Aspergillus brain abscess in a patient with acute myeloid leukaemia successfully treated with voriconazole.

Cerebral aspergillosis is associated with very high mortality in immunocompromised hosts. Conventional antifungal agents like amphotericin-B and itraconazole are almost ineffective in cerebral aspergillosis. Newer azoles have been shown to penetrate the blood, cerebrospinal fluid barrier and achieve effective fungicidal concentrations. These newer azoles may change the outlook of this fatal condition. We report here a patient with cerebral aspergillosis who was successfully treated with voriconazole.

Co-existing conjunctival non-Hodgkin's lymphoma and pulmonary sarcoidosis.

A 55 year old woman with a conjunctival non-Hodgkin's lymphoma was found to have pulmonary nodules on a thoracic computed tomographic scan which were initially thought to be lymphomatous deposits. A subsequent biopsy specimen demonstrated granulomas consistent with sarcoidosis. The relationship between sarcoidosis and malignancy, in particular lymphoma, is discussed.

Posterior fracture-dislocation of the shoulder. A superior subacromial approach for open reduction.

We describe 11 cases of posterior fracture-dislocation of the shoulder that required open reduction and fixation. Difficulties with access through anterior approaches led us to use the superior subacromial approach. This is an extension of the approach often used to expose the rotator cuff; the joint is opened by splitting the supraspinatus tendon 5 mm behind the cuff interval. The glenoid, proximal humerus and any fracture fragments can be seen from above, allowing reduction of the dislocation and osteosynthesis to be performed with minimal risk of damage to the humeral head and its blood supply. The proximity of the axillary nerve limits the exposure of the proximal humeral shaft. The superior subacromial approach is ideal for posterior dislocation with fracture of the articular segment, but is not suitable when there is a fracture of the proximal humeral shaft.

A classification of acute acromioclavicular dislocation: a clinical, radiological and anatomical study.

Forty-eight patients with acute acromioclavicular dislocation were assessed clinically and radiologically before random allocation to non-operative management (28) or open reduction and coracoclavicular screw fixation (20) and followed for a minimum of 4 years. In 6 patients, late salvage surgery was required, the results of which were inferior to early operative intervention. Early surgery also gave better results than non-operative treatment in severe disruptions which could be identified in the acute stage. Three types of acromioclavicular dislocation which have predictable clinical outcomes could be distinguished on radiographs. When treated non-operatively, type A dislocations (19 per cent) may develop painful subluxation, type B (68 per cent) remain dislocated but retain sufficient muscle attachment to avoid fatigue on activity, and type C (12 per cent) leave a weak and unsightly shoulder. In type C dislocations, the clavicle is displaced 2 cm or more from the acromion on plain anteroposterior radiographs and the attached origin of the anterior deltoid is avulsed. Type C dislocations may benefit from early operative reconstruction.

The management of acute acromioclavicular dislocation. A randomised prospective controlled trial.

In a prospective study, 60 patients with acute acromioclavicular dislocation were randomly allocated to treatment with a broad arm sling or to reduction and fixation with a coracoclavicular screw. Of these 54 were followed for four years. Conservatively-treated patients regained movement significantly more quickly and fully, returned to work and sport earlier and had fewer unsatisfactory results than those having early operation. For severe dislocations, with acromioclavicular displacement of 2 cm or more, early surgery produced better results. Conservative management is best for most acute dislocations, but younger patients with severe displacement may benefit from early reduction and stabilisation.

Intestinal folate absorption in methotrexate treated psoriatic patients.

Thirty-one psoriatic patients 14 of whom were being treated with methotrexate (MTX), participated in a controlled study to evaluate the influence of MTX therapy on the intestinal absorption of folate. Low serum and red cell folate levels in the MTX treated group confirmed previously reported findings. However, analysis of the intestinal absorption profile yielded no significant difference between the two groups. It was concluded that MTX therapy for psoriasis does not adversely affect the intestinal absorption of folate and the observed low body folate status is probably mainly the result of enhanced renal excretion.

Supplement feeds and nitrogen and calorie balance following femoral neck fracture.

A 10 day study of nitrogen and calorie balance has been undertaken in 61 women patients aged 65-96 years (mean age 81 years) with femoral neck fractures. All underwent fracture surgery with an inhalation anaesthetic lasting from 45 min to 2 h. Intake of ward food varied widely but was always low with a mean of 127 mg N kg-1 and 17 kcal kg-1 daily. Daily nitrogen production was 85-250 mg N kg-1 (mean 158 mg N kg-1) and calorie expenditure was 17-48 kcal kg-1 (mean 32 kcal kg-1). These were greatest in trochanteric fracture patients. Of the 61 patients, 90 per cent were in negative nitrogen balance with a mean 8 day deficit of 411 mg N kg-1 and all in negative calorie balance, mean 141 kcal kg-1. The deficits were greatest in trochanteric fracture patients. Sip feeding with supplementary enriched drinks raised protein and calorie intake substantially. Both nitrogen and calorie balance were significantly improved, but large calorie deficits remained; intolerance of the supplements proved to be a handicap in correcting the deficits in many patients.

Four-part fractures of the neck of the humerus.

