125“MIST Ultrasound Therapy for Recalcitrant Wounds,A new approach”

The use of adjunctive peri‐wound, ultrasound with either a 1 MgHz or 3 MgHz frequency has been reported on in the literature with variable results. MIST ultrasound therapy is a novel application of direct wound bed application of kilohertz ultrasound waves utilizing a normal saline mist as the coupling mechanism, allowing for no direct patient contact. The mist generated by the system is of relative uniform particle size and acts as a conduit of ultrasound energy. Unlike ultrasonic baths, which dissipate the vibrational energy over a large area, the transducer horn focuses the energy into a smaller area of application. The MIST? system consists of an ultrasonic power supply (generator), a transducer (or alternately referred to as the converter), and an applicator coupled to the transducer. The generator converts voltage to high frequency electrical energy. This electrical energy is transmitted to the piezoelectric transducer within the converter, where it is changed to mechanical vibrations. The generator is designed to operate the converter at 40 kHz with a distal displacement of 60 microns. Published reports have described various biological effects of low frequency ultrasound including VEGF and PDGF production, increased protein synthesis, improved bone and wound healing. Other authors have published abstracts demonstrating clinical efficacy of this device on a broad range of patients with recalcitrant wounds. This report describes the clinical results of a prospective, non‐randomized, efficacy trial, adding MIST ultrasound therapy to current treatment protocols in recalcitrant wounds. Wound healing trajectories before and after treatment will be evaluated and wound healing will be assessed with laser Doppler image analysis and trans‐cutaneous oximetry.     

THE “MEAT HOOK” OR “DOG CHAIN” RETRACTORS: A SIMPLE METHOD OF COSTAL MARGIN AND STERNAL ELEVATION RETRACTION

A brief history of sternal elevation retractors is given, and the authors detail their own method of sternal elevation and costal margin retraction, showing it to be an inexpensive, and a much simpler, more effective, and more efficient system than any other in use at this time.     

CYSTS AND “PSEUDOCYSTS” OF THE MENISCI OF THE KNEE JOINT

A series of 636 consecutive knee arthrotomies was subjected to a prospective study, including the incidence, clinical presentation, and operative findings of meniscal cysts and associated pathological conditions. The clinical differential diagnosis was studied in detail, and from this, the importance of a specific clinical sign indicating a torn lateral meniscus was realized. This sign was termed a “pseudocyst”. It was concluded that meniscectomy was the operation of choice and not simple cyst removal, and that the high incidence of associated meniscal tears and of her less frequent joint pathological conditions justified a standardized approach designed to assess the meniscus and of her intraarticular structures, rather than a simple incision over the joint-line swelling.     

THE “OUTREACH” PROGRAM: A CONSULTANCY TO REDUCE CHRONIC DISEASE MORBIDITY AND MORTALITY IN ABORIGINAL PEOPLE

Background: Aborigines in remote Australia are experiencing an epidemic of chronic disease. The “metabolic syndrome”, type 2 diabetes, hypertension cardiovascular, renal and chronic lung disease contribute to a 20‐25 yr reduction in life expectancy, and vast increases in renal failure. Prevention depends on socioeconomic advancement, education and better primary health care. However, modification of disease in people already afflicted is critical to stabilise families and communities. The Tiwi program has shown how quickly lives can be saved and dialysis avoided by timely intervention. The Outreach Program. will extend to other communities principles of risk factor identification, early diagnosis and treatment, that are already included in most regional & national guidelines. The program is supported by Rio Tinto and OATSIH, through the Australian Kidney Foundation. Diabetes Australia and the National Heart Foundation are collaborating for a unified approach. Program elements include education, training, algorithms for testing and treatment that emphasise simplicity, on‐site testing, familiarity with a limited number of medicines, ongoing medical support, help with recall & information systems and evaluation of process and outcomes. Participation of communities might be based on need (deaths and ESRD rates), unanimous request, and commitment of staff to participate in training, so that practices will be subsequently maintained in health care plans. Mechanisms of support will vary, based on the specific needs of each community: eg health worker training, local coordinators, facilitation of screening, refinement of medical management, and support of Aboriginal health promotion officers. A similar program, with a somewhat different approach, will operate from Flinders University. The program's reach and impact could be multiplied by establishing regional centres or reinforcing existing regional strategies nationwide, and asking local governments, NGOs and universities to bring additional support.     

PR19THE SUPERFICIAL LYMPHATIC DRAINAGE OF THE HEAD AND NECK – AN ANATOMICAL STUDY AND CLINICAL IMPLICATIONS

• 1 To re‐evaluate the basic anatomy of the lymphatic vessel network in the head and neck region for diagnosis and treatment of lymphogenic cancer metastases.
• 2 To compare the anatomy of the lymphatic system with the venous system.
• 3 To investigate the possibility that extensive lymphatic‐venous connections exist.

