Comparison between the radial forearm and superficial circumflex iliac artery perforator free flaps for oral soft tissue reconstruction.

The radial forearm free flap (RFFF) is widely used for oral reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap is an increasingly utilized alternative. The cases of 165 patients who received either an RFFF or SCIP flap for oral reconstruction at Chris O'Brien Lifehouse, Sydney were reviewed. The aim was to report on patient, pathology, treatment, and outcome variables and to compare these between the two flap groups. A RFFF was used in 126 patients and a SCIP flap in 39 patients. SCIP flap patients were younger (P < 0.001) and had shorter operative times (P < 0.001), shorter anaesthetic times (P < 0.001), and more frequent recipient site dehiscence (P = 0.005) when compared to RFFF patients. The SCIP flap was significantly less frequently used for composite resections including bone when compared to the RFFF (P < 0.001). The primary site distribution was more even for RFFF patients (P < 0.001). There were no SCIP flap failures; three RFFF failures occurred. SCIP flaps performed comparably in terms of operative and clinical outcomes. Most SCIP flaps were utilized in younger patients with partial glossectomy defects.

Patient compliance and mandible fractures: a prospective study.

Fractures of the facial skeleton place a burden on healthcare systems at the individual and population level. It is suggested that a high proportion of such patients are non-compliant with various aspects of their care. It stands to reason that non-compliance would contribute to adverse outcomes and increased costs in general. The intent of this study was two-fold: to determine factors associated with poor compliance in the studied population of 215 patients with 359 mandible fractures, and to determine whether poor compliance is associated with an increased incidence of treatment complications. Being male, an illicit drug user, non-employed, and living furthest from care were the factors associated with non-compliance in the studied population. Compliance with soft diet, mouthwash, oral antibiotics, cigarette cessation, and review appointment attendance was 74%, 96%, 96%, 16%, and 58%, respectively. Global compliance scores of low, medium, and high were assigned to 27%, 59%, and 14% of participants, respectively. None of the individual postoperative compliance variables was found to be significantly associated with outcomes of treatment at the 5% level. Borderline associations were found. Globally non-compliant patients were significantly more likely to experience wound dehiscence. The utility of the current postoperative regimen should be further elicited.

A prospective study examining the effects of treatment timing in the management of mandible fractures.

The ideal timing for treatment of mandible fractures has not been well established. The objective of this study was to analyse the effects of treatment timing in the surgical management of mandible fractures. A prospective evaluation of 215 continuous patients with a total of 359 mandible fractures was undertaken. Nine outcome variables were analysed in relation to treatment delay by logistic regression modelling: wound dehiscence, hardware exposure, local postoperative infection, malocclusion, trismus, nerve damage, fracture non-union, return to theatre, and radiographic outcome. Nineteen additional variables were included in the analysis to adjust for potential confounding. Delay was measured in days and ranged from 0 to 41days, with a mean delay of 4.6days. The incidence of wound dehiscence, hardware exposure, local postoperative infection, trismus, nerve damage, fracture non-union and return to theatre was 6%, 4%, 11%, 8.5%, 47%, 2% and 8%, respectively. Objective malocclusion and poor radiographic outcomes were evident in 13% and 4.5% of cases, respectively. No statistically significant association was found between treatment delay and treatment outcomes. The findings of this study suggest it may be safe to delay the definitive treatment of mandible fractures. Treatment delay may allow for improved resource distribution and prioritization of more time-dependent interventions.

A multi-outcome analysis of the effects of treatment timing in the management of zygomatic fractures.

The aim of this study was to analyze the effects of surgical treatment delay in the management of zygomatic fractures. A retrospective case series of 99 patients was undertaken. Four outcome measures were analyzed in relation to delay: facial symmetry, facial scarring, trismus, and radiographic outcome. Five additional variables were subsequently analyzed: operation, diagnosis, primary operator, regular alcohol use, and regular cigarette use. Statistically significant associations were found between delay and facial scarring, and delay and radiographic outcome. For each additional delay of a day, the odds of facial scarring being present, compared to absent, decreased by 13% (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.76-0.98). For regular cigarette users, for each additional day of delay there was a 306-fold increased risk of having a radiographic outcome of major deviation from premorbid compared to equivalent to premorbid (OR 306.38, 95% CI 2.08-45,161.49). For non-regular cigarette users/non-users, for each additional day of delay there was a 1.5-fold increased risk of having a radiographic outcome of major deviation from premorbid compared to equivalent to premorbid (OR 1.50, 95% CI 1.08-2.09). These findings correlate with commonly held beliefs and anecdotal evidence. Despite the limitations, this study allows for an evidence-based approach to the timing of treatment of zygomatic fractures.

The effect of treatment timing on the management of facial fractures: a systematic review.

