Life-threatening bite injury of the lower lip after use of metamizole

INTRODUCTION

Bite wounds of the oral mucosa heal after eliminating the causative irritant, but there are serious exceptions from the rule. We present the case of a 37-year-old woman with an ulcer of the mucosa of the lower lip, which had been present for 10 days, and leucopenia.

DISCUSSION

Agranulocytosis after the use of metamizole is part from leukaemia and lues, a rare reason for non-healing ulcers of the mucosa of the oral cavity without fulminant signs for inflammation.

CONCLUSION

As this is a life-threatening disease, medical therapy must begin immediately.

Antibacterial essential oils in malodorous cancer patients: clinical observations in 30 patients

Malodorous necrotic ulcers in cancer patients are of major concern as it leads to social isolation and poor quality of life. Current medications and topical therapies have proven inadequate in their ability to reduce foul smell to acceptable levels. We report the positive experience we have had in using antibacterial essential oils in patients with incurable head and neck cancer and associated malodorous necrotic ulcers. All patients received a standard course of therapy with oral or systemic antibiosis. In addition, we rinsed the ulcers with an antibacterial essential oil mix (mainly based on Eucalyptus oil) twice a day. All patients experienced complete resolution of the foul smell by only the third or fourth day of therapy. As a secondary effect we saw that besides smell reduction the oils had anti-inflammatory effects on neoplastic ulcers. In some patients ulcers started to heal and achieved complete re-epithiliazation. The patients experienced great personal relief upon resolution of their malodorous conditions. Quality of life improved significantly with the resulting reintroduction of social contact with friends and relatives.

Innate immunity in human bone

Bone has exceptional regenerative properties. Oral bone appears to be particularly resistant to infection despite exposure to oral flora, even in circumstances such as oral surgery where the thin mucosal layer covering the bone is disrupted. The goal of this study was to determine whether the innate immune system of antimicrobial peptides exists inside bone. Biopsies of non-infected and chronically infected mandibular bone were harvested from patients during maxillofacial surgical procedures. Bone biopsies from the iliac crest and fibula served as controls. Immunohistochemical staining was performed, directed against the human beta-defensin antimicrobial peptides (hBD) -1, -2 and -3. In addition, cultures of osteoblast-like cells were examined for the presence of each of the three beta-defensins and their mRNA transcripts. All three human beta-defensins were detected within the mineralized bone matrix of chronically infected mandibular bone in the vicinity of the endosteum and osteocytes. hBD-1, -2 and -3 were also found in the cytoplasm of osteocytes. Expression of all three beta-defensins was detected in each of the non-infected bone types including the controls, however, to a lesser degree than that found in the chronically infected mandibular bone. This may reflect upregulation of antimicrobial peptide expression in the presence of chronic infection. Cultures of non-infected osteoblast-like cells were found to express mRNA for each of hBD-1, -2 and -3. Immunohistochemical staining of the cultures was positive for hBD-1 and -2, but not for hBD-3. We provide the first evidence of a previously unrecognized innate immunological function of bone through the demonstration of the presence of the human beta-defensins hBD-1, -2 and -3 in bone.

Intraoral lesions associated with sebaceous nevus syndrome

The sebaceous nevus syndrome describes the rare association of a sebaceous nevus with systemic features such as mental retardation, seizures and colobomas (among others). It is thought to be a cutaneous mosaic inherited as a paradominant trait. Three cases are provided illustrating the intraoral manifestations of the syndrome. The first histological comparison of contiguous mucosal and cutaneous lesions is provided. We also describe the possible association of SFM syndrome with a benign fibrous histiocytic lesion of the mandible. This and other mandibular tumors associated with the sebaceous nevus syndrome may have significant implications for patients. Awareness of the potential presence or development of significant intraoral lesions in association with the sebaceous nevus syndrome is important for those involved in the care of patients with this syndrome.

Growth and transplantation of a custom vascularised bone graft in a man

BACKGROUND

A major goal of research in bone transplantation is the ability to avoid creation of secondary bone defects. We aimed to repair an extended mandibular discontinuity defect by growth of a custom bone transplant inside the latissimus dorsi muscle of an adult male patient.

