Coronary artery fistulae : 4 cases repaired surgically

Coronary artery fistulae involve a communication between a coronary artery and a heart chamber or part of the pulmonary circulation. Most are asymptomatic and discovered incidentally, whilst larger ones may cause coronary steal syndrome. Fistulae may produce continuous murmurs and are diagnosed at echocardiography or angiography. Treatment is by percutaneous coil embolisation or open surgery. This article reviews four cases treated with surgical closure. All patients were asymptomatic and diagnosed incidentally at angiography. One case involved a failed attempt at percutaneous coil embolization requiring immediate open surgery. The other three cases required other operative procedures and the fistulae were oversutured during the same procedure.peer-reviewe

Chest wall reconstruction following a speedboat propeller injury

Propeller blade injuries to the chest are uncommon but can result in devastating injuries. We describe a case of a 44 year-old male scuba diver who was dragged by sea currents into the propeller of a speedboat. He suffered extensive chest wall trauma but narrowly escaped damage to major organs and vessels. He was admitted directly to the operating theatre. There was significant loss of bone from the manubrium, costal cartilages, overlying skin and muscle which were stripped off in 3 horizontal bands. During reconstruction the bony fragments were anchored to the nearest stable sternal or costal cartilage entities using steel wires, to achieve stability. The overlying muscle and skin were sutured directly to its opposite edge in layers and in an interdigitating fashion following the shape of the propeller blade lacerations. The patient remained intubated for 3 days in ITU and was transported back to his home country. He required a small skin graft to one area of necrosis but eventually made a full recovery with only his scars as a reminder of his accident. There have been other cases of propeller injuries in Malta but this is unique in being a severe injury to the chest, in which the patient made a full recovery. This report highlights the importance of legislation in preventing propeller injuries by restricting swimmer zones and introducing propeller guards or jet drive systems.peer-reviewe

Recurrent chest infections in two young non-smoker men

Pulmonary mucinous cystic carcinomas are rare salivary gland type carcinomas of the lung. They form part of a wide spectrum of mucin secreting glandular mixed type tumours. They comprise 0.1 – 0.2% of all lung tumours. They occur more frequently in young patients and present with cough or recurrent chest infections and therefore may be easily misdiagnosed. Since treatment depends fully on complete surgical resection early diagnosis is essential. Even with treatment the 10-year survival is quoted at 53%. We describe two cases of such rare tumours both of who underwent curative surgical resection. Both patients were younger than 35 years old and presented with recurrent chest infections. The patients were followed for up to eight years and the outcome recorded. A literature search confirms the occurrence in younger patients, who often present with pneumonias and that surgery is the only hope for cure.peer-reviewe

Stories for change: is online campaigning the new politics or just noise?

On Thursday Katherine Sladden, a campaigner at Change.org, presented “Stories that make change” to the Polis LSE Summer School. Here’s Ngozi Chuku’s report on the talk and her reflections on online campaigning

Psychiatric community nursing: a study of a working situation

A descriptive account is presented of a community psychiatric nursing service based at a psychiatric teaching hospital in Edinburgh. The object of the study was to contribute to the identification and analysis of the role and functions of community psychiatry nurses. The study was focused mainly on nurse-patient contact and on the process and content of nurse—patient interaction. The fieldwork for the study was carried out in 1972-73- The main instruments used were self-administered record schedules reporting nurses' contacts with patients and their families and interviews to obtain background information on factors which influenced the nurses' activities. It was found that the service was functioning mainly as an after-care agency. A high proportion of the work of the service took place in a hospital context; the case-load had close connections with hospital care, and the nurses mainly called on hospital resources and staff in support of their work. It was concluded that the staff were acting primarily as intermediaries between the patient and the hospital, and that their direct care functions were secondary to this. Factors which influenced the activities of the nurses included role concepts, role—relationships (which presented some problems) and the needs of the patient and his family. A combination of clinical-psychiatric and psycho-social needs were observed and it was inferred from the evidence that the former were better catered for than the latter. Particular problems in family relationships were recognised. It was concluded that the situation demanded enhanced skills which could be developed through supervised practice. It was also suggested that the functions and case-loads of community psychiatric nursing services were profoundly influenced by their location and organisation, and that these should, therefore, be decided in the light of an explicit formulation of desired objectives

Laparoscopic omentoplasty and split skin graft for deep sternal wound infection and dehiscence patient

