AN INTEGRATED HAEMATURIA CLINIC

The prognosis of bladder cancer is worsened by delay in its management. To reduce such delay we have organised a clinic where intravenous urography and cystoscopy, using a flexible cystoscope, are carried out at the patient's first visit. In a two-year period 321 patients attended this clinic. The results of investigation in 305 patients are reported. A total of 6% of patients with microscopic haematuria (n = 52) and 15% of patients with macroscopic haematuria (n = 253) had transitional cell carcinomata. This difference was not significant (P=0.08, chi-squared). The delay between referral and trans-urethral resection of tumour for patients with bladder tumours was reduced from a mean of 60 days to a mean of 33 days by the institution of the clinic (P<0.01, Mann-Whitney). We recommend that all patients referred to a urological service with haematuria, whether macroscopic or microscopic, should be investigated. The integration of that investigation in a single day decreases delays in diagnosis and management.     

Anterior lamellar keratoplasty: ‘Back to the Future’– a review

Newer forms of lamellar keratoplasty techniques have emerged in the last decade or so revolving around the concept of targeted replacement of diseased corneal layers. These include anterior lamellar keratoplasty (ALK) techniques that aim to selectively replace diseased corneal stroma and, endothelial keratoplasty techniques aiming to replaced damaged endothelium in endothelial disorders. ALK surgery has a distinct advantage over penetrating keratoplasty (PK) in that it minimizes unnecessary replacement of the unaffected healthy endothelial layer thereby almost eliminating the risk of endothelial rejection, a major cause of graft failure in PK. Overall it provides increased life expectancy to the graft and with advancements in the surgical technique and instrumentation for ALK, the visual outcomes are now comparable if not better to standard PK. There are several forms of ALK procedures that have evolved to cater to a wide range of stromal disorders. This article reviews the various emerging techniques of anterior lamellar surgery, its indications and visual outcomes, to emphasize the shift from PK to ALK for stromal disorders with a healthy endothelium.     

Bipolar Radiofrequency Dissection Tonsillectomy: A Prospective Randomized Trial

OBJECTIVES: To conduct a prospective randomized controlled study presenting and comparing bipolar radiofrequency dissection tonsillectomy (BRDT) to cold dissection tonsillectomy (CDT) regarding intra-operative blood loss, operative time, postoperative pain, and postoperative complications including hemorrhage. MATERIALS AND METHODS: From January 2004 to March 2005, 200 children planned to undergo tonsillectomy were included in this study. Children were prospectively randomized into two equal groups: bipolar radiofrequency dissection tonsillectomy and cold dissection tonsillectomy. The operative time and intra-operative blood loss were recorded. Children were asked to record their pain on a standardized visual analog scale on days 1, 4, 7, and 14. All children were reviewed on the 4th, 7th, and 14th day after surgery. Postoperative complications were recorded and dealt with. RESULTS: There was a shorter operative time (mean 8.5 minutes, P < 0.001) in the radiofrequency group. BRDT showed a decrease of 7 minutes in the mean when compared to the CDT group. The amount of blood lost during BRDT was minimal (mean 13 cc), with a mean difference of 69 cc when compared to CDT (P < 0.001). There was no statistical significant difference in pain score between the two groups except in the first postoperative day where the BRDT demonstrated a statistically significant lower parameters (P < 0.05). No evidence for statistically significant difference between the two groups regarding postoperative complications. CONCLUSION: BRDT is a new, easy, and safe technique that offers a complete eradication of the tonsillar disease, short operating time, minimal intra-operative blood loss, and a suitable cost with no additional increase in postoperative pain and hemorrhage when compared to the conventional CDT. Our experience promotes BRDT as the preferred method of tonsillectomy.     

Study of propranalol as a premedication in cataract surgery a pilot study

In a randomized and double-blind study, we found that propranolol (40 mg) given 2 hours prior to cataract surgery under local anesthesia reduces perioperative rise in heart rate and blood pressure. Relative to controls, cases showed lower mean pulse rate and mean systolic blood pressure at all time intervals. Propranolol effectively reduces anxiety before and during the surgery. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article. The authors also do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.     

Post-operative sputum retention treated by minitracheostomy — a ward procedure?

Cricothyroidotomy, using the percutaneous ‘minitracheotomy’ technique, was performed in 67 patients (55 for sputum retention, two for endobronchial rupture of an empyema, 10 prophylactically). In two patients the cricothyroid membrane was penetrated with considerable difficulty, and in one further patient insertion was not possible due to calcification of the cricothyroid membrane. One patient required exploration of the insertion site because of bleeding. Two patients inhaled the “Mark 1 Minitrach' device and required urgent bronchoscopic removal. In those patients undergoing successful cricothyroidotomy, there was a dramatic improvement in respiratory distress. There were no deaths related to the insertion of the minitracheotomy device in this series.     

A Case of Spontaneous Coronary Artery Dissection: It is Not Always Plaque Rupture

Background

Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of acute coronary syndrome (ACS). Patients may present with a broad spectrum of clinical scenarios, ranging from angina pectoris to myocardial infarction, cardiogenic shock, and sudden death. Standard therapy has not been established; current treatments range from conservative management to percutaneous revascularization or coronary artery bypass surgery.

Objective

SCAD greatly mimics ACS, and this diagnosis should be considered when evaluating young patients who present with ACS with or without classical risk factors for coronary artery disease.

Case Report

We report a case of a 45-year old man who presented with chest pain typical of ACS. He had no risk factors except for a smoking history of 2.5 pack-years. Once the clinical findings suggested acute inferolateral myocardial infarction, the patient underwent emergent cardiac catheterization, which revealed left anterior descending coronary artery dissection. This in itself is not a common cause of inferolateral ST elevation changes on electrocardiogram.

Conclusion

This case highlights the fact that although SCAD is a rare entity, it is increasingly being recognized as a significant cause of ACS. Urgent angiography should be considered if SCAD is suspected, because early diagnosis and appropriate management significantly improve the outcome in these patients.