METHODS

Three-dimensional computed tomography (CT) scanning and computer-aided design techniques were used to produce an ideal virtual replacement for the mandibular defect. These data were used to create a titanium mesh cage that was filled with bone mineral blocks and infiltrated with 7 mg recombinant human bone morphogenetic protein 7 and 20 mL of the patient's bone marrow. Thus prepared, the transplant was implanted into the latissimus dorsi muscle and 7 weeks later transplanted as a free bone-muscle flap to repair the mandibular defect.

FINDINGS

In-vivo skeletal scintigraphy showed bone remodelling and mineralisation inside the mandibular transplant both before and after transplantation. CT provided radiological evidence of new bone formation. Postoperatively, the patient had an improved degree of mastication and was satisfied with the aesthetic outcome of the procedure.

INTERPRETATION

Heterotopic bone induction to form a mandibular replacement inside the latissimus dorsi muscle in a human being is possible. This technique allows for a lower operative burden compared with conventional techniques by avoiding creation of a secondary bone defect. It also provides a good three-dimensional outcome.

Successful use of an inhalational phytochemical to treat pulmonary tuberculosis: a case report

Multi-drug resistant strains of tuberculosis pose a serious threat in many third- and first-world countries. The aim of this case report is to describe a potential new method for treating those with primary pulmonary tuberculosis using phytochemicals via inhalation. We report the first case of using inhaled phytochemicals in treating primary pulmonary tuberculosis. A 28-year-old female presented with symptoms suggestive of primary pulmonary tuberculosis, and she was found to be positive via chest X-ray and sputum culture. She subsequently underwent treatment with conventional DOTS treatment. Ten days post-inhalation of the phytochemical, the patient is tuberculosis negative (via sputum culture), with no clinical symptoms. This may be a potential new method and type of treatment for pulmonary tuberculosis.

The sebaceous nevus as part of the Schimmelpenning-Feuerstein-Mims Syndrome--an obvious phacomatosis first documented in 1927

The sebaceous nevus is a common nevus and can be easily diagnosed because of its typical rough fatty surface due to its amount of sebaceous glands. In some rare cases, the sebaceous nevus is part of a genetic disorder, the Schimmelpenning-Feuerstein-Mims (SFM) syndrome. If the SFM syndrome is suspected, further investigation is necessary, because multiple organ involvement is highly likely. We suggest that diagnosis of the SFM syndrome is simple, considering the special linear arrangement of sebaceous nevi in cases of SFM syndrome.

Factors determining the duration of tracheal intubation in cardiac surgery: a single-centre sequential patient audit

BACKGROUND AND OBJECTIVE

The study was designed to identify those factors associated with early tracheal extubation following cardiac surgery. Previous studies have tended to concentrate on surgery for coronary artery bypass or on other selected cohorts.

METHODS

Sequential cohort analysis of 296 unselected adult cardiac surgery patients was performed over 3 months.

RESULTS

In total, 39% of all patients were extubated within 6 h, 89% within 24 h and 95% within 48 h. Delayed extubation (>6 h after surgery) appeared unrelated to age, gender, body mass index, a previous pattern of angina or myocardial infarction, diabetes, preoperative atrial fibrillation, and preoperative cardiovascular assessment, as well as other factors. Delayed tracheal extubation was associated with poor left ventricular, renal and pulmonary function, a high Euroscore, as well as the type, duration and urgency of surgery. Early extubation (<6 h) was not associated with a reduced length of stay in either the intensive care unit or in hospital compared with patients who were extubated between 6 and 24 h. In these groups, it is presumed that organizational and not clinical factors appear to be responsible for a delay in discharge from intensive care. Patients who were extubated after 24 h had a longer duration of hospital stay and a greater incidence of postoperative complications. Postoperative complications were not adversely affected by early tracheal extubation.

CONCLUSIONS

In an unselected sequential cohort, both patient- and surgery-specific factors may be influential in determining the duration of postoperative ventilation of the lungs following cardiac surgery. In view of the changing nature of the surgical population, regular re-evaluation is useful in reassessing performance.

