Endoscopic Reconstruction of Cranial Base Defects following Endonasal Skull Base Surgery.

The expanded endonasal approach provides access to the entire ventral skull base for resection of neoplasms involving the skull base and brain. The creation of large defects of the bone and dura endoscopically presents unique reconstructive challenges. A layered reconstruction of the dura with inlay and onlay fascial grafts covered with fat grafts is an effective technique for repair. An intranasal balloon catheter is used to provide counterpressure in the early phase of healing and a lumbar spinal drain is a useful adjunct in patients at increased risk of a cerebrospinal fluid leak. Vascularized flaps may be necessary in some patients receiving radiation therapy. Continued advances in surgical technology and the introduction of new biomaterials will facilitate the reconstruction of skull base defects following endonasal brain surgery.     

Development of methods to analyse transcranial Doppler ultrasound signals recorded in microgravity

During space flights, several clinical syndromes may be the result of changes in cerebral circulation. The purpose of the paper is to describe the development and initial evaluation of a system for recording, processing and displaying transcranial Doppler ultrasound (TCD) waveforms from the middle cerebral artery (MCA) in microgravity. Volunteers were repeatedly subjected to 15–20 s intervals of microgravity (‘near zero gravity’) during flights on the KC-135 military aircraft. Continuous TCD recordings from the MCA were stored on magnetic tape. The paper describes the system that was developed to digitise the Doppler ultrasound data and markers that corresponded to the various levels of microgravity, obtain the maximum and mean Doppler waveforms, identify the waveforms and quantify them. The results demonstrate the feasibility of making TCD recordings in a microgravity environment and illustrate excellent performance of the system and its ease of operation. Quantitative waveform analysis of the recordings from the first subject studied in the supine position showed statistically significant changes in MCA velocity waveforms during microgravity.     

Can we reduce morphine use in elderly,proximal femoral fracture patients using a fascia iliac block?

Proximal femoral fractures are becoming increasingly common with an ageing population. Many patients have multiple comorbidities increasing their risk of opiate complications. 40 consecutive patients presenting with a proximal femoral fracture to a trauma centre in the UK were given either a Fascia Iliaca Block (FIB) with oral analgesia or just oral analgesia to control their pre-operative pain. Numeric pain scores and morphine consumption were used as outcome measures. Patients receiving a FIB had significant reduction in their pain scores compared to patients only receiving oral pain relief. There was also a significant reduction in both the actual oral morphine taken and the renal calculated level of morphine products in the group receiving the FIB. Patients undergoing a FIB required almost 50 mg less oral morphine pre-operatively. Nerve blocks should be used routinely to help pre-operative pain in proximal femoral fracture patients and to reduce the amount of morphine products prescribed. This prevents potential opiate complications in a highly susceptible cohort of patients often suffering with impaired renal function as a co-morbidity.     

Small Intestinal Bacterial Overgrowth: Should Screening Be Included in the Pre-fecal Microbiota Transplantation Evaluation?

Digestive Diseases and Sciences - Fecal microbiota transplantation (FMT) is safe and effective for recurrent Clostridium difficile infection (rCDI) and often involves terminal ileal (TI) stool...     

Epidemiology and Risk Factors for Bloodstream Infections in a Home Parenteral Nutrition Program

Background: An increasing number of patients with intestinal failure are receiving home parenteral nutrition (HPN). Associated complications include bloodstream infections (BSIs), but data on rates and risk factors for HPN‐related BSIs are scarce. Methods: A retrospective review was conducted of patients enrolled in the regional HPN program between 2001 and 2008. Demographic information and data on indication for HPN, duration of PN therapy, type and date of insertion of central venous access device, and blood culture results were recorded. Results: In total, 155 patients (165 courses of HPN) were included for a total of 45,876 catheter days. The mean patient age was 49 years, and 105 (64%) patients were female. A total of 105 organisms were cultured from 93 distinct episodes of BSIs. The rate of BSI was found to be 2.0 per 1000 catheter days, but excluding BSIs with a single positive culture of coagulase‐negative staphylococcus and diphtheroid bacilli, the rate of infection was 1.4 per 1000 catheter days. Male sex and underlying malignancy were significant predictors of BSI, with hazard ratios of 1.69 (95% confidence interval [CI], 1.14–2.60; P = .009) and 2.38 (95% CI, 1.53–3.50; P < .001). Conclusion: In a large heterogeneous group of HPN patients, the BSI rate ranged between 1.4 and 2.0 infections per 1000 catheter days. Isolated organisms were similar to those found in hospitalized patients. Male sex and underlying malignancy were significant risk factors for BSI. These high‐risk patients are likely to benefit from interventions aimed at reducing BSIs.     

Parapharangeal edema: an uncommon complication of TMJ arthroscopy

Ohnishi in 1975 first described temporomandibular joint (TMJ) arthroscopy. Along with its extensive use, a range of complications has emerged. We describe a patient who experienced parapharyngeal swelling after undergoing arthroscopy. Prolonged intubation up to 1 hour postoperatively was required. The swelling resolved completely over 6 h without further intervention.