Mycobacterium malmoense infections in Scotland: an increasing problem.

During 1982-4 20 cases of Mycobacterium malmoense infection were identified in Scotland (13 male, seven female; age 34-82, median 62 years). Features of the disease were obtained from case notes and radiographs of 19 patients and were found to be indistinguishable from those of patients with pulmonary tuberculosis. Chronic chest disease, predominantly chronic airflow obstruction, was the most frequent associated disease. The organisms showed in vitro resistance in eight patients to rifampicin, in 19 patients to isoniazid, and in all patients to pyrazinamide and p-aminosalicylic acid. Nevertheless, all patients showed an early response to standard combination chemotherapy with rifampicin, isoniazid, and ethambutol, with or without pyrazinamide. Five have been cured and none had died of the infection, although four died of unrelated disease. Of nine patients still having treatment, five had relapsed after completing a course of antituberculosis drugs. All had received ethambutol for less than five months. The response to standard drugs was more satisfactory when the course included administration of ethambutol for at least nine months. Currently one new infection with M malmoense occurs in Scotland for every 40 with tuberculosis, and the incidence appears to be rising. In view of this, it is suggested that when tuberculosis is suspected the chemotherapeutic regimen should include ethambutol until the culture results are reported. If these then show M malmoense, ethambutol should be continued in the combination for at least nine months.     

Iliac ureteral fistulas. Diagnosis and management of an increasing problem

Iliac-ureteral fistulas (IUF) are a rare but potential life threatening event and an important cause of gross hematuria. We report on three cases of IUF. In all cases, prior chronic ureteral stenting, extended pelvic surgery or pelvic irradiation had been performed. Diagnosis was confirmed with angiography in one case, in the others a CT scan revealed the IUF. Treatment included surgical exploration with local reconstruction, extra-anatomical bypass and nephrectomy with arterial patch repair. The increasing incidence of IUF is a consequence of an increasing number of advanced and extended pelvic operations, radiation therapy and long-term ureteral stenting. Diagnosis should be made by provocative angiography or CT. Treatment options vary depending on the site and morphology of the local situation, but morbidity and mortality is still high due to delayed adequate diagnosis and treatment. A conclusive algorithm should be followed for the successful management of IUF.     

Adult ankle fractures—an increasing problem?

The epidemiology of ankle fractures is changing. Increasing longevity has resulted in the highest age-specific incidence of ankle fractures being in women between 75 and 84 years of age. the introduction of the AO classification has facilitated analysis of the commonest fracture types. This survey of 1, 500 ankle fractures, seen in a 3-year period in the Edinburgh Orthopaedic Trauma Unit, shows that the commonest ankle fractures are the B1.1 and A1.2 lateral malleolar fractures. Isolated malleolar fractures accounted for two thirds of the series, with bimalleolar fractures occurring in one fourth of the patients and trimalleolar fractures in the remaining 7%. Open fractures occurred in 2%.     

Inhalation injury--an increasing problem

Inhalation injury is a common complication of thermal accidents occurring in one-third of patients burned. The routine use of fiberoptic bronchoscopy on all patients incurring thermal burns provides an accurate and safe means for diagnosis. Although complications for inhalation injury are common, the mortality can be reduced by early diagnosis and attention to careful fluid resuscitation, aggressive pulmonary therapy and the avoidance of prophylatic steroids.     

The medical malpractice problem, and some possible solutions.

The solutions to the problems of medical malpractice and malpractice insurance coverage are primarily in the hands of state legislatures. Legislation enacted has been primarily palliative, to assure continued availability of professional liability insurance. Unfortunately, no limit can be placed on the costs of such coverage. Unfortunately, too, no long-term solution has been forthcoming. Any long-term solution must encompass some method or methods of reducing injuries to patients and at the same time changing the system from defense of the physician to compensation of the patient. If such changes are not forthcoming, physicians will become uninsurable and the private practice of medicine as we now know it will disappear in this country.     

Osteogenesis imperfecta as an interdisciplinary medical problem]

In years 2001-2003 six children (3 boys ond 3 girls) from 2.1 to 18.7 years old with osteogenesis imperfecta (OI) were treated in our clinic. Besides clinical and radiological evaluation, densitometry and biochemical analysis of collagen were performed. Biochemical analysis was performed on cultured in vitro fibroblasts from the skin biopsies. Based on this findings 1 child was graded as type I of OI, 4 children as type III and 1 as type IV. Recognition of collagen defect helps with diagnosis and makes the decision for pharmacological treatment easier. In 1 child with the dramatic type III OI therapy with pamidronian was implemented with good result. Performed surgical treatment, intramedullar stabilisation with Rush rod, proved to be useful choice in correcting axial deformations of the lower extremities and preventing from the future fractures.     

Specific language disability--a medical or an educational problem?

Specific learning disabilities are often regarded as a medical problem for which medication or other treatment and investigation is requested. However, when problems of concentration are the result rather than the cause of the learning problem, medication is not indicated. This applies to specific language disabilities, which handicap seemingly normal children who do not understand or comprehend the spoken or written word and are therefore failures in a language-orientated classroom. The cause may be an organic disorder of the left hemisphere or a dominant right hemisphere, but the management should be educational, using unconventional learning techniques utilizing right hemisphere abilities.     

The occult pneumothorax: an increasing diagnostic entity in trauma

The increasing use of CT for the evaluation of blunt abdominal trauma has diagnosed undetected pneumothoraces in many patients. We performed a retrospective study at a major trauma center to determine the incidence of occult pneumothorax in the trauma patient. All trauma patients (3121) admitted to a Level I trauma center over a 51-month period were reviewed to determine the incidence of pneumothorax and occult pneumothorax, the method of diagnosis, and treatment. All major trauma patients received a chest X-ray (CXR), whereas 842 patients (27%) underwent an abdominal CT scan. In the 172 patients diagnosed with pneumothorax, 157 abdominal CT scans were performed and 143 were positive for pneumothorax. CXR revealed 49 right-sided pneumothoraces and 58 left-sided pneumothoraces in 95 patients. Abdominal CT scans diagnosed 73 right pneumothoraces and 90 left pneumothoraces in 143 patients. There were 67 patients (71 thoraces) who were seen to have a pneumothorax on abdominal CT scan not seen on admission CXR. This represents 2.2 per cent of all trauma patients and 7.9 per cent of patients with abdominal CT scans. In looking at just trauma patients with pneumothorax, the CT scan was responsible for diagnosing 39 per cent of the patients with a pneumothorax. The occult pneumothorax is being diagnosed more frequently as methods of evaluating and diagnosing trauma patients become more sensitive.     

The meatal problem with TUR prostate: the value of post-operative self-dilatation

In a preliminary retrospective study, we found that 37% of patients about to undergo a transurethral resection of the prostate had an external meatus too small to admit a 26 F resectoscope sheath. In a prospective study, a formal meatotomy was compared with an Otis urethrotomy for patients with a narrow meatus. This study was stopped because 71% of cases having a meatotomy developed strictures compared with 29% having an internal urethrotomy. In a further study of 59 patients, regular self-dilatation of the cut meatus with a plastic spigot was compared with internal urethrotomy of the meatus alone. Seven per cent of cases having self-dilatation developed strictures compared with 34% having internal urethrotomy. It was concluded that in those patients with a narrow external meatus meatotomy should not be carried out, but self-dilatation following internal urethrotomy greatly reduces the incidence of meatal strictures.