A prospective randomized controlled study of VAX-D and TENS for the treatment of chronic low back pain

Low back pain is one of the most significant medical and socioeconomic problems in modern society. International guidelines call for evidence-based management for the pain and disability associated with musculoskeletal disorders. The purpose of this randomized controlled trial is to address the question of efficacy and appropriateness of vertebral axial decompression (VAX-D) therapy, a new technology that has been shown in clinical research to create negative intradiscal pressures, and has been shown to be effective in treating patients presenting with chronic low back pain (> 3 months duration) with associated leg pain. Successful outcome was defined as a 50% reduction in pain utilizing a 10 cm Visual Analog Pain Scale and an improvement in the level of functioning as measured by patient-nominated disability ratings. Patients were randomly assigned to VAX-D or to TENS which was used as a control treatment or placebo. The TENS treatment demonstrated a success rate of 0%, while VAX-D demonstrated a success rate of 68.4% (p < 0.001). A statistically significant reduction in pain and improvement in functional outcome was obtained in patients with chronic low back pain treated with VAX-D.

Effect of dopexamine hydrochloride on renal vascular resistance index and haemodynamic responses following coronary artery bypass graft surgery

A randomized double-blind study was carried out on 20 patients after coronary artery bypass surgery to investigate the effects of graded doses of dopexamine hydrochloride or placebo on systemic haemodynamic responses and renal vascular resistance index (RVRI) measured using Doppler ultrasound. Pre-operatively, all patients had good left ventricular function and normal renal function. Eleven were allocated randomly to receive incremental infusions of dopexamine 0.5, 1, 2, and 4 micrograms kg-1 min-1 for 40 min each, and nine received corresponding infusions of placebo. One patient was withdrawn from the dopexamine group because of tachycardia. In the remaining 19, heart rate (HR) and cardiac index (CI) were significantly (P < 0.05) increased from base-line with dopexamine: the HR values with dopexamine differed significantly from those with placebo at the 2 and 4 micrograms kg-1 min-1 dose and at 4 micrograms kg-1 min-1 for CI. Systemic vascular resistance index (SVRI) fell significantly in both groups: the reduction was significantly greater with dopexamine 4 micrograms kg-1 min-1 than with the corresponding infusion of placebo. RVRI increased and urine output decreased significantly during the infusions in both groups, but with no significant difference between groups. There were no changes in systemic arterial pressures, pulmonary artery occlusion pressures, stroke volume index or left ventricular stroke work index. Where changes from base-line occurred in either group, they had not returned to base-line within 40 min of stopping the infusions (except perhaps for CI in the dopexamine group). Dopexamine appears to offer no particular protection to the renal vascular bed.

Becoming an orthopaedic surgeon: background of trainees and their opinions of selection criteria for orthopaedic training

A questionnaire survey of registrars in training in Australia in orthopaedic surgery was used to profile successful applicants and to ascertain what entry criteria they considered appropriate for the Orthopaedic Training Scheme. Typically, trainees were male, average age 31 years, married with children, born in Australia, privately educated and from a traditional family background. Respondents believe that referees' reports, performance as a resident and a registrar, and experience as a non-accredited registrar are the most appropriate selection criteria. Trainees held the opinion that too much emphasis may currently be placed on the support of influential surgeons and hospitals, and too little emphasis on medical school performance and surgical expertise. Academic achievement was considered to be of little relevance. The implications of these findings are discussed.

Replacement of the proximal humerus in primary bone tumours

BACKGROUND

Primary bone tumours have traditionally been treated by forequarter amputation. However, recent limb salvage techniques have become available which are comparable for tumour control and preserve a useful distal limb. This report describes the use of the Huckstep ceramic shoulder with ceramic spacers, non-vascularized fibular grafts and Huckstep nail with ceramic spacers.

METHODS

Three techniques are described for the reconstruction of the humerus following primary tumour excision. The seven primary bone tumours in this series included three patients with osteosarcoma, two with chondrosarcoma, one with fibrosarcoma and one with an aneurysmal bone cyst. The mean age of the four males and three females was 27 years (range 18-57). Mean follow up was 8.8 years (range 1-18). The techniques used were the Huckstep ceramic shoulder prosthesis with spacers (three cases), non-vascularized fibular grafts (three cases) and the Huckstep nail with ceramic spacers (one case).

RESULTS

One fibular graft required supplementary bone grafting and one patient with a shoulder prosthesis died of metastatic disease. The other five patients are well with a good range of shoulder abduction and external rotation.

CONCLUSIONS

Limb salvage surgery of the upper limb is possible. Deltoid, rotator cuff and radial nerve functions can be preserved.

Infusion nomograms

Seven infusion nomograms are presented for the rapid and accurate composition of continuous infusions. The construction of these nomograms is described.

