613 Microsurgical Salvage of Neonatal Upper Limb Ischaemia Subsequent to Intrauterine Brachial Vessel Constriction

Introduction

We report a case of limb salvage due to intra uterine brachial artery thrombosis. Treatment modalities include medical, endovascular, and surgical. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity.

Description

A male baby at (36 + 6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. The child was noted to have a ‘flail’ ischeamic limb post-delivery. There were no palpable pulses in the limb and ultrasonography confirmed thrombosis of the proximal brachial artery. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularisation was achieved with a contralateral interposition reversed great saphenous vein graft.

Discussion

Neonatal limb ischaemia is a rare disease entity with devastating morbidity- including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The initial diagnosis is based on the characteristic sequelae of ischaemia. Therapy should be individualised based on the clinical presentation. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity.

Mortality estimates in the elderly burn patients: the Northern Ireland experience

There is a relative paucity of mortality data in the medical literature from UK burn units. The objective of this study was to audit our mortality in the elderly during a 10-year period and compare it with the most robust data available in the UK from Birmingham. Data were collected on all patients 65 years of age and older between 1st January 1996 and 31st December 2005. Data included age, burn size, cause of thermal injury, outcome (survival/death) and the expected mortality derived from the revised Bull mortality grid. Notes on 143 patients were available for review. The mean age was 76.7 years and the maximum burn size treated was 65%. Ten patients were diagnosed with smoke inhalation. All but 22 patients had a pre-morbid condition, predominantly cardiovascular disease. Surgical procedures were performed on 113 patients. We performed excision and grafting of burned tissue, in 50% of patients, within 72 h of sustaining thermal injury. There were 18 deaths in the group while the expected number of deaths was estimated to be 33. This difference was found to be statistically significant (x(2)=8.92, d.f.=1, p<0.005). In conclusion, our experience has shown better survival in the elderly than was expected. This we mainly attribute to an aggressive therapy approach including admission to the intensive care unit and early surgery.

Potential of microemulsion electrokinetic chromatography for the separation of priority endocrine disrupting compounds

This work examines the potential of microemulsion electrokinetic chromatography for the separation of several priority endocrine disrupting compounds (EDCs). The optimised microemulsion system comprised 25 mM phosphate buffer pH 2, 80 mM octane, 900 mM butanol, 200 mM sodium dodecyl sulphate and was further modified with 20% propanol. The use of a low pH buffer resulted in the suppression of electroosmotic flow within the capillary. Reversal of the conventional electrode polarity resulted in faster migration of hydrophobic compounds. Test analytes included the octylphenol, nonylphenol and nonylphenol diethoxylate, which are breakdown products of the alkylphenolic detergents. The synthetic oestrogens diethylstilbestrol and ethynyloestradiol were also included in the separation along with the plastic monomer bisphenol-A. Test analytes were selected due to their reported presence in environmental samples namely industrial and domestic wastewater treatment effluents and sludges. Using the optimised method a separation of six EDCs was achieved within 15 min. The optimised method was then applied to the analysis of a spiked wastewater influent sample with UV detection of all six compounds at 214 nm.

Development of comparative methods using gas chromatography-mass spectrometry and capillary electrophoresis for determination of endocrine disrupting chemicals in bio-solids

Two analytical separation techniques are being investigated for their potential in determining a wide range of endocrine disrupting chemicals (EDCs) in the environment. Capillary electrophoresis (CE) in the micellar mode in conjunction with a cyclodextrin (CD) modifier is shown to have potential for determination of alkylphenol breakdown products. Gas chromatography with mass spectrometric (GC-MS) detection is being utilised for validation of the CE method development and in addition as a separation technique to optimise preconcentration using solid-phase extraction. GC has demonstrated potential for the separation of 26 priority chemicals suspected as being endocrine disrupting compounds. The challenge of the method development process lies in the fact that these compounds are of differing polarities, size and charge and therefore are difficult to separate in a single run. Capillary electrophoresis in the CD-MEKC (micellar electrokinetic chromatography) mode is showing potential in this regard. Limits of determination are in the low mg/l range for CE and GC, however, using preconcentration it is possible to improve detection sensitivity with >80% recovery for some analytes and up to 100% recovery for most target species.

