Biomedical subjects
Publications and source records attributed to J O'Beirne.
Alcoholic hepatitis is a common condition with a high mortality. Although treatment options for established alcoholic hepatitis are limited, many of the complications of this condition are preventable. This case report and discussion illustrate the important role of early diagnosis and intervention in this patient group. Important management points are stressed to aid physicians who may encounter this condition rarely.
BACKGROUND: Cyclosporine is the most common maintenance immunosuppressant in liver transplants patients, but it is often associated with nephrotoxicity. METHODS: We evaluated the safety and efficacy of monotherapy with mycophenolate mofetil (1 g twice daily) in five stable liver transplant patients with cyclosporine-induced renal impairment despite reduction of cyclosporine to subtherapeutic levels. Follow-up was 8.4+/-2.4 (range: 6-12) months. RESULTS: No major side effects have been observed to date. Serum creatinine levels were significantly reduced from a median of 201 micromol/L before to 142 micromol/L at 3 months after mycophenolate (P=0.04) and remained low at 6 months. New onset cellular rejection occurred in only one patient after 3 months on mycophenolate monotherapy, and it responded completely to an intravenous course of methylprednisolone. CONCLUSIONS: Monotherapy with mycophenolate mofetil in a dose of 1 g twice daily seems to significantly improve cyclosporine-induced renal impairment in stable liver transplant patients without major side effects or significant risk of rejection.
Over a four year period, 20 segments in 16 patients were treated by lengthening by callotasis or chondrodiastasis. The indications for treatment were leg length discrepancy in 13 patients and short stature in three. Patients with leg length discrepancy were all treated by femoral lengthening; the mean length gained was 4.4 cm (range 2.5 to 6.Ocm). For patients with short stature, the mean femoral length gain was 10.0 cm (9.0 to 10.5 cm), and the mean tibial length gain was 8.0 cm (6.5 to 9.0 cm). The commonest problem was pin tract infection, but this always settled with antibiotic therapy. Most other complications were also successfully dealt with, and did not compromise the outcome of treatment. At the time of review, 13 of the 16 patients said they were very happy with the result; two patients were reserving judgement until completion of treatment, and, only one thought the treatment had been of no benefit. Our initial experience, with callotasis in particular, has been that it is a highly satisfactory method of limb lengthening, has an acceptable complication rate, and involves minimal hospitalization as compared with older techniques.
Magnetic Resonance Imaging (MRI) examination was carried out on 44 patients who had spinal injuries with neurological involvement. The technique provided valuable information about the nature of the injuries and, in particular, about the state of the spinal cord. The appearances of the cord on MRI ranged from normal, to oedema, to more severe damage such as cord haemorrhage or transection or, in later cases, myelomalacia. The appearance of the cord on MRI correlated strongly with both the severity of the neurological deficit and also the degree of subsequent recovery. In the assessment of the acute spinal injury, MRI has been shown to be a good prognostic indicator; it may also help to identify which patients are likely to benefit from early decompression.
Sixteen polytraumatized patients with a variety of unstable pelvic ring fractures were treated with operative fixation. We have found that an aggressive approach with adequate early stabilization of the pelvis offers many advantages over conservative management particularly in polytraumatized patients.
Thirty-seven tibial shaft fractures in 34 patients were treated with the Grosse-Kempf interlocking intramedullary nail over a two year period. Thirty-six tibiae were consolidated at a median of 17 weeks; one had re-fractured following nail removal in a separate injury, but was now uniting on conservative treatment. Using very detailed clinical and radiological analysis, and excluding the patient who had re-fractured, the results were excellent in 19, good in 8, fair in 6 and poor in 3. The most significant complications were haematoma formation and additional comminution during nail insertion. Overall, we found tibial nailing to be a satisfactory procedure, facilitating rapid rehabilitation with early weight bearing and resulting in predictable fracture healing in good alignment.
Eighty-one patients who had spinal fusions performed for back pain over a 7-year period were reviewed; 74% were satisfied with the outcome of their surgery, mainly because of the degree of pain relief obtained. Based on lateral radiographs of the fusion area in flexion and extension, there was a 34% pseudarthrosis rate in first-time fusions. However, there was no clear relationship between the integrity of fusion and clinical success, indicating that many factors other than bony fusion influence the eventual outcome of the operation.
To determine whether equilibrial dysfunction is the cause or effect of idiopathic scoliosis, patients with idiopathic scoliosis, congenital scoliosis, and comparable controls were tested, using clinical postural tests and electronystagmographic recording of spontaneous and positional nystagmus, smooth visual pursuit, and rotation-induced nystagmus. The scoliosis patients were stratified as progressive or nonprogressive. Dysfunctional responses occurred in the idiopathic progressive and congenital progressive groups, and in two idiopathic non-progressive patients whose curves subsequently deteriorated. These results suggest that equilibrial dysfunction is characteristic of patients with progressive curves, regardless of etiology, implying that it is secondary to the curve rather than a primary event. Seven patients with progressive curves undergoing surgical correction and stabilization were tested preoperatively and 6 months postoperatively. No change in the responses occurred, suggesting the dysfunction persists at least 6 months following arrest of progression.
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A review of 56 fractures of the femoral shaft plated by the anterolateral approach was undertaken. The final results were graded as excellent or good in 37 cases (66 per cent). Loss of flexion of the knee of more than 10 degrees occurred in 17 cases (30 per cent); these were mostly patients whose plating was delayed by more than 14 days, or was done as a secondary procedure. Patients with open fractures and with other fractures in the same femur tended to have poorer final results. The late complication rate was 18 per cent, which was similar to that for the posterolateral approach for plating the femoral shaft. It is our view that the anterolateral approach is satisfactory for plating the femoral shaft.
Eighty-six fractures of the femoral shaft were treated by open reduction and plating. Seventy-seven fractures (90 per cent) were reviewed 12-72 months (average 38 months) after operation. An excellent or good result was achieved in 70 fractures (91 per cent). There was no case of deep infection. The most common complication was a fatigue fracture of the plate, which occurred in five cases. In patients over the age of 60 years, loosening of the implant was troublesome. Primary bone grafting is essential if rigid internal fixation is not obtained. Plating is an excellent method of treating fractures of the femoral shaft in patients under the age of 60 years, provided that the surgeon is technically competent and experienced in this method of treatment.
A prospective study of all knee injuries seen at a Casualty Department was organized. A clinical diagnosis was made in each case, based on standardized criteria, and the subsequent progress followed. Meniscal tears tended to be over-diagnosed clinically. Many injuries thus classified settled in three to four weeks without further sequelae. Conversely, complete ligament tears were under-diagnosed and in particular these tended to be missed in the presence of a haemarthrosis. Examination under anaesthesia is recommended if there is any doubt concerning ligamentous stability and all unexplained haemarthrosis should have early examination under anaesthesia and arthroscopy. Among those injuries initially regarded as less serious e.g. traumatic synovitis, no serious pathology subsequently emerged.
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Eighteen patients with slipped upper femoral epiphyses were treated by internal fixation using single pins in the centre of the femoral head. In 15 patients, prophylactic pinning of the unaffected side was performed; therefore, 33 hips were pinned. Results were encouraging in that no slip progressed following fixation, no pins broke, and no late reslips occurred. The optimum position for a pin is in the centre of the femoral head, with subsequent pins in suboptimal sites. The method of single pinning is simple and, theoretically, minimizes the risk of joint penetration.