Surgical management for chronic pain

Chronic pain in the UK affects up to 43% of the population. The consequences include physical and psychological distress, loss of function, employment, family and social strain and increased utilization of healthcare services. Modern pain management services operate across primary, secondary and tertiary care and incorporate general practitioners, psychologists, physiotherapists, pharmacists, specialist nurses, pain physicians and surgeons. This allows for a coordinated approach to chronic pain, engaging the patient in a structured pathway from conservative measures, through to surgery if necessary. Surgical interventions have been utilized effectively throughout the 20^th century for the treatment of a variety of conditions, some of which are now effectively managed with improved pharmacological approaches or novel neuromodulation techniques. Ablative procedures that aim to permanently interrupt the pain pathway still represent the final solution for some conditions, particularly those with cancer associated pain; however, the search for less invasive, less risky measures continues. This is stimulated by an increased understanding of the neurobiology of pain transmission and the physiological changes which occur in persistent pain.     

Free tissue transfer at an army medical center

Free tissue transfer has been demonstrated to be an effective modality of treating a variety of wounds and conditions in the civilian population. The use of these procedures has been underreported by American military surgeons. Military surgeons face unique hurdles that make the effective performance of these procedures difficult. We report our experience with free flap reconstruction at an American Army medical center. We performed 44 free flaps in 38 patients; although operative times and hospital length of stay were comparatively long, our success rates were excellent with only one partial flap loss. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense.     

Management of dislocations of both ends of the clavicle

We treated six patients who had a dislocation of both ends of the clavicle (an anterior dislocation of the sternoclavicular joint and a posterior dislocation of the acromioclavicular joint). Two patients who had fewer demands on the shoulder--an elderly woman and a woman who had had an ipsilateral amputation of the hand--did well; they had only minor symptoms after non-operative management. The other four patients (all men) had continuing pain at the acromioclavicular joint; each had a reconstruction of the joint, which resulted in a painless, full range of motion and return to normal activity. No patient had continuing pain in the sternoclavicular joint.     

Congenital endophthalmitis following maternal shellfish ingestion

Purpose: To highlight an unusual organism causing a unilateral endophthalmitis by transplacental spread.
Method: We report a case of Plesiomonas shigelloides endophthalmitis, presenting in a newborn, with co-existing septicaemia and meningitis. There was a significant maternal history of diarrhoea associated with the ingestion of oysters 2 weeks prior to delivery.
Result: The endophthalmitis was treated with parenteral antibiotics and topical mydriatics with complete resolution, although subsequent assessment of the affected eye suggests a poor visual outcome.
Conclusion: Endophthalmitis in the newborn is an unusual clinical finding and usually presents with other manifestations of bacteraemia. Plesiomonas shigelloides is fortunately an infrequent cause of neonatal infection, but is associated with a high degree of morbidity and mortality. We postulate that this neonate acquired P. shigelloides via the transplacental route, and suggest that this organism be included in the list of 'other' causes of transplacental infection that has been abbreviated to 'O' in the acronym TORCH.     

Suppurative corneal ulceration in Bangladesh

Suppurative keratitis is an important preventable cause of blindness, particularly in the developing world. This study analyses 142 cases of suppurative keratitis referred to Chittagong Eye Infirmary, Bangladesh. Some 53.5% of cases were bacterial and 35.9% were fungal. The five most common pathogens were: Pseudomonas sp. 24%, Streptococcus pneumoniae 17%, Aspergillus sp. 13%, Fusarium sp. 7% and Curvularia sp. 6%. Gram stain and culture results were consistent in 62.6% of cases. Previous antibiotic treatment was a significant factor for failure of culture isolation and less so for Gram stain failure. On Gram stain, 55.9% of pseudomonal cases were missed, but only 2% of fungal cases were missed. Over all, Gram stain had a sensitivity of 62% and positive predictive value of 84% for bacterial cases, and 98% and 94% for fungal cases, respectively. Fungal ulcers were typically filamentous, but an antecedent history of trauma was not common. The most frequent injury was due to rice grains, but the inoculum appeared to be introduced during eye washing with contaminated water. Pseudomonal ulcers occurred most frequently in the monsoon season, and Fusarium cases were seen only in the hot, dry season.