Admixture of propofol and alfentanil. Use for intravenous sedation and analgesia during transvaginal oocyte retrieval

An admixture of propofol and alfentanil provides adequate sedation and analgesia during transvaginal oocyte retrieval in the absence of a paracervical block. In 100 patients the technique provided haemodynamic stability, sedation which was easily controlled, rapid recovery and universal patient acceptance.

Total intravenous anaesthesia with propofol and alfentanil protects against postoperative nausea and vomiting

The incidence of postoperative nausea and vomiting and requirements for anti-emetic medication were assessed in 80 female patients undergoing day-case anaesthesia during assisted conception therapy. Anaesthesia was induced with alfentanil 50 micrograms.kg-1 and propofol 1 mg.kg-1; atracurium 0.5 mg.kg-1 was given to facilitate tracheal intubation. The patients were allocated to receive either total intravenous maintenance of anaesthesia with an infusion of propofol and increments of alfentanil (Group P) or inhalational maintenance of anaesthesia with nitrous oxide and enflurane (Group E). Postoperative nausea, retching, vomiting, requirements for anti-emetic therapy, and unplanned admission for overnight stay in hospital were recorded. Overall incidence of nausea was 64% in group E and 39% in Group P (P less than 0.05). Incidence of vomiting was 67% in Group E and 34% in Group P (P less than 0.05). Metoclopramide was requested by 62% of patients in Group E, and 32% of those in Group P (P less than 0.05); 21% of the patients in Group E were admitted to hospital overnight, while only 5% of the patients in Group P required unscheduled admission to hospital (P less than 0.05). We conclude that total intravenous anaesthesia with propofol and alfentanil is superior to inhalational maintenance with nitrous oxide and enflurane in that it is associated with less nausea and vomiting, less requirement for anti-emetic medication, and a lower probability of unplanned admission to hospital after day-care gynaecological surgery.

Trends in skiing injury type and rates in Australia. A review of 22,261 injuries over 27 years in the Snowy Mountains

OBJECTIVE

To show the trends in the rate and type of skiing injuries in Australia.

DESIGN

A retrospective analysis of skiing injuries in the Snowy Mountains from 1962 to 1988.

SETTING

All injuries were seen and treated at the Ski Injury Clinic in Perisher Valley.

PATIENTS

A total of 22,261 injuries were seen over this 27 year period (data for 1963, 1964, 1966, 1977, 1978, 1981 and 1982 were missing).

INTERVENTIONS

Injured skiers were treated at the Clinic with a small number sent to main centres for tertiary care.

MAIN OUTCOME MEASURES

The overall injury rate (1962-1988) and the specific injury rate for six subgroups of injuries (1974-1988) were calculated.

RESULTS

The overall injury rate declined dramatically over this period. The incidence of tibial fractures, ankle injuries and lacerations also declined. Upper body injuries continue to rise although this trend was not statistically significant. There was a statistically significant increase in knee injuries.

CONCLUSIONS

The trends reported here are similar to those overseas except that the incidence of thumb injuries has not changed in Australia. The changes in the rates of lacerations, and tibial and ankle injuries can be related to improvements in ski bindings and boots.

Project Orbis

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Deaths associated with skiing in Australia: a 32-year study of cases from the Snowy Mountains

We present the first study of skiing-related deaths in Australia--a 32-year study of skiing-related deaths in the Snowy Mountains. We have reported 29 such cases; eight subjects died of trauma, 15 subjects died of cardiovascular causes, and six subjects died of hypothermia. The over-all incidence of death was 0.87 deaths per million skier-days; the specific incidence for trauma-related deaths was 0.24 deaths per million skier-days; for cardiac-related deaths was 0.45 deaths per million skier-days; and for hypothermia-related deaths was 0.18 deaths per million skier-days. These findings compare most-favourably with US figures. Death that is associated with skiing in the Snowy Mountains is a rare event.

Nordic (cross-country) skiing injuries in Australia

A retrospective study of 88 nordic skiing injuries from the 1984 and 1985 skiing seasons in Australia is presented. To our knowledge, this is the largest study to date of such injuries. These injuries are compared with alpine skiing injuries from the same medical clinic for the 1985 skiing season. There was a much lower incidence of injury from nordic skiing; however, when injuries did occur, they tended to be more serious than those of alpine skiing and frequently required immediate evacuation to hospital for treatment. As the nordic skier is relatively isolated from medical services, these findings need to be considered in the future planning of rescue services for such skiers.

