Fecal Bacteria Contamination of Floodwaters and a Coastal Waterway From Tidally-Driven Stormwater Network Inundation

Inundation of coastal stormwater networks by tides is widespread due to sea-level rise (SLR). The water quality risks posed by tidal water rising up through stormwater infrastructure (pipes and catch basins), out onto roadways, and back out to receiving water bodies is poorly understood but may be substantial given that stormwater networks are a known source of fecal contamination. In this study, we (a) documented temporal variation in concentrations of Enterococcus spp. (ENT), the fecal indicator bacteria standard for marine waters, in a coastal waterway over a 2-month period and more intensively during two perigean spring tide periods, (b) measured ENT concentrations in roadway floodwaters during tidal floods, and (c) explained variation in ENT concentrations as a function of tidal inundation, antecedent rainfall, and stormwater infrastructure using a pipe network inundation model and robust linear mixed effect models. We find that ENT concentrations in the receiving waterway vary as a function of tidal stage and antecedent rainfall, but also site-specific characteristics of the stormwater network that drains to the waterway. Tidal variables significantly explain measured ENT variance in the waterway, however, runoff drove higher ENT concentrations in the receiving waterway. Samples of floodwaters on roadways during both perigean spring tide events were limited, but all samples exceeded the threshold for safe public use of recreational waters. These results indicate that inundation of stormwater networks by tides could pose public health hazards in receiving water bodies and on roadways, which will likely be exacerbated in the future due to continued SLR.

Skin Clips are Contraindicated when there is Nickel Allergy

Four patients are described who developed generalized dermatitis following surgical wound closure with disposable skin clips. In 3 of them a vesicular palmar eczema was a prominent feature. They were found to have contact allergy to nickel, a component of the clips. If skin clips are to be used to close a surgical wound, it should be established that the patient is not allergic to nickel.

Aspergillosis of the cranial base

Aspergillus is an ubiquitous organism seldom pathogenic in normal hosts. Aspergillus osteomyelitis of the spine occurs rarely in immunocompromised patients as a result of hematogenous spread from distant foci. We present a case of Aspergillus osteomyelitis in the region of the jugular foramen in a previously healthy male with no antecedent event. He presented with dysphagia, hypophonia, and weight loss of several months duration. Diagnosis was delayed due to nonspecific results of various imaging tests. We review the clinical course of fungal osteomyelitis, including appearance on magnetic resonance imaging and computed tomography, culture characteristics, and gross appearance. Current treatment consists of surgical debridement and antifungal medications such as amphotericin B and itraconazole, and the efficacy of these are discussed.

A survey of Eimeria species in commercially-reared chickens in France during 1994

In a survey of chicken coccidia in France during 1994, samples of litter were collected from 41 farms. On 31 of these farms, eimerian oocysts were abundant enough to allow monitoring of their numbers in the litter. Peak total oocyst counts on these farms ranged from 16,200 to 1,254,000/g of litter, but no coccidiosis was observed. The chickens reared without anticoccidial agents in their food (poulets biologiques) produced higher and earlier peak oocyst counts in litter than the chickens given medicated food (poulets labels). The oocysts in litter samples from 22 farms (13 poulet biologique, five poulet label, two standard broiler, one breeder and one layer) of the original 41 were identified. Six of the seven eimerian species known to parasitize chickens were found, using combinations of five methods (oocyst morphology, intestinal lesions, enzyme electrophoresis, growth in embryonating eggs and prepatent time). Multispecific infections predominated (95% of 22 farms), up to six species occurring together. Of farms where oocysts were detected, the percentages with each species were: Eimeria acervulina (100%), E. mitis (82%), E. tenella (77%), E. maxima (73%), E. praecox (45%) and E. brunetti (27%). These appear to be the first definite records of E. mitis and E. praecox for France. Although E. necatrix was not found in this survey, it had recently been detected by other workers in France, so that all seven chicken Eimeria species were known to be contemporaneous.

Program Directors??? Opinions about Surgical Competency in Otolaryngology Residents

OBJECTIVES

The purpose of this study was to determine whether certain surgical procedures could be used as benchmark skills to monitor resident progress in developing surgical competency.

STUDY DESIGN

Survey.

METHODS

A two-stage survey was sent to otolaryngology residency program directors in the United States. Respondents were given a list of otolaryngology surgical procedures monitored by the American Board of Otolaryngology (ABO) and were asked to indicate whether they felt residents should be able to do each as a primary surgeon. The appropriate level of training for competency in each procedure and estimated number of procedures to competency was indicated by respondents.

RESULTS

Respondents selected 16 common procedures they felt residents at different levels of training should be able to perform independently. There were discrepancies between estimated number of procedures needed for competence and the numbers reported by ABO graduates.

CONCLUSIONS

Surgical skill is one aspect of clinical competency, and this indicates agreement among program directors with regard to a set of benchmark skills we can use for concentrated evaluation efforts.

Incidence of reflux in young children undergoing adenoidectomy

OBJECTIVE

To compare the incidence of gastroesophageal reflux disease (GERD) in children under 2 years of age who have symptomatic adenoid hypertrophy requiring surgical removal or who have otitis media with effusion requiring ventilation tube insertion without adenoidectomy.

STUDY DESIGN

Retrospective chart review.

SETTING

An academic pediatric otolaryngology unit.

PATIENTS

All children under age 2 undergoing adenoidectomy (Ad group) between January 1998 and May 2000 were compared with children in the same age range having ventilation tube insertion without adenoidectomy (VT group).