Separation of two groups of oestrogen mimicking compounds using micellar electrokinetic chromatography

Two groups of compounds are being investigated due to their reported oestrogen mimicking characteristics in the environment. Separation of phenolic compounds and synthetic oestrogens using micellar electrokinetic chromatography is reported. Photodiode array detection is used for both separations. A standard separation buffer can be used for both groups of compounds including zwitterionic buffer cyclohexylamino-1-propanesulfonic acid, 20 mM at pH 11.5. It was found necessary to include 15% acetonitrile and 25 mM sodium dodecyl sulfate to aid separation and maintain analytes in solution. Optimum separations are achieved using 20 kV with hydrodynamic injection for 5 s. The relative standard deviation (RSD) for reproducibility was investigated for a mixture of phenols and synthetic oestrogens. For these compounds RSD was found to be <0.6% in all cases. Peak efficiencies ranged from 76,000 to 150,000 theoretical plates for different analytes. Application to environmental samples is discussed.

Stroke patients' views on stroke outcomes: death versus disability

AIMS

To determine how elderly stroke patients perceive different stroke outcomes, including death, relative to each other and how these views compare with those of age/sex-matched controls.

PARTICIPANTS AND SETTING

Twenty-eight elderly patients discharged from hospital with an acute stroke causing hemiplegia. Twenty-eight age/sex-matched control patients from the same hospital who had never had a stroke or transient ischaemic attack.

METHODS

Patients and controls were asked to rank 11 clinical scenarios of potential stroke outcomes, from the most to the least desirable outcome.

RESULTS

There was a striking bimodal distribution for sudden painless death in both groups. Painless death was preferred to even a minor stroke disability in over one-third of elderly individuals, whilst 20% would prefer severe disability rather than painless death. Sixty-nine per cent of stroke patients and 82% of controls ranked death as preferable to severe disability. Stroke patients may be more tolerant of disability (compared to death) than their controls (39% patients and 61% controls preferred death to any disability, p = 0.11).

CONCLUSIONS

Our results suggest that many elderly individuals would rather die than be alive and severely disabled. This may have important implications for acute stroke treatments such as thrombolysis.

A study of the prevalence of male intrameatal warts using meatoscopy in a genitourinary medicine department

A cross-sectional study is undertaken to determine the prevalence of male intrameatal and distal urethral warts, using meatoscopy. A group of 169 patients presenting for anogenital warts and a group of 74 unselected patients attending the Department for a variety of reasons during the study period, were examined. Twenty-one patients (13.5%) out of 155 patients with anogenital or related warts had external warts at the meatus. Of these 21 cases, 12 (57.1%) had further extension of their warts into the distal urethra. Fifteen other cases of intrameatal and distal urethral warts were detected in the absence of external warts at the meatus. Twenty-three cases out of 107 males with genital warts (21.5%) were found to have intrameatal or distal urethral warts, thus reflecting the common occurrence of these lesions. A highly significant association between the presence of intrameatal/distal urethral warts and the presence of male genital warts was found (P = 0.003). One hundred and fifty-three repeat meatoscopic examinations were carried out, 6 weeks after their first examination. Three new cases of intrameatal/distal urethral warts were found. Intrameatal and distal urethral warts occurred from a depth of 5 mm to 25 mm. One hundred and eighty-three female partners of the study patients were examined. An association between the presence of intrameatal/distal urethral warts and female anogenital warts was found (P = 0.028). No corroborating association between the presence of male and female anogenital warts was found (P = 0.47). This observation may have a bearing on disease transmission and control. The detection of intrameatal/distal urethral warts will be important in achieving successful treatment of male anogenital warts.

The value of primary colposcopy in genitourinary medicine--a six year review

OBJECTIVE

To evaluate the effectiveness of primary colposcopy in the genitourinary medicine setting by comparing the cervical cytology and punch biopsy results for women identified as having an abnormal cervical transformation zone.

METHOD

A retrospective audit of six years' findings in primary colposcopy was carried out. The punch biopsy findings of 1338 women were compared with their last cervical cytology results. A small sample of biopsies were subjected to in situ hybridisation for human papilloma virus types 6, 11, 16, 18 and cytomegalovirus.

RESULTS

The tabulated results demonstrated the variability between histology and cytology. This was explored with reference to other studies. The viral typing showed the dominance of low oncogenic risk human papilloma virus types.

CONCLUSION

The findings are discussed against the overall concept of sexual health. Primary colposcopy facilitates empowerment of the patient and her partner through the opportunity for demonstration and explanation of disease processes and options for management. Experience and expertise gathered in six years of primary colposcopy confirm the value of primary colposcopy not only in improved diagnosis and management but also in teaching, audit and research.