Cauda equina compression by hydrogel dural sealant after a laminotomy and discectomy: case report.

STUDY DESIGN: The authors present a case of cauda equina compression after laminotomy and discectomy where incidental durotomy was managed with the application of hydrogel sealant. The patient reported return of radicular symptoms on the first postoperative day, and deterioration to early cauda equina syndrome after bending on the sixth day. OBJECTIVE: To demonstrate that in addition to its recognized volume expansion properties, that the product has the ability to migrate and produce symptoms remote from where it was inserted. SUMMARY OF BACKGROUND DATA: The physical properties of DuraSeal (Confluent Surgical, Waltham, MA), a hydrogel dural sealant, make it an effective adjunct to dural closure. Its volume expansion has been associated with neural compression after posterior fossa decompression. We have found no reported migration of this product. METHODS: Sequential postoperative imaging shows swelling and migration of the hydrogel into spinal canal with resultant compression. Exploration on postoperative day 10 revealed sealant causing cauda equina compression proximal to the site of the durotomy. CONCLUSION: The authors recommend that in addition to caution regarding its potential mass effect, that cognizance be taken of the product's potential to migrate and result in symptoms at a distant site.

The influence of small aerosol particles on the properties of water and ice clouds.

In this paper, results are presented of the influence of small organic- and soot-containing particles on the formation of water and ice clouds. There is strong evidence that these particles have grown from nano particle seeds produced by the combustion of oil products. Two series of field experiments are selected to represent the observations made. The first is the CLoud-Aerosol Characterisation Experiment (CLACE) series of experiments performed at a high Alpine site (Jungfraujoch), where cloud was in contact with the ground and the measuring station. Both water and ice clouds were examined at different times of the year. The second series of experiments is the CLOud Processing of regional Air Pollution advecting over land and sea (CLOPAP) series, where ageing pollution aerosol from UK cities was observed, from an airborne platform, to interact with warm stratocumulus cloud in a cloud-capped atmospheric boundary layer. Combining the results it is shown that aged pollution aerosol consists of an internal mixture of organics, sulfate, nitrate and ammonium, the organic component is dominated by highly oxidized secondary material. The relative contributions and absolute loadings of the components vary with location and season. However, these aerosols act as Cloud Condensation Nuclei (CCN) and much of the organic material, along with the other species, is incorporated into cloud droplets. In ice and mixed phase cloud, it is observed that very sharp transitions (extending over just a few metres) are present between highly glaciated regions and regions consisting of supercooled water. This is a unique finding; however, aircraft observations in cumulus suggest that this kind of structure may be found in these cloud types too. It is suggested that this sharp transition is caused by ice nucleation initiated by oxidised organic aerosol coated with sulfate in more polluted regions of cloud, sometimes enhanced by secondary ice particle production in these regions.

Outcome of reaching end stage renal failure in children under 2 years of age.

AIMS: To determine the outcome of children who reach end stage renal failure before the age of 2 years. METHODS: Using a retrospective questionnaire, 10 years' data were collected from the paediatric nephrology units in Britain and Ireland (1988 to 1997, follow up 1.3-11.5 years). RESULTS: A total of 192 children were identified; 0.31/million/year. Most had congenital or inherited conditions, and there were more boys. Latterly, half were diagnosed antenatally. Ninety per cent were dialysed initially, most using home peritoneal cyclers, some by haemodialysis through central lines. Five per cent recovered sufficient function to come off dialysis. Most required tube feeding (often gastrostomy) and erythropoietin; some needed growth hormone. A total of 56% received a transplant (2% without prior dialysis) at (medians) 2.6 years and 12.3 kg. The 2 and 10 year survival of first kidneys was 78%. Growth improved following transplantation. Fourteen per cent died because treatment was not started or was withdrawn. Most had particularly complex renal conditions, or additional major non-renal diagnoses. Typically, decisions not to treat were made mutually between clinicians and families. When treatment was continued, 71% survived, and few had serious non-renal conditions. Most attended normal schools, and by 6 years of age, less than 10% still required dialysis. Infants starting treatment under and over 1 month of age fared equally well. CONCLUSIONS: By school age, most infants treated for end stage renal failure will have a functioning transplant, reasonable growth, and will attend a normal class, regardless of the age at which they commence treatment. Treatment is seldom sustained in children who have serious additional medical conditions. It is reasonable to treat infants with uncomplicated renal failure.

Coming of age. Cystic fibrosis--once a childhood disease--makes its way to adulthood.

Cystic fibrosis patients and their caregivers face unusual complexities when these patients move from the pediatric to adult setting.

Evaluating the reliability and utility of cumulative intake and output.

During times of scarce resources available for providing patient care, it becomes necessary to validate the effectiveness of standard practices that consume caregivers' time and efforts. Three nurse managers of nursing units serving diverse patient populations studied the effectiveness of continuous intake and output in estimating daily fluid balance. They examined 48-hour records of daily weight and intake and output of 73 patients and correlated the two. Their findings suggest that even when caregiver charting compliance is optimal, daily intake and output recording provides unreliable results. The authors recommend daily weights alone be adopted for all patients who are not experiencing acute renal conditions.

Cost-benefit analysis of an automated medication system.

Automated medication distribution systems have helped solve issues of efficiency and effectiveness. Cost-benefit analysis conducted by nursing and pharmacy departments can help to objectify the decision to adopt this technology.