MAIN OUTCOME MEASURES

Whether a diagnosis of GERD was made, how it was made, GERD treatment, and resolution of symptoms were compared.

RESULTS

There were 95 children in the Ad group and 99 in the VT group. GERD incidence was significantly higher in the Ad group where it was 42% versus 7% in the VT group (P < .001). In the Ad group, 88% of children age 1 or less had GERD, and 32% of those older than 1 had GERD diagnosed. In the VT group, 14% of patients age 1 or less and 2% of those older than 1 had a diagnosis of GERD.

CONCLUSIONS

Children under age 2 with symptomatic adenoid enlargement requiring adenoidectomy have a significantly higher incidence of GERD than children in the same age group presenting with otitis media requiring ventilation tube insertion.

Complications in pediatric tracheostomies

OBJECTIVE

To examine complications of pediatric tracheostomy.

STUDY DESIGN

Retrospective.

METHODS

Chart review of children undergoing tracheotomy or laryngeal diversion between 1990 and 1999.

RESULTS

Charts of 142 children were examined. Average age was 2.64 years (standard deviation [SD], 4.73 y) at surgery. Duration of tracheostomy was 2.08 years (SD, 1.72 y) for those decannulated, 3.12 years (SD, 2.5 y) for those still with a stoma, and length of follow-up for the whole group was 4.14 years (SD, 8.69 y). At last follow-up, 56% had a tracheostomy, 29% had none, and 15% had died; one death was tracheostomy-related. Three percent had intraoperative complications, 11% had complications before the first tracheostomy tube change, and 63% had complications after the first tube change. Thirty-four percent had a trial of decannulation; 85% of these were successful. Fifty-four percent of those decannulated had complications. Number of complications was not related to duration of follow-up. In-hospital mortality was congruent to mortality predicted by PRISM (Pediatric Rate of Mortality) scores.

CONCLUSIONS

Forty-three percent had serious complications involving loss of the tracheostomy airway (tube occlusion or accidental decannulation) or requiring a separate surgical procedure. Deaths directly attributable to tracheostomy complications occurred in 0.7%.

Success rates in paediatric tympanoplasty

OBJECTIVE

To determine if the success of paediatric tympanoplasty is dependent on certain criteria, which are determinable prior to surgery.

DESIGN

Retrospective chart review.

SETTING

An academic paediatric otolaryngology department.

PATIENTS

Seventy-seven patients who had undergone tympanoplasty with or without ossicular reconstruction, but without mastoidectomy, between April 1997 and May 1999.

MAIN OUTCOME MEASURES

Status of the repaired tympanic membrane at last follow-up visit measured by otoscopic examination and with tympanometry.

RESULTS

Eighty-nine tympanoplasties were performed during this period. The age range was 2.9 to 22 years. The success rate was 75% overall. For patients younger than 11 years (n = 43), the success rate was 82%, and for those 11 to 18 years (n = 44), it was 74%, which was not significantly different. In 18 patients 7.5 years or younger, the success rate was 79%. Perforation location, size, presence of myringosclerosis, status of the other ear or nose, history of the perforation, surgical approach, middle ear findings, canal packing, and gender were not shown to be significantly different between successful and unsuccessful tympanoplasty groups.

CONCLUSION

These young patients had a good success rate post-tympanoplasty, which we believe reflects less severe disease. These results mitigate against delaying tympanoplasty in young children.

Improving the otolaryngology consultation service in a teaching hospital

OBJECTIVE

To examine the type and quality of consultations requested from the otolaryngology service at a tertiary care hospital.

STUDY DESIGN

Retrospective.

METHOD

Review of written documentation of consultations over a 6-month period.

RESULTS

One hundred eleven requests were received, and 107 written reports were made. Twenty services made requests. Thirty-two percent of requests had a legible requester or contact listed. Sixty-seven percent of requests stated why the patient was in hospital, and 85% stated the otolaryngological complaint. Thirty-two percent of requests made accurate reference to the otolaryngological history, and 6% recorded an ENT examination that was accurate. Seven percent of patients were intubated, and 16% had a tracheostomy prior to evaluation. Forty-eight percent of patients required flexible nasopharyngolaryngoscopy. Sixteen percent of patients required rhinoscopy, and 16% required tracheotomy. Twelve percent of patients needed audiograms, and small numbers of patients required biopsy, debridement of ears, ventilation tube insertion, nasal packing, or radiological studies. Reports were made by senior residents, and evidence that the case was discussed with or seen by an attending surgeon was present in 43% of reports. A diagnosis was stated in 85% of reports, and in 3% the diagnosis appeared to be inaccurate as compared with the history and physical examination recorded. A follow-up plan was stated in 70% of reports.

CONCLUSIONS

There is a need to educate physicians about collegial communication regarding patients. This information can direct curriculum needed to prepare otolaryngology residents to provide a consultative service in a teaching hospital. This method of determining "true learning needs" can be used in other situations to improve resident training.

Ceruminolytic efficacy in adults versus children

OBJECTIVES

An inexpensive, nontoxic ceruminolytic with reasonable efficacy that can be used by the patient or their caregivers at home could represent significant financial saving for patients and health care systems. The purpose of this study was to compare two simple ceruminolytics for in vitro efficacy.

STUDY DESIGN

Randomized controlled trial.

METHODS

Thirty-six children and 33 adults presenting to a community family practice clinic who had cerumen occluding at least one external auditory canal were randomly assigned to compare use of 10% aqueous sodium bicarbonate and 2.5% aqueous acetic acid as ceruminolytics in occlusive cerumen.

