Testing a policy for skull radiography (and admission) following mild head injury

There has been, and continues to be, conflicting advice regarding skull radiography following an apparently uncomplicated head injury. Policies on admission are often ill defined. In 1983, representatives of the Royal College of Radiologists met neurosurgeons at a seminar in Harrogate organized by the DHSS and laid down clear, but little publicized, joint recommendations: "The Harrogate Criteria". The survey described here evaluated an existing liberal policy for skull radiography (and a loose policy for admissions) against these recommendations, and it was concluded that the number of patients having skull radiography (74% of head injury attenders) was excessive. Measured against the "Harrogate Criteria", requests for 36% of the adult and 47% of children's skull radiographs did not fulfil these criteria. As a corollary, it was also concluded that loose admissions policies could usefully be altered to comply more closely with the Harrogate recommendations. This would not necessarily reduce the numbers admitted, but would provide casualty officers with a framework on which to base this crucial aspect of clinical decision making, where presently there is often very little structure at all. The authors suggest that all the options have not been fully explored, and that a simple but important alteration to the Harrogate guidelines would provide an even closer link between policy on skull radiography and patient admission. Specifically, most patients who are to be admitted do not need skull radiographs.     

The effect of the illumination time when treating port-wine stains

This paper reports the electron microscopy results obtained from two patients who were treated with 5 W of yellow (578 nm) light from a copper vapour laser with an illumination time of 3.6 ms and a 0.3 mm spot diameter. The endpoint of treatment was transient blanching. Following treatment, erythema was observed. There was minimal damage to the epidermis and non-vascular tissue such as the nerve fibres. There was severe damage to the endothelial cells of the ectatic vessels. Twenty-four hours after treatment, platelet activation and collagen were present, indicating that these vessels were no longer viable. Theoretical calculations are used to determine the flow of heat within and away from a 50m diameter vessel. From this, heating of the entire vessel is shown to occur with illumination times of 4 ms, with minimal heating of the non-vascular tissue. Shorter illuminations do not heat the entire vessel, while the use of longer illumination times will cause excessive damage to the surrounding non-vascular tissue. Illumination times close to 4 ms must be regarded as optimal.     

Sexual Knowledge,Experience and Feelings Among People with Disability

The current study was designed to evaluate the sexual knowledge, experience, feelings and needs of people with intellectual disability or physical disability, and compare them to people from the general population. Sixty people with mild intellectual disability (28 males, 32 females, mean age=27.62 years), 60 people with physical disability (33 males, 27 females, mean age=28.65 years) and 100 people from the general population (40 males, 60 females, mean age=30.10 years) participated in the study. Each respondent completed the Sexual Knowledge, Experience and Needs Scale (SexKen). This scale assesses levels of knowledge, experience, feelings and needs in 12 different areas of sexuality. The results demonstrated that people with intellectual disability experienced lower levels of sexual knowledge and experience, more negative attitudes to sex and stronger sexual needs than people with physical disability, in all areas of sexuality. People with physical disability demonstrated these same trends when they were compared to people from the general population. An interpretation of these results as they relate to the sexuality of people with intellectual or physical disability is provided.     

Actinomyces and nocardia infections in immunocompromised and nonimmunocompromised patients

A retrospective survey of nocardia and actinomyces infections in five local hospitals was conducted over a 3-year period in El Paso, Texas, a border city, in the southwestern United States. The medical records of 42 patients with suspected nocardiosis or actinomycosis were reviewed. One patient was diagnosed with actinomyces and 12 patients with nocardia. Microbiological data included morphologic characteristics, biochemical profile, and susceptibility testing. Predisposing factors included leukemia, renal insufficiency, renal transplant, and lymphoma. No predisposing factors were found in 67% (n = 8) of patients (including the patient with actinomycosis). Twenty-three percent (n = 3) of patients had disseminated disease without evidence of underlying disease or immunosuppression. The mortality and morbidity of these infections appeared to be low.     

Cerebral vasculitis in a case of Sydenham's chorea

A 10-year-old girl with acute-onset hemichorea had multiple areas of abnormal signal seen on magnetic resonance imaging of the brain, associated with middle and anterior cerebral artery vasculitis seen on cerebral angiography. Her serology and clinical course were supportive of the diagnosis of Sydenham's chorea. Other causes of cerebral vasculitis were excluded. Follow-up studies revealed resolution of changes seen on magnetic resonance imaging and partial resolution of angiographic abnormalities. This is the first report of abnormal cerebral angiography in Sydenham's chorea.     

