Paediatric otogenic cerebral venous sinus thrombosis: a multidisciplinary approach.

BACKGROUND: Paediatric otogenic cerebral venous sinus thrombosis is a rare, heterogeneous and life-threatening condition, with possible otological, neurological and ophthalmological sequelae. Its course and outcomes can be widely variable. The publications available often consider individual aspects of paediatric otogenic cerebral venous sinus thrombosis management. The condition itself and the nature of the currently available guidance can lead to uncertainties when holistically managing patients with paediatric otogenic cerebral venous sinus thrombosis. OBJECTIVES: Clear recommendations for the comprehensive assessment and management of paediatric otogenic cerebral venous sinus thrombosis are presented, along with the literature review upon which they are based. Its clinical and radiological assessment are discussed. CONCLUSION: A multidisciplinary approach to assessment and management is recommended, inclusive of infectious diseases, ENT surgery, neurology, ophthalmology and haematology. On balance, anticoagulation is recommended for three months. Follow-up imaging is not recommended in the absence of clinical concern. Follow up by ENT surgery, neurology and ophthalmology departments is recommended.

Prioritising topics for the undergraduate ENT curriculum.

OBJECTIVE: Knowledge of ENT is important for many doctors, but undergraduate time is limited. This study aimed to identify what is thought about ENT knowledge amongst non-ENT doctors, and the key topics that the curriculum should focus on. METHODS: Doctors were interviewed about their views of ENT knowledge amongst non-ENT doctors, and asked to identify key topics. These topics were then used to devise a questionnaire, which was distributed to multiple stakeholders in order to identify the key topics. RESULTS: ENT knowledge was generally thought to be poor amongst doctors, and it was recommended that undergraduate ENT topics be kept simple. The highest rated topics were: clinical examination; when to refer; acute otitis media; common emergencies; tonsillitis and quinsy; management of ENT problems by non-ENT doctors; stridor and stertor; otitis externa; and otitis media with effusion. CONCLUSION: This study identified a number of key ENT topics, and will help to inform future development of ENT curricula.

Recent dioxin contamination from Agent Orange in residents of a southern Vietnam city.

Marked elevation of dioxin associated with the herbicide Agent Orange was recently found in 19 of 20 blood samples from persons living in Bien Hoa, a large city in southern Vietnam. This city is located near an air base that was used for Agent Orange spray missions between 1962 and 1970. A spill of Agent Orange occurred at this air base more than 30 years before blood samples were collected in 1999. Samples were collected, frozen, and sent to a World Health Organization--certified dioxin laboratory for congener-specific analysis as part of a Vietnam Red Cross project. Previous analyses of more than 2200 pooled blood samples collected in the 1990s identified Bien Hoa as one of several southern Vietnam areas with persons having elevated blood dioxin levels from exposure to Agent Orange. In sharp contrast to this study, our previous research showed decreasing tissue dioxin levels over time since 1970. Only the dioxin that contaminated Agent Orange, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), was elevated in the blood of 19 of 20 persons sampled from Bien Hoa. A comparison, pooled sample from 100 residents of Hanoi, where Agent Orange was not used, measured blood TCDD levels of 2 parts per trillion (ppt). TCDD levels of up to 271 ppt, a 135-fold increase, were found in Bien Hoa residents. TCDD contamination was also found in some nearby soil and sediment samples. Persons new to this region and children born after Agent Orange spraying ended also had elevated TCDD levels. This TCDD uptake was recent and occurred decades after spraying ended. We hypothesize that a major route of current and past exposures is from the movement of dioxin from soil into river sediment, then into fish, and from fish consumption into people.

Agent Orange and the Vietnamese: the persistence of elevated dioxin levels in human tissues.

OBJECTIVES: The largest known dioxin contamination occurred between 1962 and 1970, when 12 million gallons of Agent Orange, a defoliant mixture contaminated with a form of the most toxic dioxin, were sprayed over southern and central Vietnam. Studies were performed to determine if elevated dioxin levels persist in Vietnamese living in the south of Vietnam. METHODS: With gas chromatography and mass spectroscopy, human milk, adipose tissue, and blood from Vietnamese living in sprayed and unsprayed areas were analyzed, some individually and some pooled, for dioxins and the closely related dibenzofurans. RESULTS: One hundred sixty dioxin analyses of tissue from 3243 persons were performed. Elevated 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) levels as high as 1832 ppt were found in milk lipid collected from southern Vietnam in 1970, and levels up to 103 ppt were found in adipose tissue in the 1980s. Pooled blood collected from southern Vietnam in 1991/92 also showed elevated TCDD up to 33 ppt, whereas tissue from northern Vietnam (where Agent Orange was not used) revealed TCDD levels at or below 2.9 ppt. CONCLUSIONS: Although most Agent Orange studies have focused on American veterans, many Vietnamese had greater exposure. Because health consequences of dioxin contamination are more likely to be found in Vietnamese living in Vietnam than in any other populations, Vietnam provides a unique setting for dioxin studies.

Unreasonable expectations of reconstructive patients affecting rehabilitation.

Common difficult and recurring problems develop which make the demands of certain cosmetic surgical patients appear reasonable or not reasonable to the people operating upon them. In spite of careful preparation and repeated instruction, a number of patients continue to entertain fixed and elusive ideas about themselves, their body images, and the results they desire from surgery. These wishes are often not logical, and derive from personal experiences of the patients, and are not related to the actual degree of deformity or the objective reactions that other people have to these defects. while it is generally true that more gross deformities force a more realistic perspective upon the patients and their families in contrast to many normal-looking persons who seek cosmetic surgery, this is not always the case. The authors attempt to examine and describe several specific cases of these problems, along with the psychological mechanisms which underlie them, and present possible ways in which such behavior can be managed by the aesthetic surgeon. An attempt is also intended to be as practical as possible about the use of the busy surgeon's time in these situations.

Public and professional reactions to the facially disfigured which interfere with rehabilitation.

The rare appearance in public and the difficulty in obtaining follow-ups indicate the general tendency of facially disfigured people toward seclusion and restriction of their work lives and social functioning. Investigation of some of the reactions in the community, the underlying mental mechanisms, and the ways in which the nurses, doctors, and teachers they meet lead to the awareness of the ways in which professional and public attitudes may function synergistically against the rehabilitation and optimal functioning of these patients. The innate and biological mechanisms which cause observers of the disfigured to react with alarm, fear, rejection, and withdrawal are examined, as also are the ways in which professional attitudes differ, and how professional attitudes evolve. The variables of authoritarianism, friendliness, and the ways in which caretakers perceive and manage people in deviant roles in order to advance their rehabilitation will be explored and illustrated with case examples. Techniques for educating doctors and nurses about handling disfigurement in the complex matrix of modern medical care will be outlined, with emphasis upon comprehensive care and the emerging concepts of a case manager system of care in the handling of these chronic and tragic problems.

Advantages of double releases in axillary, antecubital and popliteal contractures.

The advantages of the double release technique in axillary contractures are discussed. The procedure is useful for releasing contractures involving the antecubital and popliteal spaces as well. The risk of cutting vital structures involved in the scar tissue is minimized; also, the skin in the center of the axilla, if infected or ruptured, can be covered without as much threat to the axillary space. In addition, by placing the skin grafts on the surfaces at edges of the antecubital or in the popliteal space, the take of the skin graft on a flat surface is better insured.