RESULTS

We were unable to demonstrate a difference between in vivo efficacy of these two ceruminolytic solutions, but both solutions were significantly more efficacious in children than adults.

CONCLUSIONS

There is a role for these ceruminolytics in children with occlusive cerumen, but adults would be better treated in another way.

Correlation of findings at direct laryngoscopy and bronchoscopy with gastroesophageal reflux disease in children: a prospective study

OBJECTIVE

To correlate direct laryngoscopic and bronchoscopic findings with the presence of positive test results for gastroesophageal reflux disease (GERD) in children.

DESIGN

Prospective collection of structured data.

SETTING

An academic pediatric otolaryngology department.

PATIENTS

Seventy-seven consecutive patients who underwent direct laryngoscopy and bronchoscopy between June and October 1999.

INTERVENTIONS

During direct laryngoscopy and bronchoscopy, descriptions of 7 laryngeal and 6 cricotracheal findings were recorded on a 3-point scale (i.e., absent, mild, or severe). Medical records were later reviewed to obtain results of the following tests, if they were part of the record: gastric scintiscan, 24-hour pH probe monitoring, upper gastrointestinal tract series, and esophageal biopsy.

MAIN OUTCOME MEASURES

Correlation of mucosal abnormalities with the presence or absence of a positive test result for GERD.

RESULTS

Fifty (65%) of 77 patients had GERD diagnosed with at least 1 positive test result, 21 (27%) had no clinical symptoms and no positive GERD test results, and 5 (7%) had clinical symptoms but no positive test results. There were significant differences for total laryngeal and cricotracheal scores (P<.001) between the groups with positive and negative results. Significant differences were as follows: in the larynx-large lingual tonsil (P<.001), postglottic edema (P<.001), arytenoid edema (P<.001), ventricle obliteration (P =.03), and true vocal fold edema (P = .001), and in the cricotracheal region-general edema and erythema (P =.003) and blunting of the carina (P<.001). Severe arytenoid edema, postglottic edema, or enlargement of lingual tonsil were pathognomonic of GERD.

CONCLUSION

Many direct laryngoscopic and bronchoscopic findings correlate well with the diagnosis of GERD as determined by using other tests.

Comparison of postoperative pain: tonsillectomy by blunt dissection or electrocautery dissection

PURPOSE

To compare post-operative pain in children undergoing tonsillectomy by blunt dissection or electrocautery.

METHOD

Thirty-six children between the ages of 5 and 15 years were recruited for the study. Tonsillectomy was done in a standardized fashion with uniform anaesthetic practices. Each child kept a pain diary for 10 days, recording pain twice daily on a Visual Analog Scale and Faces Pain Scale. Doses of analgesics were recorded.

RESULTS

There were no statistically significant differences in the pain scores for the groups, although there was a trend toward more pain in the blunt dissection group. There were more complications in this group, and these children used significantly more doses of acetaminophen. Sources of bias are discussed.

CONCLUSION

These results suggest a trend toward greater postoperative pain in children who have tonsillectomies by blunt dissection techniques.

Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease

OBJECTIVE

To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD).

STUDY DESIGN

Retrospective chart review

METHODS

Operative notes of 155 children undergoing direct laryngoscopy and bronchoscopy between 1996 and 1999 for airway symptoms for whom there was a suspicion of EERD were examined. Gastroesophageal reflux disease (GERD) was considered present if at least one test was positive (including upper GI series, pH probe, gastric scintiscan, or esophageal biopsy).

RESULTS

A total of 130 (84%) patients had GERD diagnosed. Ninety percent had at least one laryngotracheal abnormality: 83% had an abnormal larynx and 66% had an abnormal trachea. Laryngeal abnormalities in GERD included postglottic edema, 69%; arytenoid edema, 30%; large lingual tonsil, 16%; vocal fold edema, 12%; vocal fold nodule, 12%; ventricular obliteration, 5%; and hypopharyngeal cobblestoning, 3%. Tracheobronchial abnormalities in GERD included tracheal cobblestoning, 33%; blunting of carina, 12.5%; subglottic stenosis, 11%; increased secretions, 11%; and generalized edema or erythema, 5%. The best sensitivity or specificity was obtained by combining postglottic edema, arytenoid edema, and vocal fold edema, resulting in a sensitivity of 75% and a specificity of 67%. Positive predictive value was 100% for the combination of postglottic edema and any vocal fold or ventricular abnormality.

CONCLUSION

Laryngoscopy and bronchoscopy can reveal findings with a high positive predictive value for the presence of GERD. Endoscopy of the upper airway in children with clinical signs and symptoms of EERD is a promising tool for diagnosis.

Clinical presentation as a guide to the identification of GERD in children

OBJECTIVE

to determine if there is a correlation between common otolaryngologic symptoms and presence of gastroesophageal reflux disease (GERD) in children.

METHODS

charts of 295 children presenting with suspicion of GERD were reviewed for presenting symptoms including: (1) airway symptoms: stertor, stridor, frequent cough, recurrent croup, wheezing, nasal congestion, obstructive apnea, blue spells, hoarseness, throat clearing; (2) feeding symptoms: wet burps, globus sensation, frequent emesis, dysphagia, choking/gagging, sore throat, halitosis, food refusal, stomach aches, arching, drooling, chest pain, irritability, and failure to thrive. At least one positive test of barium esophagram, gastric scintiscan, pH probe or esophageal biopsy resulted in inclusion in the GERD positive group.