Neonatal herpesvirus sepsis following internal monitoring

The use of internal monitoring, in which an electrode is attached to the fetal scalp, may be associated with serious complications. The authors present a case of fetal neonatal sepsis due to herpesvirus arising at the electrode site.     

Immunogenicity of guinea pig cells transformed in culture by chemical carcinogens

The immunogenicity of inbred strain 2/N guinea pig fibroblasts transformed to the malignant state in vitro by chemical carcinogens was evaluated with the use of a variety of in vivo and in vitro methods including delayed-type hypersensitivity skin and tumor transplantation tests and analysis of antibody production by immunofluorescence, complement fixation, and staphylococcal protein A binding tests. Neoplastic transformation was induced by direct treatment of cells in culture with benzo[a]pyrene, 3-methylcholanthrene, or N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) or by the host-mediated method by which fetuses were exposed to diethylnitrosamine or MNNG in vivo prior to cell culture. Rabbits and syngeneic guinea pigs were inoculated with unirradiated and X-irradiated clonally derived cells. Delayed hypersensitivity skin reactions to immunizing or other cells were equivalent in immunized or control guinea pigs, and no protection to tumor outgrowth from a challenge inoculum of immunizing cells was observed. Antibody activity induced in the sera of immunized guinea pigs was cross-reactive and removed by absorption with nontumorigenic cells. Rabbit antisera after absorption with fetal guinea pig cells were nonreactive with the specific immunizing or other culture cells. Chemical carcinogen-induced neoplastic transformation of guinea pig cells can, therefore, occur without formation of detectable, individually distinct cell surface tumor-specific neoantigens.     

Postoperative spinal wound infection: a review of 2,391 consecutive index procedures

Postoperative infection remains a troublesome but not uncommon complication after spinal surgery. Most previous reports, however, are small or involve cases with more than one surgeon often at different institutions. This study represents a single surgeon's 9-year experience with postoperative infection at one institution. The authors describe the features of wound infection after spinal surgery with reference to diagnosis, microbiology, and treatment and they describe a protocol for effective management of postoperative spinal wound infection. The records of the senior author (F.P.C.) during a 9-year period for cases of postoperative wound infection were reviewed. Of 2,391 operative procedures, 46 cases of wound infection were identified, yielding an overall infection rate of 1.9%. Patients' preoperative risk factors, original diagnosis prompting the surgery, onset of infection, presentation, treatment, and outcome were analyzed. The mean age of the 23 men and 23 women was 57.2 years. The preoperative diagnoses included lumbar degenerative scoliosis or spinal stenosis in 28 cases, disk prolapse in 8 cases, metastatic disease in 4 cases, degenerative disk disease in 1 case, and a group of 5 miscellaneous cases. Seventeen (37%) of the patients underwent at least one previous spinal surgery at the same site. Twenty-three patients had a fusion, of whom 22 also had instrumentation. Forty-three (93%) of the patients had significant wound drainage after an average of 15 days (range, 5-80 days). The other three patients were examined approximately 2 years after the surgery. Fourteen of the patients also had pyrexia (temperature >37.5 degrees C) at presentation. Staphylococcus aureus alone was cultured in 29 patients, whereas another six patients had a different single organism. In nine patients, more than one organism was cultured during their hospital stay. Surgical treatment included primary closure in only seven patients, with most undergoing wound drainage and debridement followed by delayed closure. Instruments were removed in the three patients with late presentation who had solid fusion at operation. Viable bone graft and instrumentation were left in situ in all patients who were seen before fusion. All wounds healed without sequelae, except for three that required flap closure. Pseudarthrosis was noted in three patients after more than 1 year of follow-up in this series. Postoperative spinal wound infection is a potentially devastating problem. In this series, infection was more common in patients undergoing fusion with instrumentation and in patients with cancer metastatic to the spine. An aggressive surgical approach, including repeated debridement followed by delayed closure, is justified. Instrumentation may be safely left in situ to provide stability for fusion.