Biomedical subjects
Publications and source records attributed to R Sanders.
A case report of a cavernous haemangioma arising in the nasal bones is described, together with a discussion of the relevant literature. The condition, although rare, can be reliably diagnosed pre-operatively.
Prophylactic subconjunctival antibiotics and steroids have been used in cataract surgery since the early 1950s. However despite their widespread acceptance, there has, to date, been no direct comparison of subconjunctival and topical routes of administration. We therefore carried out a prospective comparison of the effects of subconjunctival and topical administration of antibiotics and steroids in sixty patients undergoing elective, uncomplicated, extracapsular cataract extraction and posterior chamber lens implantation. The patients were examined by a single observer on the first and third post-operative days and two and six weeks following surgery. The observer was blinded to the patient treatment group. Significantly higher degrees of conjunctival injection and anterior chamber activity were noted in those who received subconjunctival injections compared with those who received topical treatment. There were no significant differences between the two groups in best corrected visual acuity, central corneal oedema, cystoid macular oedema, intraocular pressure and infection. We conclude that prophylactic subconjunctival therapy in uncomplicated cataract surgery is not necessary.
Between 1983 and 1989, 11 open grade IIIB ankle or talus fractures were treated according to protocol including debridement, temporary placement of antibiotic beads, soft tissue coverage (including seven free vascular tissue transfers), intravenous antibiotics and fusion using an anterior plate, and bone graft. All patients had a minimum of three separate hospitalizations. Each had at least five operative procedures performed with an average of 8.2/patient (range: 5-12). The total in-patient hospital stay averaged 61.6 days (20-107 days) and in patient costs averaged $62,174.43/patient (range: $33,535.06-$143,847.45). Overall hospital cost averaged $1,009.32/day. Follow-up averaged 47.8 months (range 32-85 months), with an average time to union of 4.4 months. Fusion rate and muscle flap success was 100%. Although fusion and eradication of infection in this specific group of patients was possible, significant functional and psychosocial disability remained. Eight of eleven patients had significant pain, difficulty with stairs, and limited ambulation. All changed jobs or were unemployed. Patients with open grade IIIB tibiotalar injuries with significant bone loss may therefore benefit from early amputation. A multicenter randomized clinical outcome study is needed.
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Indirect reduction and percutaneous screw fixation were attempted in 20 displaced tibial plateau fractures in 20 patients. Closed, indirect reduction was successful in 18 fractures; two others, both Schatzker type II fractures, required open reduction. The 18 fractures were followed for an average of 16.2 months (range, 12-24 months). Of the fractures successfully reduced with indirect techniques, 13 were reduced anatomically (72.2%), and five were considered nonanatomic (27.8%). Four of the five fractures with a nonanatomic reduction were type II fractures. Clinically, there were six excellent (33%), 10 good (56%), and two fair (11%) results. No fracture lost reduction; no patient developed an infection. Indirect techniques could effectively reduce only split fragments. Depressed fragments could not be reduced reliably with either ligamentotaxis or percutaneous elevation with a tamp. There was no correlation between radiographic reduction and clinical outcome. It did not matter whether two, three, or four screws were used to stabilize the fracture.
A retrospective review of complications with connectors and lead-to-header interfaces was performed following 649 pacing procedures between 1980 and 1990. There were 88 lead revisions (13.6%), 81 device replacements or modifications (12.5%), and 480 new implants (74%) using devices of five manufacturers. Two basic connector types were studied, one utilizing a set screw and the other using a side-lock compression fitting. The set screw makes electrical contact and mechanically secures the lead connector pin with a set screw insulated by a self-sealing grommet or an integral or separate set screw cover. The side-lock makes electrical contact with an automatic spring mechanism while the plastic lead terminal is secured in the connector block of the pacemaker by a Delrin side-lock compression fitting. Four hundred fifty-nine set screw connector devices were followed for up to 12 years with 14 complications (3.1%) whereas 82 side-lock connector devices were followed for up to 5 years with one complication (1.2%). The set screw and side-lock connectors were reliable over the period of follow-up. Although the complication rate appeared lower with the side-lock, follow-up was shorter and the number of implants smaller. With the leads used in this study, the side-lock proved to be a desirable feature due to simplicity, speed, safety, and ease of use. One limitation is the requirement for a precise IS-1 connector terminal diameter.