RESULTS

214 children had GERD diagnosed while 81 had no positive tests for GERD. Between the GERD positive and GERD negative groups, the significantly different symptoms were stertor (P=0.040), cyanotic spells (P=0.043), frequent emesis (P=0.007), failure to thrive (P=0.006), and choking/gagging (P=0.044). Three pooled variables were created: airway flow (stertor, stridor, cyanotic spells), airway irritation (frequent cough, recurrent croup, throat clearing), and feeding (dysphagia, failure to thrive, frequent emesis). GERD patients who were 2 years or less were compared to those older than 2 years and all three of these pooled variables were significantly different between these groups (P<0. 001).

CONCLUSION

children who present with a certain constellation of airway or feeding symptoms are more likely to have a positive GERD test. Children 2 years old or less are more likely to present with airway symptoms or feeding difficulties while children older than 2 years are more likely to present with airway irritation.

Assessment and management of idiopathic facial (Bell's) palsy: comparison of Nova Scotia family physicians and otolaryngologists

Acute idiopathic facial paralysis, or Bell's palsy, is frequently encountered in clinical practice. The present study compares knowledge of Bell's palsy assessment and management between a group of family physicians and otolaryngologists practising in Nova Scotia. Respondents completed a questionnaire and statistical analyses were performed on selected data. There were similarities regarding Bell's palsy assessment and management, but there were notable differences in the ability to distinguish Bell's palsy on the basis of symptomatic complaints, specific counselling strategies, length of patient follow-up, and use of appropriate diagnostic tests. This needs assessment suggests several areas where a family physician continuing medical education program on management of acute facial paralysis may be beneficial.

Communication after laryngectomy: an assessment of quality of life

The purpose of this study was to examine quality of life in laryngectomees using different methods of communication. A survey was mailed to all the living laryngectomees in Nova Scotia. Patients were asked to rate their ability to communicate in a number of common situations, to rate their difficulty with several communication problems, and to complete the EORTC QLQ-C30 quality-of-life assessment tool. Sixty-two patients responded (return rate of 84%); 57% were using electrolaryngeal speech, 19% esophageal speech, and 8.5% tracheoesophageal speech. These groups were comparable with respect to age, sex, first language, education level, and years since laryngectomy. There were very few differences between these groups in ability to communicate in social situations and no difference in overall quality of life as measured by these scales. The most commonly cited problem was difficulty being heard in a noisy environment. Despite the fact that tracheoesophageal speech is objectively most intelligible, there does not seem to be a measurable improvement in quality of life or ability to communicate in everyday situations over electrolaryngeal or esophageal speakers.

Severe non-obstructive sleep disturbance as an initial presentation of gastroesophageal reflux disease

A 2.5-year-old child presented with a sleep disturbance initially diagnosed as a behavioral problem. The child had several atypical symptoms of gastroesophageal reflux disease (GERD). The sleep disturbance resolved quickly after treatment of GERD. GERD is a disease with protean manifestations which is becoming of greater interest to the pediatric otolaryngologist. We discuss diagnosis of this entity.

Effect of steroids on posttonsillectomy pain in adults

OBJECTIVE

To determine whether a single intraoperative dose of intravenous dexamethasone has an effect on pain after tonsillectomy.

DESIGN

Double-blinded randomized controlled clinical trial.

SUBJECTS

Thirty-four consecutive nonpediatric patients presenting for tonsillectomy.

INTERVENTION

Patients scheduled for electrocautery tonsillectomy were randomized to receive either intravenous dexamethasone or placebo during surgery. Pain was measured twice daily for 10 days by means of a visual analog scale.

RESULTS

There were no statistically significant differences between the groups, but the dexamethasone group had a trend to report less pain over the first several days. The dexamethasone group received less analgesic in the recovery room, but there were no differences between the groups in the 10 days afterward.

CONCLUSIONS

There is evidence that a single dose of dexamethasone reduces pain after tonsillectomy to a small degree. A single dose was not associated with adverse effects, so the risk-benefit ratio may be favorable for this practice.

Comparison of computer-assisted instruction and seminar instruction to acquire psychomotor and cognitive knowledge of epistaxis management

Epistaxis is a common problem faced by primary care physicians. Typically, first-hand experience with this problem is not obtained in medical school. A computer learning module was developed to address practical management of epistaxis. It was evaluated by use of third-year clerks and compared with an interactive seminar based on the same material. Fifty-eight students doing their required otolaryngology rotations were randomly separated into 3 groups: (1) doing a preinstruction test, (2) using the computer module, and (3) participating in a small-group seminar. All participants were tested with a short written test and a practical test that involved performing anterior nasal pack placement in a model patient. Percentage scores for the 2 groups were compared by use of t tests, and there was no significant difference between the written, practical, or combined scores at a level where P = 0.05. This study shows that basic patient management and a simple procedure can be taught as effectively with a computer module as with a small-group interactive seminar.

Needs assessment for an undergraduate otolaryngology curriculum

A needs assessment was conducted to determine what family doctors need to know about otolaryngology. A survey was mailed to a group of community otolaryngologists and family doctors. They were asked to rate the importance of 46 otolaryngologic topics. A true needs assessment was carried out with a small group of family practice residents to examine which needs were perceived to be significantly different in importance between these 2 survey groups. A list of important topics was generated from the survey. There were many statistically significant differences between the survey groups, but only 2, vertigo and epistaxis, appeared to be potentially important. The family practice residents (n = 8) were asked to complete a short-answer test about epistaxis management and then to demonstrate placement of an anterior nasal pack. Despite having already faced this problem in 50% of cases, the residents had average scores of less than 30%, indicating a lack of knowledge in this area.