Dietary nucleotides: effects on the gastrointestinal system in swine.

Nucleotides in the intestinal lumen may decrease the inflammatory response to ischemia-reperfusion. In a newborn-swine model, we showed that perfusion of the intestinal lumen with nucleotides in concentrations similar to those in human milk induced hyperemia. The levels of hypoxanthine (and xanthine) were not increased in the presence of nucleotides during ischemia-reperfusion, and the number of leukocytes accumulated in the intestine was reduced in the presence of nucleotides. Furthermore, nucleotides may have decreased protein leak and the production of nitric oxide during ischemia. These effects are not changed significantly in the presence of an adenosine antagonist. We interpreted our results to indicate that the protective effects of nucleotides in the intestinal lumen are not due to adenosine alone.

Imaging in children with spinal tuberculosis. A comparison of radiography, computed tomography and magnetic resonance imaging.

We compared the usefulness of radiography, CT and MRI in 25 children with spinal tuberculosis. Radiography provided most of the information necessary for diagnosis and treatment. Axial CT was the most accurate method for visualising the posterior bony elements. Sagittal MRI best showed the severity and content of extradural compression and helped to differentiate between an abscess and fibrous tissue. The main value of CT and MRI is in the preoperative evaluation of the small proportion of patients who require surgical treatment for paraplegia.

Air in unusual places: some causes and ramifications of pneumomediastinum.

Five unusual cases of pneumomediastinum are described. In three the probable cause was thoraco-abdominal straining against a closed glottis during violent exercise, in criminal assault, or competitive sport. The resultant increase in intra-alveolar pressure produces an air leak which passes via the pulmonary interstitium into the mediastinum. It can then pass up into the neck to produce widespread subcutaneous emphysema and down through the diaphragmatic hiatuses to produce extraperitoneal emphysema. This may outline the lower surface of the diaphragm to stimulate intraperitoneal air, but it can also leak through the parietal peritoneum to result in actual intraperitoneal air. Therefore, in the patient who has been hospitalised after violent physical stress with or without blunt trauma, pneumomediastinum does not necessarily indicate tracheobronchial or oesophageal rupture and subdiaphragmatic air does not necessarily indicate bowel rupture. Probably any form of exercise in which the Valsalva manoeuvre is performed may cause pneumomediastinum, as may other causes of increased intra-alveolar pressure such as mechanical ventilation, bronchospasm, coughing and vomiting. Vomiting is a likely contributing cause in the pneumomediastinum of diabetic ketosis, of which a case is described. Another case is presented in which air passed in the opposite direction, from perforated extraperitoneal bowel up into the mediastinum.

Cholecystojejunocholecystostomy: a new method of biliary drainage in auxiliary liver allotransplantation.

A subhepatic, whole auxiliary liver allotransplant technique, previously developed in the pig, was assessed for technical feasibility in 26 human cadaver transplants. All technical aspects of the subhepatic technique were feasible, with the exception of donor to recipient gallbladder-to-gallbladder anastomosis, which could only be performed in 50% of subjects due to excessive separation of the two gallbladders. To oversome the problem, an original technique was developed--namely, the use of an isolated, vascularized, isoperistaltic loop of jejunum to act as a conduit between donor and recipient gallbladders (cholecystojejunocholecystostomy). Cholecystojejunocholecystostomy was subsequently developed and studied in a series of live porcine auxiliary allografts. The local, reginal, and general effects seen in 14 allografted pigs with cholecystojejunocholecystostomy were compared with those seen in a parallel and identical series of 14 allografts with cholecystocholecystostomy. The subhepatic transplantation technique is described in detail for the first time. Liver biopsies, blood samples, and clinical data were obtained at weekly intervals and at 28 days all survivors were killed. Cholecystojejunocholecystostomy proved to be a successful method of biliary drainage in the pig. Thirteen of the 14 interposed jejunal loops were viable and essentially normal at autopsy, leaks and naked eye stasis were infrequent, and the histological incidence of intrahepatic cholangitis and cholestasis minimal. The local, regional, and general effects were comparable in every way with those obtained with cholecystocholecystostomy.

Percutaneous control of post-traumatic hepatic hemorrhage by gelfoam embolization.

A case is reported in which a male laborer sustained severe hepatic lacerations after a tree fell across his abdomen. Despite intensive resuscitation and a laparotomy, bleeding continued from the liver and a second laparotomy was performed. When this also failed to control the hemorrhage a selective hepatic angiogram showed a false aneurysm in the right lobe of the liver with surrounding hematoma. This was successfully embolized with Gelfoam emboli. Bleeding ceased immediately with an uneventful recovery. The role of embolization in the management of hepatic trauma is discussed, especially in relation to surgical hepatic artery ligation.

Problems with an electromagnetic blood flowmeter.

Recurrent unexplained interference and day-to-day variation were encountered during preliminary studies with a sine-wave electromagnetic flowmeter. Using in vitro techniques, contributory causes were found to be defective leads to the flowmeter cuffs, inadequate contact between cuff and vessel, and failure to use an earth lead. When these faults were corrected, a study was made of the effects of haematocrit, temperature and the comparison of blood vessel or dialysis tubing in vitro. Final in vivo confirmation of the validity of the cuff was obtained by comparison with a cannula probe.