Re-expansion pulmonary oedema and circulatory shock in a 20-year-old man.

Re-expansion pulmonary oedema is a well-recognized rare complication of the treatment of spontaneous pneumothorax. It has been associated with death in 20% of cases. A fit 20-year-old man who had returned from holiday 2 days previously presented with a large left-sided pneumothorax of 10 days' duration. He had exhibited symptoms of chest pain and shortness of breath during the return flight. He showed no signs of respiratory distress at presentation to the Accident and Emergency Department, but after treatment with a chest tube in the ensuing 90 min developed severe unilateral re-expansion pulmonary oedema and circulatory collapse. Factors in the aetiology of the condition and prevention are considered.     

Options in bariatric surgery: modeled decision analysis supports Roux-en-Y gastric bypass and sleeve gastrectomy as the treatments of choice

Background

Obesity is a chronic disease associated with significant morbidity and mortality. Bariatric surgery has been shown to significantly reduce both morbidity and mortality. Numerous surgical strategies exist, but the most frequently used worldwide are adjustable gastric banding, sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB). It is not clear which of these strategies provides the optimal quality-of-life pay-off.

Assessment of disease severity (in terms of function) using the internet

OBJECTIVE: To determine whether visual analog scales (VAS) can be used over the Internet to assess the patient with ankylosing spondylitis (AS) accurately or if the use of this different medium will affect the results. METHODS: Patients with AS (n = 50) attending a physiotherapy/educational course completed both an Internet based and a paper based version of the Bath Ankylosing Spondylitis Functional Index (BASFI) that uses VAS. The Internet version was completed twice to assess intrarespondent variation reliability and compared with the paper version to assess interrespondent variation reliability. Patients were also asked to assess ease of use and to suggest changes to the Internet version. RESULTS: The interclass coefficient of intra- and interrespondent reliability were 0.989 (p < 0.001) and 0.976 (p < 0.001), respectively. There was a 3% difference in assessments carried out over the Internet compared to those on paper and a 2% difference in repeatability of Internet assessed questionnaires. Bland and Altman plots showed a mean difference between paper compared to the Internet version was 0.0156 with 95% limits of agreement at -1.07 to 1.03. More than half the participants reported that the Internet version was easier to complete than the paper version (96% rated usability as 1 on a scale of 1-10, with 1 being extremely easy and 10 being impossible). CONCLUSION: Assessment of disease severity by VAS may be accurately carried out over the Internet. This means that the evaluation of disease status and the longterm followup of people in different countries and perhaps in different languages may now be possible, using the Internet.     

Pseudomembranous colitis in four patients with cystic fibrosis following lung transplantation

Pseudomembranous colitis is an uncommon complication in patients with cystic fibrosis, despite the use of multiple high-dose antibiotic regimens and the frequency of hospital admissions. Four patients from a total of 137 patients with cystic fibrosis undergoing lung transplantation are described who developed fulminant pseudomembranous colitis. Initial presentation was variable and the mortality rate was 50% despite urgent colectomy. In one case the presenting abdominal distension was thought to be due to meconium ileus equivalent. It is concluded that Clostridium difficile colitis may be a difficult diagnosis in patients with cystic fibrosis and follows a fulminant course after lung transplantation.     

Improving access to HCV treatment: external jugular venepuncture can overcome problems with difficult venous access

Many patients requiring antiviral treatment of chronic hepatitis C (HCV) have a background of significant injection drug use (IDU). In a proportion of patients, IDU results in difficulty with blood collection from conventional sites. We audited patients from the Liver Clinics and Drug Health Pharmacotherapy Service of The Royal Prince Alfred Hospital (RPAH) to determine the incidence of difficulty with blood collection. This survey identified the need for an innovative venous access strategy to better manage this group of patients. An external jugular venepuncture (EJV) protocol and education package was developed in collaboration with the Department of Anaesthetics, Gastroenterology and Liver Centre and HCV clinical nurse consultants (CNC). RPAH policy and procedure committee approved the protocol and patient information sheet. Patients with a history of difficulty with blood collection were eligible for the protocol. Patient satisfaction surveys were conducted. The initial survey of patients from the liver clinics and pharmacotherapy service identified that 48 percent had difficulty with blood collection from conventional sites. In the period October 2002 to July 2006, 29 patients (89 percent with history of IDU) were referred for EJV assessment. Major indications for EJV were for blood testing for initiation and monitoring of antiviral therapy and ongoing assessment of HCV infected patients. No adverse events resulted from the procedure. All patients surveyed report high levels of satisfaction with the technique compared to previous venous access attempts. EJV improves access to antiviral therapy and is a safe and effective technique for patients with difficult venous access (DVA). In addition, we have utilised EJV for post-transplant care of patients and used external jugular vein cannulation as vascular access for contrast imaging in hepatocellular carcinoma (HCC) assessment.     

Smaller volume of anterior cingulate cortex in abuse-related posttraumatic stress disorder

OBJECTIVE: The anterior cingulate cortex (ACC) plays an important role in emotion, and studies in animals have shown changes in ACC structure with early life stress. The purpose of this study was to measure volume of the ACC in PTSD. METHOD: Magnetic resonance imaging (MRI) was used to measure ACC volume in 8 subjects with abuse-related PTSD and 13 healthy subjects without PTSD. ACC volume included Brodmann's area [BA] 24 and 32. RESULTS: Right ACC volume in PTSD patients was significantly smaller than in non-PTSD subjects. CONCLUSION: These results are consistent with smaller ACC volume in PTSD.