Disturbances of loudness perception

This article reviews information on some auditory disorders that have in common a disturbance in loudness perception. The perceptual disturbances in these disorders have interchangeably been labeled "hyperacusis," "dysacusis," or "phonophobia." Our question concerns whether the loudness disturbances associated with these auditory disorders are sufficiently different as not to justify the equivalence implied by the labelling. Emphasis is placed on those articles that have given clear accounts of the phenomenology of the disturbed perceptual experience and have offered testable hypotheses about the mechanisms underlying it. Hypotheses about the origins of disturbed loudness perception are compared with independent experimental and clinical evidence on those mechanisms. The disturbances of loudness perception that occur in cochlear hearing loss, facial nerve paralysis and stapedectomy, and in more "central" disorders are phenomenologically different, have different underlying mechanisms, and merit different labels that most of them do not currently receive.

Nodular fasciitis in the parotid region of a child

BACKGROUND

Nodular fasciitis is a common pathologic entity in the limbs of adults but rare in the head and neck of children. It is defined by the World Health Organization as a benign and probably reactive fibroblastic growth extending as a solitary nodule from superficial fascia into subcutaneous tissue. Treatment is local excision, and recurrence is rare.

METHOD

Case Report

RESULTS

A 3.5-year-old boy was initially seen with a 1-year history of gradually enlarging but otherwise asymptomatic right facial mass. On examination, a firm nodule was palpable anterior to the right ear, and facial movement was symmetrical. Computed tomography showed a rounded, well-defined solid mass continuous with the parotid fascia. The patient underwent superficial parotidectomy without complication. The pathology was reported as nodular fasciitis, and the child has had no clinical recurrence over 2 years.

CONCLUSION

Benign lesions in this region in children may present similarly to malignancies but require much more-conservative treatment.

Ichthyosiform erythroderma associated with generalized pustulosis

Two unrelated boys are described who were born as collodion babies and subsequently developed non-bullous ichthyosiform erythroderma and flares of generalized sterile pustulosis, similar to generalized pustular psoriasis. Both patients had a good response to treatment with oral retinoids.

Congenital teratomas of the head and neck

OBJECTIVE

This article reviews teratomas, neoplasms composed of the three germinal layers of the embryo that form tissues foreign to the part in which they arise. These are most common in the sacrococcygeal region and are rare in the head and neck. In this region, major concerns are airway obstruction and cosmesis.

METHOD

Pathology records at two tertiary care paediatric hospitals were reviewed for diagnoses of head and neck teratomas. This revealed nine cases between 1983 and 1993, five males and four females. Two males were stillborn. Five were cervical, two were in the nasopharynx, and two were facial. The lesions were immature in two cases and mature in the remainder. All of the liveborn children underwent surgery within the first year of life, and only one required tracheotomy.

RESULTS

One child had recurrence of teratomatous tissue diagnosed with CT, which was treated surgically. The child has remained free of tumour for over 3 years. Pathogenesis, clinical appearance, diagnostic work-up, and currently accepted modes of therapy are reviewed.

Tonsillectomy: indications for referral by family physicians versus indications for surgery by otolaryngologists

OBJECTIVE

The purpose of this study was to compare reasons for family physician (FP) referral of children for tonsillectomy to the indications for this surgery used by otolaryngologists practising in the same region.

METHOD

A checklist-type survey was sent to a random sample of 300 FPs and all of the practising otolaryngologists in Nova Scotia in the spring of 1995.

RESULTS

There were significant differences between reasons for referral and indications for treatment in many areas, the most important of which was that over 60% of FPs referred cases because of parental insistence, while no surgeons operated for this reason. If inappropriate referrals are taken to be those for which no specialist intervention occurs, it appears that there is a significant number of referrals.

CONCLUSION

These results suggest that both FPs and parents require information about these common paediatric problems.

Detection of silent intervals between noises activating different perceptual channels: some properties of "central" auditory gap detection

This article describes four experiments on gap detection by normal listeners, with the general goal being to examine the consequences of using noises in different perceptual channels to delimit a silent temporal gap to be detected. In experiment 1, subjects were presented with pairs of narrow-band noise sequences. The leading element in each pair had a center frequency of 2 kHz and the trailing element's center frequency was parametrically varied. Gap detection thresholds became increasingly poor, sometimes by up to an order of magnitude, as the spectral disparity was increased between the noise bursts that marked the gap. These data suggested that gap-detection performance is impoverished when the underlying perceptual timing operation requires a comparison of activity in different perceptual channels rather than a discontinuity detection within a given channel. In experiment 2, we assessed the effect of leading-element duration in within-channel and between-channel gap detection tasks. Gap detection thresholds rose when the duration of the leading element was less than about 30 ms, but only in the between-channel case. In experiment 3, the gap-detection stimulus was redesigned so that we could probe the perceptual mechanisms that might be involved in stop consonant discrimination. The leading element was a wideband noise burst, and the trailing element was a 300-ms bandpassed noise centered on 1.0 kHz. The independent variable was the duration of the leading element, and the dependent variable was the smallest detectable gap between the elements. When the leading element was short in duration (5-10 ms), gap thresholds were close to 30 ms, which is close to the voice onset time that parses some voiced from unvoiced stop consonants. In experiment 4, the generality of the leading-element duration effect in between-channel gap detection was examined. Spectrally identical noises defining the leading and trailing edges of the gap were presented to the same or to different ears. There was a leading-element duration effect only for the between channel case. The mean gap threshold was again close to 30 ms for short leading-element durations. Taken together, the data suggest that gap detection requiring a temporal correlation of activity in different perceptual channels is a fundamentally different task to the discontinuity detection used to execute gap detection performance in the traditional, within-channel paradigm.

