Another idea for the treatment of patients with borderline personality disorder.

We are not suggesting that casting is appropriate for all patients with BPD, nor are we suggesting that patients need be casted for prolonged periods of time. In the 3 stated cases, the patients were desperate to have some behaviour modification introduced into their lives and welcomed the procedure. In all these cases, comorbidity existed. Because marked skin damage and open wounds often occur, other specialists with expertise in wound healing and joint mobility maintenance need to be involved. We were fortunate to have the services of a plastic surgeon with a special interest in psychiatric disorders. We believe that psychiatrists should be aware of this technique as a possible strategy to be used in very specific circumstances. It appears, in our short series of 3 cases, to have benefits in very specific cases. If it appears that casting may be helpful, our recommendations are as follows: 1. The behaviours should be thoroughly evaluated, and all alternative managements should be reviewed. 2. Reasonable rapport needs to be established between the patient and the major therapists so that compliance can be assured. 3. Other specialists should be consulted, such as plastic surgeons, who have the expertise to manage prolonged casting. 4. Along with casting, appropriate medications and psychotherapy must be in place for a balanced approach to management.

Decreasing the perioperative complications associated with the superior pharyngeal flap operation.

This outcome study was a continuation of a previously published review. It examined whether there had been a decrease in the number of acute perioperative complications surrounding superior pharyngeal flap operations since a patient's death in 1990. A total of 386 patients were divided into two groups: the early group (July of 1985 to December of 1990) n = 164, and the later group (January of 1991 to June of 1996) n = 222, which were statistically comparable. The patient complication rate decreased from 19.5 to 6.3 percent (chi square, p = 0.0001). Airway obstruction decreased from 11 to 3.2 percent (chi square, p = 0.0012). Bleeding complications decreased from 7.3 to 1.4 percent (chi square, p = 0.0027). The majority of airway complications (72 percent) and bleeding complications (80 percent) occurred in the first 24 hours. Predictive factors for complications included the surgeon involved, patients with associated medical conditions, having an associated procedure performed concurrently, and leaving the donor site open (multiple logistic regression). Hospital stay also decreased from 5.8 +/- 2.5 to 3.8 +/- 1.6 days (Student's t test p = 0.0001). The decrease in complication rate was due to the increased awareness of all staff involved and also due to changes in surgical management, including a decrease in the number of surgeons (from seven to four surgeons), a decrease in the number of associated procedures (10.4 to 4.5 percent, chi square, p = 0.026), a decrease in the number of open donor sites (34.8 to 4.5 percent, chi square, p = 0), and an increase in the use of nasopharyngeal airways (17.1 to 45 percent, chi square, p = 0). The superior pharyngeal flap operation has become a safer procedure in this hospital.

[A non-traditional procedure in the surgical treatment of portal hypertension in a child]. / Netradicní postup pri chirurgické lécbe portální hypertenze u dítete.

The authors present the case-history with a uncommon surgical procedure in a child with portal hypertension and hypersplenism. Half the spleen was resected and concurrently a distal splenorenal anastomosis of the Warren type was created. This procedure was selected because the child had a very enlarged spleen and marked hypersplenism. The postoperative course was free from complications and the satisfactory condition of the child 15 months after operation with normal haematological values confirms the justification of the selected procedure.

Perioperative complications of superior pharyngeal flap surgery in children.

A 7-year retrospective review of perioperative complications associated with surgical correction of velopharyngeal insufficiency was carried out. A total of 219 children who underwent surgery for velopharyngeal insufficiency between the years 1985 and 1992 were reviewed. Gender distribution was 58 percent male and 42 percent female. The mean age was 9.6 years, with a range of 4 to 22 years, at the time of surgery. Fourteen cases (6.4 percent) were considered a difficult intubation. There were 36 patients with early complications (16.4 percent incidence). Of these, 18 had postoperative bleeding and 20 developed airway obstruction. Most of these episodes occurred in the first 24 hours. Three patients required reintubation. Nine children developed sleep apnea after discharge. Four patients required take-down of the pharyngoplasty, while 7 others had revision of the flap. There was 1 death in the 219 patients. In summary, most complications following surgical correction of velopharyngeal insufficiency in our institution occur in the early postoperative period and are the result of bleeding and/or airway obstruction.

Syngnathia: a report of two cases.