The ideal timing for treatment of facial fractures has not been well established. The objective of this systematic review was to examine the effects of treatment delay on outcome in the management of facial fractures. The PubMed database was used to search for relevant English-language articles published between 1979 and 2013. Cross-referencing identified additional studies. There were no selection restrictions for study type. The first author, using pre-defined data fields, extracted information independently. Studies were assessed by study type, evidence level, sample size, data collected, outcome variables, control of confounding variables, and findings. Thirty studies were identified. Inconsistency was identified with data collected, outcome variables, and findings. Of the 30 studies identified, 28 were case series, thereby providing a low level of evidence overall. The majority of case series were retrospective and sample sizes were predominantly small. Control of confounding variables was poor. Eighteen studies found no statistically significant relationship between treatment delay and treatment outcome. Nine studies found a statistically significant relationship between treatment delay and worse treatment outcomes. There were three studies with conflicting results. With the current body of evidence, definitive conclusions cannot be drawn on the timing of treatment for facial fractures.

Implementation of a standards-based anaesthesia record compliant with the health level 7 (HL7) clinical document architecture (CDA).

With the increasing use of anaesthesia information management systems (AIMS) there is the opportunity for different institutions to aggregate and share information both nationally and internationally. Potential uses of such aggregated data include outcomes research, benchmarking and improvement in clinical practice and patient safety. However, these goals can only be achieved if data contained in records from different sources are truly comparable and there is semantic inter-operability. This paper describes the development of a standard terminology for anaesthesia and also a Domain Analysis Model and implementation guide to facilitate a standard representation of AIMS records as extensible markup language documents that are compliant with the Health Level 7 Version 3 clinical document architecture. A representation of vital signs that is compliant with the International Standards Organization 11073 standard is also discussed.

The worm that turned.

When a patient presents with acute myelopathy in the developed world, helminthic infection is not routinely considered in the differential diagnosis. We report the case of a 34-year-old South African male who presented with acute urinary retention and lower leg paraesthesiae. Subsequently, myeloradiculopathy secondary to Schistosoma mansoni was diagnosed on the basis of typical magnetic resonance imaging changes in the conus medullaris and positive stool microscopy. Prior to this presentation the patient had lived in urban western South Africa and more recently in New Zealand, without exposure to infected water for 22 years. His symptoms and signs resolved following treatment with praziquantel and methylprednisolone. Spinal schistosomiasis is a rare but serious cause of myelopathy and should be considered in any patient who has ever visited or lived in an endemic area.

Vagolysis.

We describe the case of a 75-year-old man presenting with labile hypertension and symptomatic postural hypotension 13 months following radiotherapy for squamous cell carcinoma of his external auditory canal. Magnetic resonance image (MRI) scan demonstrated scarring and a probable recurrence of his tumour. He underwent autonomic testing, including muscle sympathetic nerve activity (MSNA), heart rate (HR) and blood pressure (BP) responses to a variety of stimuli. Results were consistent with baroreflex failure. Urinary catecholamine levels were within the high normal range. We postulate that baroreflex failure was caused by vagal and glossopharyngeal nerve damage secondary to radiotherapy and tumour recurrence. This diagnosis is rare, but should be considered with pure autonomic failure and phaeochromocytoma in the presence of labile hypertension, especially in patients with a history of radiotherapy to the neck and high-normal catecholamine levels.

Prototype system for enhancement of frontal chest radiographs using eigenimage processing.

A prototype system is described for enhancement of radiographic images in the eigen domain. The images chosen to enhance are frontal chest radiographs. This class of images has been chosen because it is both a clinically important examination and an example of the high-resolution images used within radiology. The enhancement method is based on principal components analysis, a multivariate statistical technique first used within image processing for face recognition. The method requires a training set of normal images to identify normal patterns of variance. The enhancement process then removes these normal patterns of variance, often increasing the relative intensity of pathologies. Enhanced images presented in this paper include a range of common pathologies found on chest radiographs. Details of implementation, computing expense and possible applications within radiology are discussed.

Tilt-test diagnosis of hypotensive transient ischaemic attacks.

Eight elderly patients with postural hypotension who presented with transient ischaemic attacks are reported. Six patients underwent head-up tilt testing with continuous blood pressure monitoring. During tilt, postural hypotension was found in five patients and in three patients transient ischaemic attacks were reproduced. Postural hypotension is probably a rare cause of transient ischaemic attacks, but may be underrecognized.

Reversible posterior leukoencephalopathy syndrome: a misnomer reviewed.

Reversible posterior leukoencephalopathy is a syndrome of headache, seizures and visual loss, often associated with an abrupt increase in blood pressure. Prompt diagnosis and therapy with antihypertensives, anticonvulsants, removal of any offending medication and treatment of associated disorders is essential since early treatment might prevent progression to irreversible brain damage. We present six illustrative cases presenting to Christchurch Hospital and review the condition. All were hypertensive, two were receiving immunosuppressant therapy after transplantation and one chemotherapy. Only three made a full recovery. The term reversible posterior leukoencephalopathy is a misnomer as the condition is not always reversible, is not necessarily confined to the posterior regions of the brain and can affect both white and grey matter. Magnetic resonance imaging findings of increased T2 and fluid attenuated inversion recovery signal predominantly involving the posterior regions of the cerebral hemispheres should alert the clinician to the possibility of this diagnosis.

