Training model for nasal packing.

A model is described for practising packing of the nose with ribbon gauze in the treatment of epistaxis. The model was constructed from accurate casts of a cadaveric nasal cavity. The value of the model as a practical teaching aid is shown by a trial on a group of 15 accident and emergency (A&E) doctors. After training on the model, there was a significant improvement in the confidence of the doctors to pack a nose, the amount of gauze packed and the visual appearance of the pack. Use of the model should raise the generally poor standard of nasal packing by doctors working in A&E departments.     

Traumatic Aortic Transection: Repair Using Left Atrial to Femoral Bypass

Traumatic aortic transection is a life-threatening surgical emergency. Therapy must be directed at rapid repair and prevention of postoperative complications, the most serious being paraplegia. Controversy over the optimal method of repair exists-specifically whether the use of a shunt modifies the outcome. Our series of 17 patients using left atrial to femoral bypass with the Biomedicus pump will be discussed. Preoperative preparation and operative technique will be outlined. Mortality in this series was 18%, the incidence of paraplegia was 0.     

Bone and soft-tissue lesions: diagnosis with combined H-1 MR imaging and P-31 MR spectroscopy

The feasibility of combined magnetic resonance (MR) imaging and surface coil phosphorus-31 MR spectroscopy at 1.5 T was examined in a clinical study of 34 patients before biopsy of bone or soft-tissue lesions of the extremity and trunk. The results confirmed the inability of MR imaging alone to distinguish most benign lesions from malignant ones. Malignant lesions were distinguished from benign lesions on the basis of significantly higher mean peak ratios of phosphomonoester (PME) to beta-nucleoside triphosphate (NTP) and of phosphodiester to NTP, a significantly lower mean peak area ratio of phosphocreatine to NTP, and a higher mean pH. The diagnostic performance of the PME/NTP peak area ratio is characterized by a sensitivity (true-positive fraction) of 1.00 and a specificity (true-negative fraction) of 0.93. This study provided preliminary evidence that P-31 MR spectroscopy may be used to improve diagnostic specificity in bone and soft-tissue lesions.     

A Study of Neuropathy in HIV Infection

A prospective study of possible aetiological factors for neuropathyassociated with HIV infection was performed in 80 patients and28 homosexual controls. At entry to the study twelve patients(15 per cent) had evidence of a generalized neuropathy not dueto any other cause and a further three patients developed symptomaticneuropathy during a mean (SD) follow-up of 20 (7.5) months.All but two of these neuropathies were of the distal symmetricalsensory type. Electrophysiology was consistent with an axonalpathology and nerve biopsy confirmed this as the major pathologicalchange. Warming threshold was the diagnostic test most frequentlyabnormal, sometimes in the absence of other electrophysiologicalabnormalities. No association was seen with opportunistic infection(cytomegalovirus, herpes simplex, Pneumocystis pneumonia, toxoplasmosis,Cryptococcus infection or tuberculosis). HIV proviral DNA couldnot be detected in paraffin sections of peripheral nerve insix patients with neuropathy. The presence of the neuropathydid not show significant correlation with depression of thenumber of CD4⁺T cells in the blood, impaired T cell functiontests, or IgG, IgM, or IgA levels. Immune complexes containingC1q,but not those containing IgG, IgM, IgA or C3c, were significantlymore common among neuropathic patients (     

Factors associated with veterans' decisions about living wills.

Most states have adopted legislation that allows patients to designate by advance directives the type of health care they would like to receive if they should become incompetent while suffering from a terminal illness. The living will is one of the most common of these legal instruments. Unlike most studies that have examined very sick or hospitalized patients' preferences regarding life-sustaining treatments, our study explores the concerns of 70 ambulatory veterans from a general medical clinic regarding living wills. Before the interview, 43% of patients reported never having heard of living wills. At interview, 4% of the patients had a living will, 33% intended to sign a living will but had not done so (INTEND), 54% were undecided about living wills (UNDECIDED), and 9% did not want a living will. Compared with UNDECIDED patients, all other patients did not differ in the use of health care services during the previous year or in diagnoses. INTEND patients, however, were significantly more likely to be white, to express poorer health status, to know someone with a living will, and to have previously discussed the topic. UNDECIDED patients were more likely than INTEND patients to report that religious beliefs about living wills affected their decision. Virtually all (91%) of the respondents believed that signing a living will would not affect their treatment. These data suggest that many patients may not know that they can have a living will and that discussions with those who already have a living will may be helpful in educational programs designed to promote informed patient decision-making.     

Techniques in the Angiographic Analysis of Coronary Flow: Past, Present, and Future

The current method of analyzing coronary flow data is the TIMI flow grade method. This method is convenient and easy to apply, but there are limitations to this categorical method of analyzing coronary artery flow. We have developed a new method of analyzing coronary blood flow called the "TIMI frame count." Using the TIMI frame counting method, we have shown that the flow in the coronary arteries is in fact distributed as a continuous variable and that there are nondiscrete categories of slow and fast flow. This article discusses the statistical basis for the development of this new, simple, and continuous index of coronary flow and provides a "how-to manual" describing the practical implementation of the new TIMI frame count method. We also describe simple new techniques for measuring the distance to the landmark used for TIMI frame counting. Knowing the distance and the time from the TIMI frame count, velocity can easily be calculated. Tables are provided that can be used for these calculations on-line in the cardiac catheterization laboratory. If the diameter is known, flow can also be calculated from these tables. We also describe new applications of marker wires to measure distance and velocity .     

Infections in prosthetic devices

Infection in prosthetic devices is a rare but potentially serious complication of prosthesis implant surgery. Infections associated with a variety of permanently implanted devices are reviewed in the context of recent knowledge of the host-prosthesis interaction.