Feasibility of near real-time image-guided sinus surgery using intraoperative fluoroscopic computed axial tomography.

OBJECTIVE: One of the main limitations of image-guided surgery is that navigation relies on the use of a CT scan obtained before surgery and is unable to be updated during the procedure. A software addition has been developed to allow reconstruction of CT-like images from a series of fluoroscopic scans and integrate these into an image-guided system (GE Healthcare Surgical Navigation, Lawrence, MA). We report our initial experience with a series of patients undergoing intraoperative fluoroscopic navigation in sinus surgery. STUDY DESIGN AND SETTINGS: After institutional review board clearance, we prospectively studied 14 consecutive patients undergoing image-guided sinus surgery with the use of intraoperative fluoroscopy. RESULTS: All patients had preoperative and postoperative fluoroscopic images reconstructed into CT-like images. By the conclusion of the study, images were adequate in quality and accurate navigation was achieved. CONCLUSION: Real-time image-guided sinus surgery using fluoroscopy is feasible. Future studies will need to focus on defining the procedures that could benefit, such as tumor resection, to enhance patient safety during these operations.     

The myth of the final hazard assessment

Hazard assessment is a basic tool used in the evaluation and regulation of chemicals, but in spite of this there are many different interpretations of the scope and function of a hazard assessment. Starting from a discussion of the essential elements and conceptual frames involved, an attempt is made to identify the sources of uncertainty that are inherent in a hazard assessment. Problems identified include unambiguous identification of the chemical source, the routes of exposure, and the possible targets to be considered. Inadequacies in effects data are frequent, but unlike many of the other sources of uncertainty, these are often compensated for by the use of safety factors when setting quantitative limits for human or environmental exposure. The inherent uncertainties in the process make periodic revisions of any hazard assessment process inevitable, as new knowledge on routes of exposure and targets becomes available.     

Bacterial meningitis in the first three months of life.

A retrospective study of infants with bacterial meningitis admitted to our hospital during 1949-52, highlighted the lack of ''classical'' signs of meningitis in these infants. We carried out a similar review of 44 infants aged less than three months, admitted during 1982-91. We also determined the causative organisms and their antibiotic sensitivities. Symptoms and signs were similar in the two series. Forty infants in the later series were either febrile, irritable or had seizures on the day of admission. Overall mortality fell from 30% to 11%. Between 1982 and 1991 Group B Streptocococcus and Neisseria meningitidis were the commonest causes of meningitis. All organisms, except one, were sensitive to ampicillin and/or cefotaxime. Bacterial meningitis should be suspected in young infants who are febrile, irritable or having seizures. Initial treatment with ampicillin and cefotaxime is appropriate.     

An analysis of fluid loss during transcervical resection of submucous myomas

Objective: To determine the contribution of several variables to fluid loss during transcervical resection of submucous myomas.Design: An observational study using multiple linear regression analyses.Setting: A university-affiliated training hospital and a university department of clinical epidemiology and biostatistics.Patient(s): Patients with submucous myomas.Intervention(s): Transcervical resection of submucous myomas and monitoring of fluid loss.Main Outcome Measure(s): Patient age, uterine enlargement, treatment with GnRH analogues or 8-ornithine-vasopressin, type of anesthesia, number of myomas, intramural extension of the myoma (type of myoma), and operating time were tested as variables.Result(s): Only intramural extension of the myoma and operating time were obviously related to fluid loss. For the other variables, such a relation was weak at best. The relation between fluid loss and operating time was not modified by any of the other variables.Conclusion(s): Because fluid loss is an important limiting factor in the transcervical resection of submucous myomas, special attention should be paid to reduction of the operating time and preoperative assessment of the intramural extension of the myoma to guide appropriate patient selection.     

Diabetes in sex offenders

Thirteen diabetic male sex offenders were compared to 13 nondiabetic sex offenders matched on age, education and offense type. A standard battery of tests administered in the assessment of sex offenders was used to compare the two groups. The tests examine sexual history and preference, substance abuse, violence, personality, and neuropsychological impairment. Results showed that diabetics more often than controls complained of impotence and were nonresponders during phallometric testing. Diabetics, as adults, tended to have less sexual experience with adults and more with pubescent females. The two groups did not differ in number of sexual or nonsexual offenses. The diabetics reported more problems controlling their emotions and more often than controls presented in assessment with inappropriate and/or aggressive behavior and poor cooperation. MMPI results showed diabetics to have more overall clinical disturbance than controls including anxiety, health concerns, family problems, authority problems, criminality, confused thinking and ruminating. Diabetics and controls did not differ in reported frequency of violent behavior but the diabetics responded more extremely, given the circumstances. Diabetics tended to show more violence to their own children. The role of diabetes in the relapse cycle model of offending is discussed.     

Ruptured petrous carotid aneurysm presenting with otorrhagia and epistaxis.

Aneurysm formation and rupture within the petrous internal carotid artery (ICA) is an extremely rare occurrence with approximately 10 such cases in the literature. Etiologies of petrous ICA aneurysms include atherosclerosis, closed head trauma, iatrogenic injury during mastoid surgery, chronic middle ear infections, and congenital causes. Therapeutic options include carotid artery ligation, aneurysm resection with or without reconstruction, and radiographically controlled vessel occlusion. The case of a patient who presented with otorrhagia, epistaxis, and transient focal neurologic signs due to a ruptured petrous ICA aneurysm is presented. The incidence, etiology, and anatomy of these aneurysms is reviewed, and the various tests for determining adequacy of collateral cerebral blood flow are described. Factors that affect the selection of surgical versus radiologic control of these lesions are also discussed.