Children's skiing injuries in Australia

Skiing is one of the most popular winter sports for adults and children in Australia. While much is known about the epidemiology of skiing trauma in adults, little has been written about the patterns of skiing injury in children in Australia. During the 1984 ski season, the injuries and risk factors of 149 children were compared with those of 1093 adults who were injured over the same period. Although Australian children were found to be possibly less prone to injury than were adults, they did sustain more serious injuries, in particular, fractures of the tibia. The significantly different associated risk factors that are thought to be responsible were the greater number of children who were injured in collisions and ski-lift accidents, and inadequate bindings on their skis. Such shortcomings are correctable; children require better boot-bindings and greater supervision on the ski-slopes.

Hypothermia among resort skiers: 19 cases from the Snowy Mountains

Even in relatively temperate environments, accidental hypothermia is a potentially lethal complication of exposure. We have reviewed our experience of accidental hypothermia among recreational alpine skiers at an Australian resort during the 1983 and 1984 seasons. There were 19 cases of accidental hypothermia, which occurred in 10 men and nine women who were aged between six and 47 years (mean age, 15.9 years) and who had rectal temperatures that ranged from less than 35 degrees C to 36 degrees C. The temperature at presentation to the Ski Injury Clinic was less than 35 degrees C in seven cases. One patient presented to the Clinic with a gastrointestinal haemorrhage in addition to hypothermia, and one was initially thought to be suffering from alcohol intoxication. Two patients were lost in the snow overnight. All patients were removed from the snow, changed into warm dry clothes where necessary, and their body temperatures allowed to return to normal spontaneously (17 patients), or were exposed to heat actively by means of inhaled, heated, humidified air (two severely obtunded patients). All patients responded satisfactorily. There were no deaths and no sequelae. We conclude that all skiers should be advised to wear effective thermal insulation, and to ski with a partner to ensure that adequate care is taken to prevent accidental hypothermia. Inhalational "warming" is effective in the treatment of hypothermia in obtunded patients.

Skiing injuries in Australia

A prospective study of 1850 skiing injuries which occurred during the 1983 skiing season in Australia is presented. To date, it is the largest prospective review of skiing injuries in Australia. All injuries were seen and treated by the same medical practitioner. In contrast with previous reports, upper extremity injuries and lower extremity injuries were almost equally represented (36% and 42% of the total number of injuries, respectively); injuries to the head, face and neck accounted for 17% of the total number of injuries. The injury rate of 3.80 per 1000 skiers establishes skiing as a safe sport. Attention is drawn to the high incidence of facial lacerations and of disruption of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb ("skier's thumb"). It is recommended that both competitive and recreational skiers wear helmets with attached visors. With adequate medical personnel and facilities, over 90% of injuries can receive definitive primary treatment on location; this results in minimum patient discomfort, complications, and hospital costs.

Factors influencing the diagnostic sensitivity of the exercise test in coronary artery disease

A continuous multistage bicycle ergometer test was performed on 50 patients with coronary artery disease. Selective cinecoronary angiography and left ventriculography were performed within a week of the test in all patients. Overall, 62% had a positive ischemic response, defined as 1 mm or greater depression of the ST segment. Patients with 75% or greater stenosis in any vessel and those with triple-vessel involvement had a higher incidence of positive tests. Those with low systolic ejection fractions and areas of asynergy had fewer positive tests than patients with normal ejection fractions and normal or minimal segmental wall motion abnormalities. The level of exercise, location of arterial disease and the presence of collateral blood supply to the diseased vessels did not appear to influence the sensitivity of the exercise stress test.

Pyloric obstruction caused by aspirin: case report

A case of pyloric obstruction caused by ingestion of enteric-coated aspirin tablets is presented. The patient was predisposed by previous pyloric stenosis. A barium meal study was diagnostic. The patient later had a massive gastro-intestinal haemorrhage requiring surgical repair. The hazards of aspirin ingestion in such a patient are discussed.

Cholestyramine in the treatment of antibiotic associated pseudomembranous colitis: a case report

A patient with antibiotic associated pseudomembranous colitis (A-PMC) is described in whom there was a dramatic response to the administration of cholestyramine. Although it is not clear why cholestyramine should be beneficial, its use should be considered whenever the diagnosis of pseudomembranous colitis is entertained.