Treatment of sternotomy dehiscence secondary to infection is complex. We describe a case where following debridement and negative pressure therapy the greater omentum was harvested laparoscopically, pedicled on the right gastroepiploic artery and transposed through a subxiphoid window and laid into the chest wound. The omentum was covered with a split skin graft. The omental transposition provided a healthy vascular bed for the skin graft to be laid on top of. This technique allows for larger defects to be closed when due to the amount of bone loss the sternum cannot be brought together. Such procedures are normally performed when all other measures have failed and myocutaneous flaps cover the omentoplasty. Our case is novel in that the laparoscopic harvest and the use of direct skin grafting make this an option to be considered earlier as a single definitive procedure.peer-reviewe

The difficulties in identifying and grafting an intramuscular coronary artery

Myocardial bridging involves tunnelling of one of the coronary arteries through the myocardium. While most patients with intramyocardial coronary vessels are asymptomatic, there is evidence that myocardial bridging may be the cause of sudden death. Given the low detection rate on coronary angiography, myocardial bridging may complicate coronary artery bypass grafting (CABG). This case report discusses a 72-year-old gentleman who underwent CABG, during which an undiagnosed intramuscular left anterior descending (LAD) coronary artery was found. With only the tapering end of the LAD visible at the apex of the heart, a small incision was made at this site and a 1mm probe inserted. At the uppermost reach of the probe the tip was felt to point superficial and therefore a second more proximal incision was performed. The left internal thoracic artery (LITA) was than successfully anastomosed with the proximal arteriotomy and a length of saphenous vein was used for anastomosis with the distal arteriotomy where the probe was originally inserted. The patient was discharged home 5 days post operatively.peer-reviewe

The difficulties in identifying and grafting an intramuscular coronary artery

Myocardial bridging involves tunnelling of one of the coronary arteries through the myocardium, resulting in what are known as intramyocardial coronaries. While most patients with intramyocardial coronary vessels are asymptomatic, there is evidence that myocardial bridging may be the cause of sudden death. Given the low detection rate on coronary angiography, myocardial bridging may complicate coronary artery bypass grafting (CABG). This case report discusses a 72-year-old gentleman who underwent CABG, during which an undiagnosed intramuscular left anterior descending (LAD) coronary artery was found. With only the tapering end of the LAD visible at the apex of the heart, a small incision was made at this site and a 1mm probe inserted. At the uppermost reach of the probe the tip was felt to point superficial and therefore a second more proximal incision was performed. The left internal thoracic artery (LITA) was than successfully anastomosed with the proximal arteriotomy and a length of saphenous vein was used for anastomosis with the distal arteriotomy where the probe was originally inserted. The patient was discharged home 5 days post operatively.peer-reviewe

Sexually transmitted infections: progress and challenges since the 1994 International Conference on Population and Development (ICPD)

AbstractBackgroundDespite being recognized as an important challenge at the 1994 International Conference on Population and Development (ICPD), sexually transmitted ınfections (STIs) other than HIV are one of the most neglected dimensions of sexual and reproductive health. STIs, often undiagnosed and untreated, have especially harmful consequences for women and their neonates.Progress since ICPDDuring the last two decades, substantial knowledge and experience have accumulated in behavior change programming during the global response to the HIV epidemic which can also be used for prevention of STIs. There has been progress in development and implementation of vaccines against certain STIs such as hepatitis B and the human papilloma virus. Development of a rapid, point-of-care test for syphilis has opened the door to control this infection.ChallengesThe estimated annual incidence of non-HIV STIs has increased by nearly 50% during the period 1995–2008. The growth in STIs has been aggrevated by a combination of factors: lack of accurate, inexpensive diagnostic tests, particularly for chlamydia and gonorrhea; lack of investment to strengthen health systems that can deliver services for diagnosis and management of STIs; absence of surveillance and reporting systems in the majority of countries; political, socioeconomic and cultural barriers that limit recognition of STIs as an important public health problem; and failure to implement policies that are known to work.RecommendationsGovernments, donors and the international community should give higher priority to preventing STIs and HIV; fully implementing behavior change interventions that are known to work; ensuring access of young people to information and services; investing in development of inexpensive technologies for STI diagnosis,treatment and vaccines; and strengthening STI surveillance, including of microbial resistance

Furosemide-induced eruption of haemorrhagic bullae on the fingers

This article describes a man who developed severe haemorrhagic necrotizing blisters within 1 week of being started on regular furosemide. The lesions were confined to the fingers bilaterally and accompanied by severe swelling and loss of function. There were no associated features. All investigations were negative and an adverse drug reaction to furosemide was diagnosed. The drug was stopped and the lesions resolved fully. This form of cutaneous drug reaction is one of the rarest forms of reactions to furosemide especially when confined only to the fingers. One must be aware of such complications and be prepared to withdraw the diuretic to confirm the diagnosis and achieve resolution of the lesions.peer-reviewe