Evaluation of the laboratory and environmental factors that induce seizures in photosensitive epilepsy.

This paper evaluates the laboratory and environmental factors that induce seizures in photosensitive epileptic patients. The aims are (i) to identify those factors that trigger seizures so that the patients could take preventive measures, (ii) to advise the patients on appropriate preventive measures that could be taken to avoid spontaneous seizures. Thirty-six photosensitive epileptic patients were studied. The electroencephalographic laboratory seizure-inducing factors identified were intermittent photic stimulation (IPS), flickering lights from both the TV and the visual display unit (VDU) at various flashes per second, grid patterns (vertical, horizontal lines, squares, black and white lines) of various cycles per degree, and blank screens. In the environmental factor investigation, 10 out of 36 patients had series of seizures induced by narrow stripes of black and white, or white and red striped coloured dresses especially, when stepping outdoors on sunny days. Other environmental factors identified include moving escalators; 'moving' trees, bushes, and houses when travelling in a vehicle, including trains; faceted patterns in the bathroom windows with light passing through; swirling light patterns especially on displayed objects of black and white colours; telegraphic post, gantry post, and luminance variance when stepping outdoors from the dark in bright sunlight. The effective preventive measures were: (i) patients should occlude one eye when travelling in a vehicle or using computers or when stepping outdoors on a sunny day, or when there are various patterns before them, (ii) patients should sit at least 3 metres away from the TV when watching a programme, (iii) they should avoid any object that transmits luminance variance; if this is not possible, they should occlude one eye.     

Karydakis operation for sacrococcygeal pilonidal sinus disease: experience in a district general hospital.

Asymmetrical excision of sacrococcygeal pilonidal sinus has been shown to be associated with low recurrence rates. We report our experience with an asymmetric technique--the Karydakis operation. Of 28 patients who had the operation over a 4-year period, no recurrences were observed in 27 patients available for follow-up (median follow-up 3 years). Three patients had complications requiring surgical intervention. The operation is easy to teach and learn and is worth considering by both specialist and non-specialist surgeons.     

Serum vascular endothelial growth factor in patients with head and neck squamous cell carcinoma.

Vascular endothelial growth factor (VEGF) is a key pro-angiogenic cytokine expressed by most human tumours. Two isoforms, VEGF121 and VEGF165, are soluble and can be assayed in serum. Serum VEGF has been shown to be significantly raised in patients with solid tumours and shows some promise as a potentially useful tumour marker. Serum levels of VEGF were assayed in 52 patients with untreated head and neck squamous cell carcinoma (HNSCC) and 104 healthy controls. Serum VEGF is significantly raised in patients with HNSCC (P < 0.001), but there was no association with either tumour stage or specifically the presence of nodal metastases. Sixteen patients (31%) had a higher serum VEGF than 95th centile of controls, suggesting that serum VEGF measurement is of little practical use as an initial diagnostic tool. The finding that patients with HNSCC have significantly raised serum VEGF probably relates to enhanced platelet aggregation in these patients.     

Low incidence of bleeding-related morbidity with left ventricular assist device implantation in the current era

Left ventricular assist device (LVAD) implantation is historically associated with high incidence of bleeding‐related complications, very high reexploration rates, and frequently massive blood transfusion. Bleeding predisposes to mortality, sepsis, allosensitization, and right ventricular failure. We present results of an integrated approach to reduce bleeding complications. Analysis of 51 implantable LVADs implanted in 50 patients (mean age 52 years; male, 45; Intragency Registry for Mechanically Assisted Circulatory Support [INTERMACS] 1 or 2, 25) in our center in 2008 and 2009, including 15 reoperations. Preoperative coagulopathy was evident in 10 patients. Our strategy included: early LVAD implantation, preoperative nutritional support and hemodynamic optimization, preferential use of continuous flow LVADs, meticulous surgical hemostasis, liberal application of tricuspid annuloplasty, and blood product utilization based on point‐of‐care testing. Two patients (4%) were reexplored for bleeding. Median transfusion rates intraoperatively were: blood: 2 units (interquartile range [IQR] 0–4); plasma: 0 units (0–2.75); platelets: 0 pools (0–1.75), while postoperative transfusion rates for first 48 h were blood: 1 unit (0–2); plasma: 0 units (0–0.75); and platelets: 0 pools (0,1). Right ventricular assist device was utilized in six patients (11%). Median chest tube drainage in first 24 h was 1230 mL (IQR 862–1687). Median time on ventilator was 2 days, intensive care unit was 6 days, and hospitalization was 18 days. Hospital mortality was 20%. Using an integrated approach, we have experienced bleeding and transfusion rates similar to that seen in non‐LVAD complex cardiac operations. The potential to reduce bleeding reduces invasiveness of LVAD surgery, reduces allosensitization, may improve outcomes, and may increase mainstream acceptability of LVADs as definitive therapy for heart failure.     

Surgical research revisited: clinical trials in the cardiothoracic surgical literature.

OBJECTIVE: Surgeons have been criticised for not undertaking high-quality research. This study examines the quality of randomised controlled trials (RCTs) in the cardiothoracic surgical literature with a view to revisiting the role of RCTs in surgical research. METHODS: All RCTs published in 1998 and 1999 in three major international cardiothoracic journals were analysed for basic components of trial design and presentation. RESULTS: We found 119 papers presented as RCTs. The median size of treatment arms per RCT was 20 (interquartile range 14-40). Of 20 dimensions of trial quality examined, 12 or more were deficient (not described or performed inadequately) in half of the studies. Key information was frequently missing. Additionally, most trials relied on 'soft' endpoints, using surrogate (72, 61%) rather than clinical, and numerical (102, 86%) rather than categorical outcomes suggesting lack of power to detect clinically relevant differences. Although most trials reported positive results (73, 63%), only in 18 (15%) did authors make recommendations for practice change. CONCLUSIONS: Many RCTs in surgery by virtue of their design, sample size, and insufficient power are incapable of answering the questions researchers seek to address. Surgical trials often may not exclude bias because of lack of blinding and variations in surgical technique and performance. It is arguable that for most study questions in clinical surgery, comparative analysis of large case series and databases will provide more robust evidence.     

Postpneumonic pleural suppuration in children

Postpneumonic pleural suppuration is a common condition seen in paediatric practice in Nigeria. One hundred and twenty cases seen at the University of Nigeria Teaching Hospital, Enugu, over a 4-year period were reviewed. The patients were aged between 1 1/2 months and 16 years. History of antecedent measles was elicited in 27 of the children, and 70% of the patients presented to the hospital later than 7 days after the onset of symptoms of pleura suppuration. From the pleural aspirates of 106 cases (88.3%) Staphylococcus aureus was cultured in 31.2%, but there were no organisms cultured in 39.4%. Twenty-nine children were treated by chemotherapy only; 11 of them (37.9%) died. Sixty-eight cases had tube drainage of the pleural collections, with 6 deaths (8.8%). Twenty-three patients had thoracotomy, evacuation of the suppurative lesion and decortication of the lung, with no mortality. There was overall hospital mortality of 14.2%, the highest mortality being in children who had associated measles, gastroenteritis, anaemia or malnutrition. Early surgical drainage by tube thoracostomy or by thoracotomy and decortication in addition to appropriate and adequate antibiotic therapy is the treatment of choice.