The Influence of Routine Completion Arteriography on Outcome following Carotid Endarterectomy

n = 69) normal; Group B (n= 29), abnormal, severe defects; Group C (n= 56), abnormal, mild–moderate defect. RCA detected 32 defects in Group B: 10 internal carotid (ICA), seven endpoint flaps, two kinks, one dissection; 16 external carotid (ECA), 10 severe endpoint defects and six total occlusion; six common carotid (CCA), five irregular proximal shelfs, one web. Thirty of 32 defects were successfully repaired as confirmed by normal repeat RCA studies; one ECA defect was not repaired and the ICA dissection was irreparable. In Group C, 67 mild–moderate defects were identified, but not corrected. These included <30% stenosis in the ICA (12), ECA (18), CCA (24), and vein patch corrugation or irregularity (13). For the entire series the postoperative ICA occlusion rate was 2% (3/154), stroke rate 2.6% (4/154), and a subsequent >50% restenosis rate of 7% (11/154). The yield from routine carotid completion arteriograms was significant, with 19% of studies identifying a severe defect that required repair. Although the difference in stroke rates and restenosis between the different groups did not reach statistical significance, patients with normal intraoperative arteriograms initially or after correction of a significant RCA defect had no early carotid occlusion (p= 0.05, Fisher's exact test) compared to patients with residual RCA defects. All early carotid occlusions occurred in patients with unrepaired defects. We conclude that RCA is an important method of quality control after CEA and exerts a subtle, but real, reduction in postoperative complications.     

The effects of population density and malnutrition on the dynamics of whooping cough.

Liverpool, a seaport in NW England, suffered severely from lethal infectious diseases in the second half of the 19th century: the population was densely crowded and malnourished and life expectancy was low. Time-series analysis shows that the epidemics of whooping cough (i) had an interepidemic interval of 2.9 years, 1863-85, which lengthened to 3.4 years, 1885-1900 (ii) were strongly coherent with wheat prices (P < 0.001) and (iii) also correlated with cycles of seasonal weather conditions. It is suggested from mathematical modelling that the epidemics in this compromised population were maintained (i.e. the system was driven) by an oscillation of malnutrition and by seasonal weather conditions. A model that incorporates both the dynamics of whooping cough and the demographic characteristics of the population is presented. It has been shown to replicate the dynamics of the epidemics and has been used to predict the changes with time of (i) the force of the infection and (ii) the proportion of those infected with whooping cough who died.     

A critical reflection on the personal impact of managerial hegemony within nurse education

This paper, written by two male nurse teachers, describes and analyses their experience of working in a nurse education culture permeated by the philosophy of business management The introduction of business management practices to nurse education is discussed as a reflection of the current political hegemony of market forces and individualism The authors discuss the implications for nurse teachers of being continually exposed to these politically motivated forces which increasingly provide the paradigm for service developments within the United Kingdom health services In discussing the impact of this exposure it is argued that at the personal level individual teachers are experiencing a degree of apathy and personal dissonance which undermines their professional value system, resulting in emotional distress and a crisis of identity It provides a critical reflection on the way organizational dynamics and power relations influence the subjective sense-making of individuals The authors use a multiplicity of perspectives, including those provided by individual psychology, power relations, feminism and personhood, to argue for the need to develop an alternative paradigm which is characterized by the valuing of individual persons, empathic sensitivity and the fostering of creativity been important to us from a personal and professional     

Fatal thermal injury

Two fatal cases of thermal injury are described, one of which was the result of heat stroke and the other was the result of the uncommon condition, neuroleptic malignant syndrome. The clinical profiles, management and post-mortem findings of these two separate conditions are compared to highlight their important differences.     

Chiari II malformation: MR imaging evaluation

The purpose of this study was to explore the value of high-detail MR imaging in the diagnosis of the Chiari II malformation. Twenty-four patients with known Chiari II malformation as diagnosed by CT scanning were evaluated with cranial MR scans. Two patients also had spine scans. The sagittal-plane images were the most informative, and abnormalities of the telencephalon, diencephalon, mesencephalon, rhomboencephalon, upper spinal cord, and mesencephalon were shown extremely well. We found MR to be an easy and accurate method for demonstrating the abnormalities of the Chiari II malformation, and it is our procedure of choice.     

The differential retrocardiac air-fluid level: a sign of intrathoracic gastric volvulus

A single retrocardiac air-fluid level on a chest radiograph typically implies the presence of a sliding hiatal hernia. A differential retrocardiac fluid level (two air-fluid interfaces at different heights) suggests not a simple sliding hiatal hernia but rather an intrathoracic gastric volvulus. Simultaneous fluid levels above and below the diaphragm are not required to make the diagnosis. We have seen four patients with chronic gastric volvulus confirmed by upper gastrointestinal barium examination. Each case was diagnosable on the basis of the chest radiographs obtained on admission, using the radiographic sign described above. We draw attention to this sign because chronic gastric volvulus has the potential to progress to acute volvulus and gastric ischemia or infarction.