Materials and Methods The lymphatic vessels in the scalp, face and neck of 5 (ten halves) fresh human cadavers were identified by using 6% hydrogen peroxide with and without India ink, then injecting the vessels with a lead oxide, milk powder and water mixture. The specimens were photographed, radiographed and analyzed. Results Radiographs and photographs show:

• 1 The lymphatic pathway “patterns” found were different in each specimen, even each side of the same head showed considerable variation.
• 2 The lymphatic pathways of the anterior neck lie in the tissue above the platysma and course horizontally and obliquely. This finding confirm those found using lymphoscintigraphy
• 3 The discovery of lymphatic bypass routes confirms the lymphoscintigraphy findings that lymphatic drainage does not always go directly to the first tier lymph nodes.
• 4 We were able to compare the anatomical relationship of the lymphatic and venous systems and demonstrate that a lymphatic‐venous shunt does exist in the occipital region.

Conclusion This study provides an anatomical picture of the superficial lymphatic system of the head and neck and will aid surgical management in the treatment of trauma, infection, lymphoedema and cancer.     

A simple bedside approach to therapeutic goals achievement during the management of deceased organ donors – An adapted version of the “VIP” approach

The disproportion between the supply and demand of transplant organs could be alleviated by improving the quality of clinical management of deceased potential donors. As a large number of donor losses by cardiac arrest occur due to hemodynamic instability, without instituting all essential maintenance measures, it is likely that the application of simplified potential donor maintenance protocols will help to decrease potential donor losses and increase the supply of organs for transplantation. The Ventilation, Infusion and Pumping (VIP) strategy is a mnemonic method that brings together key aspects of the restoration of oxygen delivery to tissues during hemodynamic instability: adequate mechanical Ventilation, volume Infusion and evaluation of heart Pump effectiveness. The inclusion of the additional initials, “P” and “S,” refers to Pharmacological treatment and Specificities involved in the etiology of shock. The use of simplified care standards can assist in adhering to essential potential donor management measures. Therefore, using a simplified method as the adapted VIP approach can contribute to improving management standards of potential organ donors and increasing the supply of organs for transplantation.     

THE INTRAARTERIAL INFUSION OF CHEMOTHERAPEUTIC AGENTS AS “BASAL” TREATMENT OF CANCER: EVIDENCE OF INCREASED DRUG ACTIVITY IN REGIONALLY INFUSED TISSUES

There is evidence from a number of centres that some forms of locally advanced and aggressive cancers which are difficult to eradicate by standard means can be reduced by the use 01 “basal” chemotherapy to a degree which will allow more certain tumour eradication by subsequent radiotherapy and/or surgery. Clinicians have been divided as to whether there is an advantage in giving the chemotherapeutic agents directly into a regional artery of supply where this is feasible, as opposed to their systemic administration. This paper documents supportive evidence that some and possibly many chemotherapeutic agents are more effective if given regionally into an artery of supply. There is a higher incidence of local side-effects in the region infused, including loss of hair, inflammatory changes, and ulceration of the skin or mucosa of the region infused. After intraarterial infusion of tagged bleomycin (indium-Ill bleomycin) into a limb, the radioactive isotope remained more concentrated in the limb infused than in the opposite limb for at least 24 hours. Systemic side-effects, including bone-marrow depression, are less frequent and less severe in patients given chemotherapeutic agents by intraarterial infusion than if the same doses of agents are given intravenously. There is now sufficient evidence of the value of basal chemotherapy used in this way to make it mandatory that medical oncologists and surgeons, working together, should plan controlled studies to determine the most appropriate applications of this technique of management.     

A Commitment to HIV Diagnostic Accuracy – a comment on “Towards more accurate HIV testing in sub‐Saharan Africa: a multi‐site evaluation of HIV RDTs and risk factors for false positives” and “HIV misdiagnosis in sub‐Saharan Africa: a performance of diagnostic algorithms at six testing sites”

As part of the global response to the HIV/AIDS epidemic, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is committed to the provision of high‐quality services and ensuring testing accuracy. Two recently published papers focusing on HIV testing and misdiagnosis in sub‐Saharan Africa by Kosack et al. report on evaluations of HIV rapid diagnostic tests (RDTs) and found lower than expected specificity and sensitivity on some tests when used in certain geographic locations. The magnitude of PEPFAR's global HIV response has been possible due to the extensive use of RDTs, which have made HIV diagnosis accessible all over the world. We take the opportunity to address concerns raised about the potential implications that these findings could have on real‐world HIV testing accuracy. PEPFAR supported countries adhere to the normative guidance by World Health Organization (WHO) supporting algorithms which require sequential positive tests for diagnostic accuracy. An analysis of Médecins Sans Frontières (MSF) RDT site‐specific data applied to PEPFAR in‐country protocols demonstrate a variation in the diagnostic accuracy of the testing algorithms, but with a very small population‐level effect. The data demonstrate, with the use of these algorithms, that the RDT outcomes found in the study by Kosack et al. would be largely mitigated and would not be expected to have a significant impact on diagnostic accuracy and overall programming in most countries. Avoiding any misdiagnosis is a priority for PEPFAR, and it remains vital to gain a deeper understanding of the causes and the extent of diagnostic errors and any misclassification. Extensive quality control mechanisms and continued research are essential. With a focus on epidemic control and ensuring diagnostic accuracy, PEPFAR recommends that all countries use WHO pre‐qualified RDTs within the recommended strategies and algorithms for HIV testing. We also support validation of HIV testing algorithms using in‐country specimens to determine optimal performance, and the reverification testing of all people diagnosed with HIV prior to starting treatment as an essential quality assurance measure.