Four-part fractures of the upper end of the humerus are uncommon injuries and there is still dispute about the best form of management. A retrospective study of 32 patients with these injuries has shown that non-operative management is frequently followed by persistent pain, stiffness and dysfunction of the shoulder. A prospective study of 49 patients with this injury presenting at the Bristol Royal Infirmary has shown that reconstruction of the upper end of the humerus with insertion of a Neer prosthesis will usually restore comfort and function. Whichever regimen is employed, disability is prolonged and dedicated physiotherapy is essential in their management.

Injuries of the proximal interphalangeal joint of the fingers.

A consecutive group of ninety-three patients with ninety-six affected joints, have been reviewed retrospectively to provide information regarding the incidence and longer term effects of injuries to the proximal interphalangeal joint of the fingers. The patients have been grouped according to the severity of the injury, judged clinically and radiologically. From this review it would appear that these injuries are somewhat less common than is suggested in the literature. The severity of the trauma would seem to influence the result in that some thirty per cent with dislocation or fracture-dislocation did badly and of these forty-three per cent had open injuries. Some experimental work on fresh cadavers, to investigate the damage to the ligaments in the more common dorsal dislocation, has been included. From our findings, suggestions have been made regarding the treatment of these injuries.

Auto-immune neutropenia in an infant.

A case of neutropenia in an infant is described, associated with repeated minor infections which responded to treatment with antibiotics. A granulocyte agglutinin was detected in the serum. Following treatment with prednisolone the neutropenia remitted, the antibody disappeared and the infections ceased. Treatment was discontinued after three months and the child remained well five months later. Reports of similar cases are reviewed and the significance of the antibody discussed.

Mefenamic acid and dextropropoxyphene with paracetamol as analgesics in the accident department.

A double-blind study was carried out in 48 patients with soft-tissue injuries to compare the effectiveness of mefenamic acid and dextropropoxyphene plus paracetamol in relieving acute post-injury pain. Patients received capsules containing either 250 mg mefenamic acid or 32.5 mg dextropropoxyphene hydochloride plus 325 mg paracetamol and were instructed to take up to 6 capsules daily as necessary. By the third post-injury day both preparations had controlled pain adequately and lessened local tenderness in most cases. There was no significant difference in response between the two patient groups. Two patients in each group stopped treatment because of gastro-intestinal intolerance, and a further 4 patients in each group reported troublesome side-effects.

Acquired von Willebrand syndrome with inhibitors both to factor VIII clotting activity and ristocetin-induced platelet aggregation.

A case of acquired von Willebrand's syndrome (vWs) is described which appeared to be due to antibodies directed against factor VIII clotting activity (FVIIIC), factor VIII-related antigen (FVIIIRAg) and von Willebrand factor. The antibodies directed against FVIIIRAg was demonstrated by the inhibitory effect of a platelet eluate on Ristocetin-induced aggregation of normal platelets. This effect was not shown by the patient's platelet-poor plasma alone, nor could it be demonstrated in platelet eluates from 13 other patients who had antibodies to FVIIIC but in whom there was no evidence of an acquired vWs.

Factor-VIII-related antigen: measurement by enzyme immunoassay.

Factor-VIII-related antigen was measured, both by an enzyme immunoassay using a microplate method and by the Laurell technique, in normal people, patients with von Willebrand's disease, haemophiliacs, and obligatory haemophilia carriers. The enzyme immunoassay was simpler to perform and gave equally reliable and reproducible results. Many more assays could be carried out at any one time.

Inpatients in an accident unit.

A one-year prospective study was undertaken in the 79-bed accident unit of the Bristol Royal Infirmary to define reasons for continuing inpatient care. This showed that, of a consecutive series of 466 patients staying in hospital for over two weeks, 35% lengthened their stay beyond that needed for acute nursing or continued medical care. A combination of factors usually led to total social dependence, the major problem being the absence of a caring relative. Other factors included pre-existing locomotor disorder or mental infirmity, unmanageable incontinence of urine after catheterisation, and institutional disorientation. If the pattern of management of elderly patients after injury is not changed and beds are to be kept available for the newly injured the unit will need about 50 new long-stay beds each year.

Effect of oral contraceptives on factor VIII clotting activity and factor VIII related antigen in normal women.

The factor VIII clotting activity (VIIIc1 and factor VIII related antigen (VIIIRAg) were determined repeatedly in 24 pairs of age-matched normal women, one of each pair being on oral contraceptives. No significant differences in either parameter or in the VIIIc/VIIIRAg ration were found between the two groups ,although the mean factor VIII clotting activity and VIIIc/VIIIRAg ratios for women on oral contraceptives were very slightly higher than for those not on oral contraceptives.

The von Willebrand syndrome.

Five patients with an original diagnosis of von Willebrand's disease are described because of their levels of factor VIII related protein, Ristocetin-induced platelet aggregation and/or family studies differed from the main group of patients with classical von Willebrand's disease. Two had normal levels of factor VIII related protein with reduced Ristocetin aggregation when this was tested in platelet rich plasma. In one, however, this was due to a plasma defect and in the other to a platelet abnormality. After cryoprecipitate infusion all abnormal tests were corrected in both these patients. The first patient, however, failed to show a secondary rise of factor VIII whereas the second showed a secondary rise of both factor VIII and of factor VIII related protein. The other three cases, who were all very severely affected, have been separated from the main group as none of their families was segregating for classical von Willebrand's disease. It is suggested that the term von Willebrand's disease should be confined to those patients who have reduced factor VIII related protein and Ristocetin aggregation, and that von Willebrand's syndrome should be used for the various sub-groups that are emerging.