Eighteen patients who were sixty years or older and had an acute displaced fracture of the acetabulum were managed with open reduction and internal fixation. The average age of the patients was sixty-seven years (range, sixty to eighty-one years). Nine fractures were a result of a motor-vehicle accident, and nine occurred in a fall. Nine patients had multiple associated injuries, and most (sixteen patients) had other complex acetabular fractures. All of the patients had open reduction and internal fixation with either the ilioinguinal approach (thirteen patients) or the Kocher-Langenbeck approach (five patients). All patients were managed postoperatively with early mobilization and physical therapy. All fractures united, and only one patient had a partial loss of reduction. Four patients who had a concentric reduction had a gap of as much as three millimeters in the articular surface due to comminution of the fracture. The complications included two pulmonary emboli, which resolved with anticoagulation, and one undetected intra-articular fragment, which led to an additional operation. No infections or iatrogenic nerve injuries were noted. Seventeen of the eighteen patients were followed for at least two years (average, thirty-one months). These patients had an average Harris hip-score of 90 points postoperatively. The treatment was regarded as having failed in only one patient. Open reduction and internal fixation of selected displaced acetabular fractures in the elderly can yield good results and may obviate the need for early and often difficult total hip arthroplasty.
A series of 30 patients who have been treated for advanced carcinoma of the parotid gland using radiotherapy followed by radical surgery is presented. Three patients deteriorated during preoperative radiotherapy and remained unfit for surgery; the remaining 27 underwent radical parotidectomy with block dissection of the neck. Twelve patients received additional radiotherapy after operation. Of those patients undergoing surgery, three have been lost to follow-up, 17 have died and seven remain alive; the period of follow-up ranges from 3 to 133 months. Fourteen patients remained free of recurrent disease at death or when last seen, and six patients developed a local recurrence at a medium period of 10.5 (range 3-36) months after surgery. For all 30 patients, the cumulative proportion surviving for 5 years was 30 per cent.
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Bacterial infection in 100 burned patients over a 10-month period has been studied. The commonest colonizing organism was Staph. aureus (69 per cent), followed by E. coli (35 per cent). Pseud. aeruginosa accounted for only 28 per cent of isolates. The role of the different bacterial species in burns pathology is discussed. Group G haemolytic streptococci were isolated from 10 per cent of patients and caused graft failure in some cases. Only 3 per cent of patients developed septicaemia and all were due to Staph. aureus. Our approach to management of infection in burns, especially the policy on systemic antimicrobial chemotherapy, is described.
A comparison was made of the morbidity of surgery for loco-regional recurrence in patients with advanced cancer of the head and neck region following continuous hyperfractionated accelerated radiotherapy (CHART), after conventional radiotherapy, and also in a group following surgery only as the primary treatment. Post-surgical morbidity occurred in 14 (77%) of the 18 patients treated with CHART, of whom 11 (78%) required a further surgical procedure. In the conventional group, morbidity occurred in 14 (58%) of the 24 patients, of whom 9 (64%) required further surgery. Finally, in the surgical group morbidity occurred in 13 (48%) of the 27 patients, of whom 7 (54%) required further surgery. Because of the many factors that may influence the chance of morbidity and of the small number of cases, considered statistical analysis is not meaningful and there must be caution in the interpretation of results. When allowance is made for the greater frequency of more advanced tumors and for sites in the oropharynx and oral cavity, where procedures associated with greater risk of complication were performed, the morbidity seen after surgery was performed upon CHART patients appeared to be no greater than when conventional radiotherapy had been given. As expected, the surgery only group showed less morbidity than either of the radiotherapy groups.