Cranial nerve defects in congenital facial palsy

METHODS

Cranial nerve defects were enumerated in 29 children with congenital facial palsy presenting for reanimation via chart review with a view to determining unaffected donor nerves. The literature was searched via Medline to reveal 186 additional case reports that were complete enough in their description to allow assessment of cranial nerve defects.

RESULTS

The group presenting for reanimation comprised 24 females and 5 males. All of the males had unilateral isolated facial nerve paralysis. Of the females, 9 had isolated unilateral palsy and 14 had bilateral palsy, and half of these were isolated. Six had bilateral abducens nerve palsy, fulfilling the original definition of Möbius syndrome. Of these, 3 had a right-sided hypoglossal weakness, one had a bilateral oculomotor palsy, and one had a bilateral trochlear palsy. One girl had bilateral facial and auditory involvement. The literature review revealed a group that was 60% male, with 85% having bilateral facial palsy. Abducens palsy was present in 68%, glossopharyngeal in 28%, hypoglossal in 26%, and oculomotor in 20%. The group was very heterogeneous in many ways.

CONCLUSIONS

There are many theories of pathogenesis of this syndrome. Isolated facial palsy is in concordance with previous findings of nerve lesions within the temporal bone. Multiple cranial nerve defects are more likely to have brainstem lesions, related to prenatal ischemic events. The cranial nerve least likely to be involved was the accessory nerve, suggesting that this may be a reliable donor for reanimation procedures.

Treatment and prevention of porcine proliferative enteropathy with oral tiamulin

The effect of an oral treatment or prevention programme, incorporating the antibiotic tiamulin, on the development of proliferative enteropathy in experimentally challenged pigs was studied. Twenty weaner pigs were challenged orally with a virulent inoculum of Lawsonia intracellularis strain LR189/5/83, a British isolate of the causative agent of porcine proliferative enteropathy, and seven control pigs were dosed with a buffer solution. Seven of the 20 challenged pigs were left untreated; they gained less weight than the controls and three of them developed mild to moderate diarrhoea two weeks after the challenge. All seven developed lesions, six visible grossly, of proliferative enteropathy, and numerous intracellular L intracellularis were detected in sections of the intestines examined three weeks after the challenge. To test a 'prevention' dosing strategy for tiamulin, six of the challenged pigs were dosed orally with 50 ppm tiamulin, incorporated in a 2 per cent stabilised premix, given from two days before the challenge until they were euthanased. To test a 'treatment' strategy, the remaining group of seven challenged pigs were dosed orally with 150 ppm tiamulin given in the premix from seven days after challenge until they were euthanased. All the control pigs and the 13 pigs treated with tiamulin, either before or after challenge, remained clinically normal and had no specific lesions of proliferative enteropathy in sections of the intestines examined post mortem.

Extremity gangrene in utero

A neonate with extremity gangrene resulting from intrauterine embolization of infarcted placental substances is discussed. This rare clinical entity is thought to be most commonly a manifestation of embolic phenomenon during maturation of the neonatal circulatory system. Management of neonatal gangrene is conservative, delaying amputation as long as possible since the line of demarcation tends to migrate distally. Evidence of multiple emboli should be carefully sought prior to definitive treatment.

Delayed rupture of the spleen and streptokinase therapy

Delayed rupture of the spleen is a rare but serious complication of blunt abdominal trauma. A 47-year-old woman with a history of fractured pelvis from a motor vehicle accident 6 months earlier presented with evidence of a myocardial infarction. Subsequent streptokinase administration was complicated by splenic rupture, which was managed by evacuation of the clotted blood and splenectomy. The patient made a complete recovery. The risk of splenic rupture and bleeding complications resulting from thrombolytic therapy for myocardial infarction is discussed, as are the controversy over whether delayed splenic rupture is a true diagnosis, the mechanism of rupture and the clues to impending rupture.

Blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome, an uncommon condition, is manifested by gastrointestinal and skin hemangiomas and gastrointestinal hemorrhage causing anemia. The authors report a unique case of the syndrome in association with a congenital cardiac malformation. A 26-year-old woman presented with iron-deficiency anemia after the birth of her first child. She had a history of skin and gastrointestinal hemangiomas and tetralogy of Fallot. Endoscopy revealed multiple new intestinal hemangiomas, which were removed through enterotomies with resolution of the anemia. Iron therapy was prescribed, and her condition was stable at follow-up 5 years later.

Human bites to the hand

Human bites to the hand or penetrating injuries contaminated with saliva can be a source of aggressive infection and debilitating injury. These types of injuries may also be a mode for the transmission of disease, notably hepatitis B. Dental personnel have an increased risk of experiencing bite injuries and should understand the general principles of appropriate management. Staphylococcal or streptococcal species are often associated with infected bite injuries, and amoxicillin and clavulanate are currently advised for prophylaxis. Wound cleansing and careful monitoring, combined with appropriate prophylaxis, are the mainstays of treatment.

