Complications of trans-sphenoidal surgery: the Wellington experience

BACKGROUND: All patients who underwent trans-sphenoidal surgery between January 1984 and December 1998 were reviewed to assess morbidity resulting from this operation. METHODS: There were 185 operations on 165 patients. The operative approach was sublabial in 80 cases and transnasal in 105. One surgeon (VB) performed the vast majority of operations. RESULTS: Complications included nasal perforation (7.6%), transient diabetes insipidus (4.9%), permanent diabetes insipidus (3.8%), cerebrospinal fluid fistula (4.3%), donor site haematoma (2.2%) and residual tumour haemorrhage (1.6%) causing ophthalmoplegia (1.1%) and loss of vision (1.1%). Other complications included epistaxis (1.1%), meningitis (0.5%) and sinusitis (0.5%). Injury to the anterior superior alveolar nerve also occurred in the sublabial approach in 6.3% of patients. There were no perioperative deaths. CONCLUSIONS: There is a small but significant risk of a number of complications that should be considered for informed consent of this procedure.     

Single lead atrial synchronised pacing in patients with cardiogenic shock after acute myocardial infarction.

A pacing system requiring only a single lead was used to establish atrial synchronised pacing in eight patients with complete atrioventricular block and cardiogenic shock following acute myocardial infarction. Spontaneous atrial activity was sensed through electrodes positioned on the pacing lead and used to trigger ventricular demand pacing. A normal atrioventricular relation could be established in each of these critically ill patients without the complexity of inserting and finding a stable position for an additional atrial sensing lead. Atrial synchronised pacing at the spontaneous sinus rate had distinct haemodynamic advantages compared with conventional ventricular pacing at 100 beats/min. Mean cardiac output for the group was 3.3 1/min with atrial synchronised pacing compared with 2.6 1/min with conventional pacing, a significant difference of 27%. Peak systolic pressure averaged respectively 91 and 73 mm Hg in the two pacing modes. With conventional ventricular pacing a pronounced phasic alteration in blood pressure was observed, dependent on the altering relation of the paced beats to spontaneous atrial activity. Atrial synchronised pacing abolished this effect and resulted in a stable blood pressure at or above the peak pressure achieved with conventional pacing. Atrial synchronised pacing with a single lead system can be established rapidly. This mode of pacing has appreciable and significant haemodynamic superiority over conventional ventricular pacing in patients with cardiogenic shock and atrioventricular block following acute myocardial infarction.     

Michel's medium: a potential alternative to cryoprotection for tissue transport in the investigation of genetic skin disease

Michel's medium is now well established as a transport medium to maintain tissue-fixed immunoreactants prior to direct immunofluorescence and immunoelectron microscopy. This is a practical alternative to cryofixation prior to transportation when sending skin biopsies for the investigation of cutaneous immunobullous disease. In this study we have demonstrated preservation of the cutaneous basement membrane zone proteins in skin biopsies stored in Michel's medium for periods of up to 28 days - proving that Michel's medium can be used as a transport medium when sending skin biopsies for immunohistochemical studies to determine the structural and molecular deficiencies in genodermatoses such as inherited forms of epidermolysis bullosa.     

Childhood dermatitis herpetiformis: an unusual presentation

Childhood dermatitis herpetiformis (DH) is rare. The true prevalence and incidence of this condition are unknown. We report a 7-year-old boy presenting with nonpruritic inflammatory papules on the buttocks and extensor surfaces, clinico-pathologically consistent with Sweet's neutrophilic dermatosis. Immunofluorescence studies showed IgA deposits in the dermal papillae consistent with DH. Remission was achieved with a gluten-free diet and dapsone. Childhood DH may present different clinical signs to the adult form and misdiagnosis can occur if immunofluorescence is not requested on skin biopsy.     

Keratolytic winter erythema with facial involvement: a novel presentation

We present a 23-year-old woman with a diagnosis of keratolytic winter erythema (erythrokeratolysis hiemalis), who developed facial lesions following a traumatic experience. This rare genodermatosis usually affects the palms and soles, and appears as mild erythema and annular scaling. The limbs and trunk can rarely be affected. To our knowledge, this is the first reported case of facial involvement.     

Single lead atrial synchronised pacing in patients with cardiogenic shock after acute myocardial infarction

A pacing system requiring only a single lead was used to establish atrial synchronised pacing in eight patients with complete atrioventricular block and cardiogenic shock following acute myocardial infarction. Spontaneous atrial activity was sensed through electrodes positioned on the pacing lead and used to trigger ventricular demand pacing. A normal atrioventricular relation could be established in each of these critically ill patients without the complexity of inserting and finding a stable position for an additional atrial sensing lead. Atrial synchronised pacing at the spontaneous sinus rate had distinct haemodynamic advantages compared with conventional ventricular pacing at 100 beats/min. Mean cardiac output for the group was 3.3 1/min with atrial synchronised pacing compared with 2.6 1/min with conventional pacing, a significant difference of 27%. Peak systolic pressure averaged respectively 91 and 73 mm Hg in the two pacing modes. With conventional ventricular pacing a pronounced phasic alteration in blood pressure was observed, dependent on the altering relation of the paced beats to spontaneous atrial activity. Atrial synchronised pacing abolished this effect and resulted in a stable blood pressure at or above the peak pressure achieved with conventional pacing. Atrial synchronised pacing with a single lead system can be established rapidly. This mode of pacing has appreciable and significant haemodynamic superiority over conventional ventricular pacing in patients with cardiogenic shock and atrioventricular block following acute myocardial infarction.     

Chronic endemic hydroarsenicism

Chronic endemic hydroarsenicism in a 48-year-old man from Antofagasta, Chile, is reported. The literature on the global health problems of hydroarsenicism is reviewed, especially with regard to the carcinogenic action of arsenic.     

Low voltage electrical activity preceding right atrial depolarisation in man.

Electrical recordings were made in the high right atrium in 28 patients undergoing cardiac catheterisation and in 3 healthy volunteers. After filtering and amplification by 3 to 10 million times, the signals were passed through a signal averaging process in a digital computer. Of the 28 subjects who had technically satisfactory recordings, 23 showed low voltage electrical activity preceding the conventionally-recorded atrial depolarisation. The low voltage activity started 50 to 200 ms before the atrial deflection and was variable in shape. These early signals may be the result of activity in the region of the sinus node.     

Xanthoma disseminatum: a case with hepatic involvement, diabetes insipidus and type IIb hyperlipidaemia

Xanthoma disseminatum (XD) is a rare benign non-X-histiocytic disorder of unknown aetiology. We report a 37-year-old man who presented with XD preceded by a decade of cranial diabetes insipidus, with associated type IIb hyperlipidaemia and computed tomographic evidence of hepatic involvement. A review of the literature is also included.