Syngnathia is a rare anomaly involving soft tissue or bony adhesions between the maxilla and mandible. Two cases of congenital syngnathia secondary to interalveolar soft tissue synechia are presented. These children present problems with airway protection and feeding in the immediate neonatal period. Most have multiple associated anomalies requiring concurrent management. Less than 50 cases have been described, most commonly in association with popliteal pterygium syndrome. Surgical management involves division of the adhesions in the first few days of life. Depending on the severity, these patients may present formidable anesthetic challenges. The prognosis is generally favorable in cases of soft tissue adhesions with eventual restoration of normal mandibular motion and function.

Frostbite in the prairies: a 12-year review.

A 12-year retrospective review of inpatient frostbite injury was undertaken in three tertiary hospitals serving a northern prairie population of 650,000. In the 125 patients identified, the mean age was 41 years, with a range of 3 to 90 years. Predisposing factors were alcohol consumption (46 percent), psychiatric illness (17 percent), vehicular trauma (19 percent), vehicular failure (15 percent), and drug use (4 percent). Profound hypothermia with a core temperature less than 32 degrees C was present in 12 percent. Anatomic distribution was 19 percent upper extremity, 47 percent lower extremity, 31 percent combined upper and lower extremity, and 3 percent facial or trunk only. Factors correlating with amputation of parts (p < 0.05) were duration of exposure, lack of proper attire, remote site of injury, presence of wound infection, and delay in seeking treatment. Prophylactic systemic antibiotics did not decrease the incidence of wound infection. Comparison with nine other civilian series revealed striking similarities in the patient populations.

Importance of blood clotting tests in the diagnosis of haemolytic-uremic syndrome and experience with its treatment.

More than half of 33 children with HUS were less than a year old, 90% less than five. A constant laboratory finding was the presence of FDP in the blood and urine, and of the remaining tests the presence of erythrocyte fragments. The absence of thrombocytopenia does not eliminate HUS. Antiplatelet treatment was given to 94% of children, heparin to 94%, thrombolysis to 27% Precise evaluation of treatment would require a controlled prospective multicentre study.

The changing concepts of condyloma. A retrospective study of colposcopically directed cervical biopsies.

Human papillomavirus has been implicated in the etiology of cervical intraepithelial neoplasia. A retrospective audit was conducted on all colposcopically directed biopsies performed from June through November, inclusive, in the years 1980 and 1982, a total of 317 cases. In 1980, the misdiagnosis rate for condyloma was 88.9% (69 of 78) and, in 1982, the misdiagnosis rate was reduced to 28.5% (40 of 140). On review, the association of cervical intraepithelial neoplasia with condyloma was 73% (107 of 146), p less than 0.005. The differences in mean ages of patients with condyloma alone, cervical intraepithelial neoplasia with condyloma, and cervical intraepithelial neoplasia alone were significant, p less than 0.02. When condyloma is not recognized, the pathologist tends to overdiagnose grade 3 cervical intraepithelial neoplasia as shown in 28 original cases; 16 of 28 (57.1%) were condyloma alone on review. Fifteen (53.6%) of these 28 patients underwent a cone biopsy or hysterectomy when a less radical procedure would have been acceptable. The morphologic changes indicating cervical condyloma were not fully appreciated by the pathologist, and this resulted in overdiagnosis and later overtreatment by the gynecologist.

Protein cross-match test for the diagnosis and prevention of reactions after the transfusion of blood and cryoprecipitate.

The examination by means of counterimmunoelectrophoresis for protein incompatibility of the serum of 62 patients who developed an allergic or pyretic post-transfusion reaction revealed incompatibility in 23 cases (37.2%). It was due to the presence of antibodies in 8 recipients (34.8%) and in 15 blood donors (65.2%). The incidence was significantly higher than in a control group of transfused patients who did not develop a reaction. In this group protein incompatibility was found in only 14.7%, 80% of which was due to antibodies in the recipient. In 13 (56.5%) of the patients with reactions agglutinating, cytotoxic or complement fixing antibodies against cellular antigens or IgG were found in addition to protein incompatibility. In 10 cases (43.5%) protein incompatibility was the only explanation for the clinical symptoms. When, in the treatment of multiply transfused haemophiliacs who regularly developed adverse reactions, donors for the preparation of cryoprecipitate were selected by means of the described technique, the almost obligatory reactions were prevented.