex alone group. Improvement was identified in the vocal quality of breathiness from 1.9 to 0.2 (arytenoid adduction) and 1.9 to 0.9 (Gore-Tex alone). CONCLUSIONS: The combined technique of Gore-Tex medialization thyroplasty and arytenoid adduction provide functional results that appear to exceed the improvement attained with medialization alone.

Delay in the diagnosis of breast cancer: medico-legal implications.

Delay in the diagnosis of breast cancer is an important cause of medical malpractice claims which if trends continue, will threaten healthcare budgets. Most malpractice claims are made by younger women. Delay is most frequently due to the physician failing to be impressed with the clinical findings, or to a false negative mammogram report. Diagnosis of breast cancer is more difficult in younger women, because of the poor sensitivity of diagnostic tests and the high prevalence of benign disease in this age group. Models of tumour growth suggest that the potential to metastasize may be present before the tumour is clinically detectable and that if the growth rate of a given tumour is constant, any clinical delay is a small proportion of the lifespan of the tumour. Patient delay is generally associated with more advanced lesions at presentation, but the effect of delay on survival or what period of delay is significant remains uncertain. Delay in the diagnosis of breast cancer is likely to cause the patient considerable anxiety, especially when the public understands that the aim of mammographic screening is to diagnose breast cancer at an early stage in order to effect a cure. For a plaintiff to successfully claim in court she must prove that she has suffered an injury, and that the injury was the result of negligent medical practice. It is easier to defend a case of delay in diagnosis if the documentation is in order and all the appropriate tests have been performed.

The use of surgical sympathectomy in the treatment of chronic renal pain.

OBJECTIVE: To assess the efficacy of renal sympathetic denervation in the treatment of chronic renal pain. PATIENTS AND METHODS: In a 10-year period, 21 patients suffering from chronic renal pain underwent 27 renal denervation operations, six of which were bilateral. The cause of pain was the loin pain haematuria syndrome in 18 patients. RESULTS: Four operations resulted in complete pain relief to date (median follow-up 53.5 months). Pain relief after the other 23 operations in 18 patients lasted a median of 6 months. Assuming that recurrent pain was due to neuronal regeneration, nine of the 18 patients with recurrent pain underwent a total of 10 re-explorations of the renal pedicle, stripping it of all nerve fibres and areolar tissue. Three of these re-explorations produced complete pain relief to date (median follow-up 40 months). The median pain-free interval of the other seven re-explorations in six patients was 19 months. CONCLUSION: Renal denervation cures severe intractable pain in about 25% of patients. Recurrence of pain could be prevented in more patients if there was a way of preventing re-innervation.

Predicting changes in the distribution of sweating following thoracoscopic sympathectomy.

BACKGROUND: Compensatory sweating is a common symptom following thoracic sympathectomy; however, the reported incidence of this complication varies greatly, and its severity has not been quantified. METHODS: In this study changes in the distribution of sweating following bilateral T2-3 thoracoscopic sympathectomy for hyperhidrosis were assessed in 42 patients. Sweat production in the palms, axillae, face, trunk and feet was assessed using a linear analogue scale. RESULTS: The operation was most successful in reducing sweat production in the palms, axillae and face (in descending order). The operation also reduced pedal sweat production in 12 of the 29 patients who suffered concomitant pedal hyperhidrosis. Compensatory truncal sweating occurred in 36 of the 42 patients; it was severe in ten, moderate in 16 and minimal in ten. CONCLUSION: Patients should be warned about compensatory sweating before thoracic sympathectomy.

Putting a finger on the deep inguinal ring.

The clinical distinction between direct and indirect inguinal hernias is often made by determining whether digital pressure over the deep inguinal ring is able to control the hernia. In 25 consecutive patients having inguinal hernia operations, the positions of the mid-inguinal point and the mid-point of the inguinal ligament were determined pre-operatively and compared with the position of the deep inguinal ring measured at operation. Neither the mid-inguinal point nor the mid-point of the inguinal ligament correctly predicted the position of the deep inguinal ring (the mean position of the deep inguinal ring was found to be 0.52 cm lateral to the mid-inguinal point and 0.46 cm medial to the mid-point of the inguinal ligament). If the position of the deep inguinal ring cannot be accurately determined using fixed landmarks, it is unlikely that direct and indirect inguinal hernias can be distinguished by clinical examination.

Cerebellar pleomorphic xanthoastrocytoma: case report.

We report a case of pleomorphic xanthoastrocytoma occurring in the midline cerebellum of a 48-year-old woman. Radiological, histological, immunohistochemical, and flow cytometric findings are discussed. Pleomorphic xanthoastrocytoma typically occurs in the superficial cerebral hemispheres of young patients. To our knowledge, this is the first report of the occurrence of this neoplasm in the cerebellum. The English literature is reviewed with regard to the clinicopathological features of this uncommon form of astrocytoma.

Fluid and electrolyte disorders in neurosurgical intensive care.

The management of fluid and electrolytes is an important aspect of the intensive care of patients with intracranial disease and injury because the central nervous system has a critical role in fluid and electrolyte and acid-base homeostasis. This article reviews fluids and electrolytes and acid-base balance, their common disturbances in neurosurgical disorders, and their practical management.

Case report: treatment of an intracranial arteriovenous malformation in a patient with complicated hemophilia.

The authors describe a young man with hemophilia complicated by chronic hepatic dysfunction, hypodysfibrinogenemia, and immune thrombocytopenia that resulted in a complex coagulopathy. The patient had a ruptured occipital arteriovenous malformation. The malformation was managed by temporary correction of the coagulopathy using cryoprecipitate, platelet transfusions, and plasmapheresis with fresh frozen plasma replacement. The patient underwent staged preoperative embolization followed by surgical excision of the lesion. Hemostasis was acceptable during the neurointerventional and subsequent surgical management, and no complications of coagulopathy occurred. Plasmapheresis may provide effective preparation for patients with hemophilia and complex coagulation abnormalities who require neurosurgical intervention.

Neurological complications of liver transplantation in adult versus pediatric patients.

Neurological complications are important contributors to morbidity and mortality after liver transplantation. We reviewed 391 patients who underwent 427 consecutive orthotopic liver transplantations to analyze the clinical features of patients who experienced one or more neurological complication (74 patients [19%]) and to compare postoperative neurological problems in adults versus children. Neurological complications were more frequent in adults (64 of 273 patients [23%]) than children (10 of 118 patients [8%]) (P < 0.01). The most common neurological complication was encephalopathy (59%), which ranged widely in severity and occurred with similar frequency in adults and children. Other common neurological complications were seizures (12 patients), brachial plexus and peripheral nerve injuries (16 patients, 15 of whom were adults), stroke (5 patients), and central nervous system infections (5 patients). In 27 patients, drug toxicity was the primary cause of neurological complications, all of which reversed with dosage reduction or discontinuation of drug. Cyclosporine and FK506, primarily during intravenous administration for induction of immunosuppression, accounted for 25 of 27 drug-induced neurological complications, which included encephalopathy, seizures, severe tremor, and severe headache. Despite a higher rate of neurological complications in adults, those in children were more severe and associated with a higher mortality rate. When compared with liver transplant recipients without neurological complications, patients with neurological complications had a higher posttransplant mortality rate (14% vs. 5% for adults, and 50% vs. 7% for children). In conclusion, neurological complications after liver transplantation are more common in adults, more severe and associated with a higher mortality rate in children, and associated with a higher mortality rate in both children and adults when compared with transplant recipients without neurological complications.