The behaviour of monoclonal antibodies in the First International Pig CD Workshop reacting with gamma delta/Null T lymphocytes in the blood of SLAb/b line pigs

Further studies were carried out on the monoclonal antibodies (mAbs) from the First International Swine CD Workshop which react with gamma delta Null T-lymphocytes, defined by the binding of mAb w020/141 (MAC320) as Swine Workshop Cluster number SWC6. Studies were also carried out on several other mAbs from the same workshop which identify other CD antigens, but whose binding is not restricted exclusively to gamma delta Null T-lymphocytes. The first group consists of 11 mAbs (w021, w022, w059-w065, w105 and w117) and the second group of 18 mAbs (w008, w026, w056, w067-w071, w080, w091-w094, w110, w111, w118, w119 and w121). All mAbs were characterised by binding to peripheral blood lymphocytes (PBL) from normal, sham-thymectomized (STx) and thymectomized (Tx) pigs of the Babraham SLAb/b line and by their overlap, using two-colour immunofluorescence with biotinylated mAb MAC320 (w020/141), which identifies all gamma delta Null cell T-lymphocytes and the Null cell subpopulation identified by MAC319 (w021). The Null cell-specific mAbs were also used in inhibition studies of MAC319 and MAC320 binding and by staining PBL with pairs of mAbs together with either MAC319 or MAC320. Based on these data we suggest a putative relationship of the Null cell subsets defined by these mAbs with each other.

The foot in ballet dancers: the importance of second toe length

Ballet dancers are prone to foot injuries. Our hypothesis was that the length of the second toe in relation to the big toe affected the distribution of stresses on the foot, correlating with calluses, injuries, and pain. Fifty-nine ballet dancers were examined for second toe length with respect to great toe, calluses, and metatarsophalangeal inflammation. Daily foot pain, limitation of work hours because of this, injuries, age, sex, and rank in the company were considered. The dancers' feet had an incidence of shorter, equal, or longer second toes which was comparable to a non-ballet-dancing cohort (N = 60). In female dancers (N = 34), total callus counts and pain scores were significantly lower in the group with shorter second toes versus those with equal or longer second toes. Counts were unrelated to age or rank. Longer second toes were related to hallux rigidus. Limitation of practice hours, ankle sprains, and foot/ankle fractures and sprains were comparable across the groups. The male dancers (N = 25) had significantly fewer calluses than did the women, but had equal pain scores and number of injuries. There were no significant differences among the males in total callus counts, pain scores, limitation of practice hours, or injuries between groups based on toe length, age, or rank. We conclude that there is no significantly more ideal pattern of toe lengths for male ballet dancers, but females with shorter second toes have fewer calluses and less daily foot pain. Those with a longer second toe had a higher incidence of hallux rigidus and correspondingly increased pain scores.

Gracilis donor site morbidity

Donor site morbidity in 104 cases of gracilis free tissue transfer was examined through a retrospective chart review and mail survey. Fifty-one females and 53 males with an average age of 23 years comprised the study group. Forty-three were under age 18. In-hospital donor site complications occurred in 10 patients. There was excessive pain in 4, wound infections in 3, hemorrhage in 2, and temporary nerve palsy in 1. Early complications were more common in the pediatric group. Sixty-two surveys were returned from patients detailing late complications where they graded parameters between 0 and 10 where 0 was "none" and 10 was "worst imaginable." The highest average score was 5.12 reported for noticeability of the scar. There was a significant difference between adults and children for sensitivity, tightness, notice-ability, and ugliness of the scar. More than half the respondents had no complaints about their donor site scar. Fifteen percent of patients reported temporary reduction of leg strength with a men duration of 6 months.

Sporotrichosis of the hand: an urban experience

Sporotrichosis is uncommon in Canadian urban centers. Lymphocutaneous and fixed cutaneous are the most common cutaneous forms of the disease, typically seen in the upper extremity in adult patients. History usually reveals a puncture injury contaminated with soil. Lesions are refractory to commonly used antibiotics. Cultures of biopsy specimens reliably grow the fungus Sporothrix schenkii. First line treatment is oral potassium iodide. We have reviewed a series of 7 cases from various Toronto teaching hospitals and compared them to the world literature.

Analyses of monoclonal antibodies reactive with porcine CD44 and CD45

Twenty-six monoclonal antibodies (mAbs), assigned to the CD44/CD45 section of the First International Swine CD Workshop, were compared for their reactivity against a selected group of target cells by one- and two-color flow cytometric analysis. Based on staining and reactivity patterns the 26 mAbs were assigned to six groups, group F1 mAbs were designated CD44 mAbs; and groups F2 and F3 as CD45 mAbs. With the information available, a CD designation could not be given to the mAbs in groups F4, F5 or F6 consisting of four, three and four mAbs each, respectively. The reactivity of all six mAbs in group F1 (MAC35, 25-32, PORC24A, H22A, BAG40A, and BAT31A) was blocked by soluble porcine CD44. One mAb in this group (MAC325) reacted with a cell surface protein with a molecular weight of 80 kDa and was designated as CD44; the other five mAbs were designated as wCD44 because no molecular weight was known. Blocking experiments utilizing a cross reactive anti-human CD44 (mAb Z062) allowed the definition of the wCD44a epitope recognized by mAbs PORC24A and H22A. The group F2 mAbs (74-9-3; MAC323; K252.1E4; and 2A5) were designated as CD45 based on their broad reactivity pattern with lymphoid and myeloid cells and their ability to immunoprecipitate three polypeptides with an apparent molecular weight of 226, 210 and 190 kDa. The F3 mAbs (MAC327; MAC326; 3a56 and -a2) were designated as CD45R based on their restricted reactivity against lymphoid and myeloid target cells, and their ability to immunoprecipitate either two polypeptides with an apparent molecular weight of 226 and 210 kDa (mAbs MAC327 and MAC326) or a single polypeptide with an apparent molecular weight of 210 kDa (mAbs-a2 and 3a56). Sequential immunoprecipitation analyses confirmed the relatedness of the F2 and F3 group mAbs. The work conducted for this first workshop led to the definition of six mAbs specific for CD44, four mAbs specific for CD45, and four mAbs specific for CD45R which should prove to be very valuable reagents for the study of the porcine immune system.