In some circumstances cyclosporine (CyA) induces autoimmune phenomena, and a lethal form of syngeneic graft-vs-host disease (SGVHD) can be induced in rats by the administration of CyA. Although several rat strains develop this disease, in this study, we report that of six mouse strains tested, only the DBA/2 strain developed SGVHD. A comparison of the effect of CyA on thymocytic and peripheral T-cell populations revealed that CyA-induced alterations were similar in the two species, although more marked in rats. Notably, CyA-treated syngeneic bone marrow chimeras (SBMC) had transiently increased numbers of peripheral CD4+ CD8+ T-cells, expressing a marker normally limited to thymocytes. Examination of T-cell receptor (TCR) V beta expression in CyA-treated mice revealed a normal pattern of clonal deletion in all strains (including disease-prone DBA/2 mice), suggesting that CyA may induce autoimmunity without blocking intrathymic clonal deletion.
Influenza viruses remain a major cause of respiratory disease in both developed and developing countries. A great deal of information concerning the structure, pathology and modes of transmission of these viruses has been accumulated, but no means of successfully combating them have, as yet, been devised. The most appropriate strategy for limiting the effects of influenza is to monitor the emergence and spread of new strains carefully and warn the public and at-risk groups of impending epidemics. In Papua New Guinea, as in most other developing countries, the major at-risk groups are the very young and the elderly. In the past, influenza epidemics were rare and affected the whole community, but with modern development and increased mobility the transmission dynamics of influenza have changed. The only influenza surveillance centre in Papua New Guinea is at the Papua New Guinea Institute of Medical Research in Goroka, and the surveillance activities of this centre are limited to the immediately surrounding areas. There is a need to establish a national influenza surveillance network, to provide nation-wide monitoring of influenza activity, and to provide a central repository of current information on influenza infections in the country.
Accurate assessment of the extent of thermal injury in the accident and emergency (A&E) department is essential if appropriate resuscitation and referral to a specialist unit is to occur. However, review of 100 referrals to a regional burns unit confirms that assessment is often inaccurate, and usually undertaken by no one more senior than a casualty officer, leading to suboptimal treatment and referral. Severe thermal injury should be assessed by a team of senior doctors, according to the major trauma protocol, and casualty officers should receive better training in the assessment of less extensive burns.
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The cases of nine patients who had a complex fracture of the distal part of the femur and a deficient medial-cortical buttress were reviewed. Stable fixation was not achieved with the lateral condylar buttress plate alone. Collapse of the distal fragment into varus angulation was noted intraoperatively, with the axis of rotation being the junction of the distal screws and the plate. Additional stabilization with a medial plate and a bone graft from the iliac crest was applied in all nine patients: in six, at the time of the index operation and in the remaining three, after the open wound and open fracture were considered clean. At an average duration of follow-up of twenty-six months (range, twenty-one to thirty-four months), all of the fractures had healed. Evaluation of the functional outcome revealed five good and four fair results. In three patients, less than 90 degrees of flexion of the knee was present and in six, the arc of flexion was limited to between 90 and 100 degrees. Additionally, four patients had an extensor lag of 5 degrees.
The accuracy of delivered dose is a primary goal in every radiation therapy department. Improved imaging techniques now enable the radiation therapist to define more precisely the area of interest, which helps the sparing of normal surrounding tissue. Tray-mounted customized blocks are routinely used to define this treatment portal accurately and reproducibly. However, the level of accuracy is dependent on the block fabrication technique and the skill of the block cutter. We at Moffitt Cancer Center have standardized our system in a way that minimizes some of the human errors, while keeping the procedure fast and accurate. This system uses a tray template that simulates our blocking trays. The function of this tray is to position the styrofoam (and therefore the cerrobend block) on the tray in such a way as to insure proper alignment with the treatment machine. We also feel this improves upon some common designs using random holes or hole patterns, which may interfere with the treatment area. This system is not overly sophisticated and can be easily implemented in most radiation therapy departments.
We describe a new, versatile bone and soft tissue compound free flap which may be transferred quickly and simply and describe its use in the treatment of compound fracture of the tibia and fibula with non-union due to loss of bone. The iliac crest and overlying soft tissue is transferred to the leg in one stage by microvascular anastomosis of the deep circumflex iliac vessels to vessels in the leg.