An audit of the assessment and management of adults admitted to Christchurch Hospital with community acquired pneumonia.

AIMS: To audit the management of adult patients admitted with community acquired pneumonia including the standards of clinical assessment, use of modified British Thoracic Society prognostic criteria and antibiotic therapy. METHODS: A prospective, 16 week, study of consecutive patients admitted to Christchurch Hospital with community acquired pneumonia. RESULTS: Ninety-six patients met the inclusion criteria. The median age was 70 years. A pathogen was identified in 28 (26%) patients. Forty two patients fulfilled the modified British Thoracic Society criteria for severe disease and all 9 deaths occurred in that subgroup. The management guidelines were followed without exception in only 15% of cases. Documentation of the prognostic criteria was often incomplete and therefore only 33% of those patients with severe disease were correctly identified. Seventy one percent of those with severe disease were treated with only one antibiotic and there was significant delay in administering the first dose in 44% of cases. A follow up chest radiograph was performed in 43 (51%) of those discharged. CONCLUSIONS: There was poor compliance with the management guidelines. There was a lack of awareness of the severity criteria leading to inadequate treatment in many cases. Further educational initiatives are indicated.

Malignant granular cell tumour of the sciatic nerve.

A case of malignant granular cell tumour of the sciatic nerve is presented. Computed tomography demonstrated isodensity with muscle and minimal enhancement. Magnetic resonance demonstrated T1 isointensity with muscle with marked enhancement, and isointensity with fat on proton and T2 images. Pathological evidence is presented for its probable Schwann cell histogenesis.

The effect of simvastatin and bezafibrate on bile composition and gall-bladder emptying in female non-insulin-dependent diabetics.

Female non-insulin-dependent diabetics have a high prevalence of gallstones. Treatment of hyperlipidaemia in these patients may modify the risk. Seventeen female non-insulin-dependent diabetics (age 35-65) were treated with simvastatin (n = 10) or bezafibrate (n = 7) and had the cholesterol saturation index (CSI) of bile and gall-bladder emptying measured before and after 3 months therapy. In both groups, there was a significant reduction in serum cholesterol following treatment. The mean pretreatment cholesterol saturation indices of bile did not differ between the two groups but, after 3 months therapy, there was a highly significant difference in CSI between the bezafibrate group (2.0 +/- 0.33) and the simvastatin group (1.1 +/- 0.14) P < 0.002. Whereas the increase in the CSI (42%) observed with bezafibrate therapy was significant, the decrease in the simvastatin group (14%) was only significant in those whose pretreatment cholesterol saturation indices were elevated. Despite the differences in CSI observed between the two treatment groups, no changes in gall-bladder emptying were detected.

Variation in the estimation of gallbladder volume using the sum-of-cylinders method.

RATIONALE AND OBJECTIVES: Gallbladder contraction was measured by ultrasound, using the sum-of-cylinders method, as part of a study of the effects of lipid-lowering drugs. Although this method of measurement has been validated in the literature, paired measurements were obtained to provide an additional check on reproducibility. METHODS: A total of 136 pairs of gallbladder measurements were made on 17 patients using the sum-of-cylinders method of calculating gallbladder volume. Each pair comprised a left posterior oblique and a supine measurement performed at the same ultrasound examination to assess measurement error. RESULTS: There was a large average coefficient of variation of 21%. CONCLUSIONS: Marked measurement variability limited the ability of the sum-of-cylinders technique to detect even modest alterations in gallbladder contractility, at least in this population subgroup.

Why do anaesthetists need codes?

With the increasing availability of information technology in hospitals and the introduction of medical audit and resource management, there is a proliferation of anaesthetic data collection systems. The amount of data recorded varies from a complete anaesthetic record to a small subset of it. Most systems hold data in coded form for reasons of accuracy and compactness. Unfortunately, all the coding systems are different, making comparisons between different centres difficult. We propose that there is a need to develop a standard national system for coding anaesthetic terms.

Cuff expander eases enema tip assembly.

Some barium enema kits are manufactured with two-part enema tips, enabling a cuff to be placed on the tip only if required. Difficulty can be experienced during enema tip assembly while attempting to place the cuff on the tip. A readily available gadget used in the farming sector provides a neat and cost-effective solution to this problem.

Hemorheology and fistula function in home hemodialysis patients following erythropoietin treatment: a prospective placebo-controlled study.

The beneficial effect of correcting anemia in end stage renal failure using recombinant human erythropoietin (rHuEPO) is sometimes complicated by thrombosis of the arteriovenous fistula. This placebo-controlled study investigated the relationship between hemorheological changes caused by rHuEPO and alterations in fistula function and heparin requirements in home hemodialysis patients. Erythropoietin induced a rise in high shear rate blood viscosity, a determinant of blood flow in large vessels. Doppler assessment of brachial artery blood flows, tests of fistula function and heparin requirements were similar in the two patient groups. These findings indicate that rHuEPO treatment of renal anemia resulted in the expected rise in red blood cell mass and blood viscosity although these changes did not cause problems with arteriovenous access or alter fistula function in the short term.