Monoclonal antibodies recognising differentiation antigens on porcine B cells

Nineteen monoclonal antibodies (mAbs) submitted to the porcine CD Workshop were analysed on porcine B cells from different lymphoid tissues by flow cytometry and immunohistochemistry. Six mAbs only bound to pig B cells and three of these were assigned cluster numbers, 76-7-4 (No. 001):CD1, K231-3B2 (No. 027):CD25 and CC51 (No. 100):CD21. Of the three remaining B cell positive mAbs, one was assigned to a swine cluster, CC55 (No. 101):SWC7, a second, LIG4 (No. 123), recognised cell surface IgM and the third, MUC106A (No. 072), remained unassigned.

Summary of first round cluster analysis: complete antibody panel

The reactivities of 141 monoclonal antibodies (mAbs) with 60 target cell types or lines were analysed by flow cytometry and the data subjected to statistical clustering. mAbs were assigned to 23 clusters by statistical similarity and information on specificity supplied by the contributor. Clustered mAbs were examined in more detail in the second round of workshop analyses.

Report on the behaviour of monoclonal antibodies in the First International Pig CD Workshop identifying the Null cell families

Clustering analyses were carried out on data from five independent laboratories testing 22 monoclonal antibodies (mAbs) reacting with CD2-sIg-lymphocytes on 14 pig blood and/or tissue lymphoid target cells using cytofluorometry. This was coupled with extensive further studies on blood lymphocytes from normal and thymectomised SLAb/b inbred pigs. These mAbs formed two groups: those mainly identifying the large blood-borne thymus-dependent Null T cells (N) and those reacting with tissue and a small number of blood-borne thymus-independent lymphocytes (N'). Based on their tissue cell reaction patterns, the 10 N' mAbs formed three main groups: N'1A and B; N'2A and B; and N'3. The 12N mAbs fell into four groups N4-N7; N6 was divided into subgroups A-D. One N' (032) and two N mAbs (010 and 063) were unclustered. Based on these data, swine workshop cluster numbers were designated to groups N5 (021, 022 and 059) as SWC4, N6 (061 and 117) as SWC5 and N7 (020 and 141) as SWC6, the latter exceptionally as a single antibody, MAC320, since it is the 'type' mAb identifying effectively all blood Null T lymphocytes. Future research and workshops will have to define with a wider range of techniques the relationships, molecular properties and functional roles of the several new, perhaps novel, antigens identified by this family of fascinating, as yet still poorly defined, mAbs.

Osteoarthritis of the thumb: clinical aspects and management

The wide range of motion of the thumb derives from the unusual nature of its carpometacarpal joint. Osteoarthritis is common in this joint. Patients may present with variable degrees of pain, reduction of thumb mobility, and joint deformity. Management is based on clinical assessment. Early disease is treated with rest, anti-inflammatory agents or analgesics, intraarticular steroid injections and splints. Since the course of osteoarthritis is often benign, avoiding early invasive treatment is important, except in the presence of proven anatomic deformity.

Extremity arteriovenous malformations: review of a series

OBJECTIVE

To examine the diagnosis and treatment of arteriovenous malformations in adults, because of the tendency of the condition to recur.

DESIGN

Chart and literature review.

SETTING

Three tertiary-care hospitals.

PATIENTS

Twelve adults with diffuse arteriovenous malformations of the extremities.

INTERVENTIONS

Surgery of embolotherapy.

MAIN OUTCOME MEASURE

Recurrence.

RESULTS

Of the 12 cases reviewed, the arteriovenous malformations recurred in 8 patients; 2 of these were well, 6 months and 2 years after a second or third treatment. Two others were well, 2 months and 5 years after surgery or embolotherapy. One pregnant woman, whose case is described in detail, received no treatment, and her arteriovenous malformation diminished in size after her child was born. The outcome in the last patient is unknown.

CONCLUSION

Diffuse arteriovenous malformations recur after ablative treatment.

Facial fractures

Emergency room physicians frequently see facial fractures that can have serious consequences for patients if mismanaged. This article reviews the signs, symptoms, imaging techniques, and general modes of treatment of common facial fractures. It focuses on fractures of the mandible, zygomaticomaxillary region, orbital floor, and nose.

Expression on porcine gamma delta lymphocytes of a phylogenetically conserved surface antigen previously restricted in expression to ruminant gamma delta T lymphocytes

A 180,000 MW molecule has been identified on porcine leucocytes that is the homologue of the 215,000/300,000 MW WC1 (T19) leucocyte antigen previously considered to be restricted to ruminants. In ruminants the WC1 molecule is expressed by a T-cell subpopulation that is CD2-CD4-CD8-CD5+ and that is gamma delta T-cell receptor positive (TcR+). In pigs, the 180,000 MW molecule, identified by a new monoclonal antibody CC101, is expressed by a gamma delta TcR+ T-cell subpopulation that is also CD2-CD4-CD8-. The p180+ cells are a major T-cell subpopulation comprising approximately 40% of the peripheral blood mononuclear cells from 6-9-month-old pigs. Expression of p180 identifies the majority of the CD2-CD4-CD8- T cells in porcine blood. The p180+ T cells have a distribution in lymphoid tissues that is distinct from that of T cells that express the CD2, CD4 or CD8 molecules. They are evident particularly in the thymic medulla, the epithelium, lamina propria and interfollicular areas of the small intestine, and the superficial dermis of the skin, but largely absent from conventional T-dependent areas of secondary lymphoid tissue.