Transvaginal repair of recurrent pouch-vaginal fistula.

AIM: Pouch-vaginal fistula is an uncommon but unpleasant complication. The chance of successful repair with various surgical procedures is around 50% and the early promise of collagen button plugs was not followed by good long-term results. We report a series of patients who underwent transvaginal repair of pouch-vaginal fistula after failed collagen plugs accompanied by a video to show the operative technique. METHOD: Patients were identified from a prospectively maintained database. Patient demographics, operation notes, complications and ultimate outcome were recorded. RESULTS: Eleven patients, each of whom had previously undergone an attempt to close the fistula with a collagen button plug, underwent transvaginal repair. Nine (81%) were successful at a median follow-up of 14 (6-56) months. The remaining two patients reported symptomatic improvement. CONCLUSION: Pouch-vaginal fistula can be successfully closed by the transvaginal technique after a failed button plug procedure.

Effects of aggressive cholesterol lowering and low-dose anticoagulation on clinical and angiographic outcomes in patients with diabetes: the Post Coronary Artery Bypass Graft Trial.

Diabetic patients have greater risk for coronary heart disease (CHD) events after coronary artery bypass graft (CABG) surgery than nondiabetic patients. The Post CABG trial studied the effects of aggressive cholesterol lowering and low-dose anticoagulation in diabetic patients compared with nondiabetic patients. A double-blind, randomized clinical trial in 1,351 patients (1-11 years after CABG), the Post CABG trial consisted of two interventions (aggressive cholesterol-lowering versus moderate lowering and low-dose warfarin versus placebo) on angiographic end points. Angiographic changes in saphenous vein graft conduits 4.3 years after entry were compared in 116 diabetic and 1,235 nondiabetic patients. Seven clinical centers participated in the trial, as well as the National Institutes of Health project office (National Heart, Lung, and Blood Institute), the coordinating center (Maryland Medical Research Institute), and the Angiogram Reading Center (University of Minnesota). Baseline characteristics of the diabetic patients differed from the nondiabetic patients in the following ways: percentage of women participants, 15 vs. 7%, P = 0.002; mean baseline weight, 87.4 vs. 82.8 kg, P = 0.006; mean BMI, 29.5 vs. 27.6 kg/m2, P = 0.0002; mean systolic blood pressure, 141.7 vs. 133.6, P < 0.0001; mean triglyceride concentrations, 2.09 vs. 1.77 mmol/l, P < 0.0001; and mean HDL cholesterol concentrations, 0.93 vs. 1.02 mmol, P = 0.0001. The percentage of clinical events was higher in diabetic than nondiabetic patients (20.6 vs. 13.4, P = 0.033) and angiographic outcomes were not different. The benefits of aggressive cholesterol lowering were comparable in diabetic and nondiabetic patients for the angiographic end points. Warfarin use was not associated with clinical or angiographic benefit. Diabetic patients in the Post CABG trial had more CHD risk factors at study entry and higher clinical event rates during the study than nondiabetic patients. The benefits of aggressive cholesterol lowering in diabetic patients were comparable to those in nondiabetic patients for both angiographic and clinical end points. The small number of diabetic patients provided limited power to detect significant differences between diabetic and nondiabetic patients or between diabetic patients in the aggressive versus moderate cholesterol treatment strategies.

Comparative effects of atenolol versus celiprolol on serum lipids and blood pressure in hyperlipidemic and hypertensive subjects.

Antihypertensive drugs may affect serum lipoprotein levels in mixed populations but data in hyperlipidemic patients are scanty. Atenolol versus celiprolol effects on serum lipoproteins were compared in 159 hyperlipoproteinemic hypertensive patients. This was a randomized, double-blind, parallel-group, positive-controlled multicenter trial with centralized lipoprotein laboratory and diet constancy monitoring. Blood pressure reduction and serum lipoprotein and apoprotein levels were monitored for 3 months. Both drugs reduced systolic and diastolic blood pressures. Atenolol had greater effects than celiprolol on diastolic pressure, but effects on systolic blood pressure were not different. Patients receiving atenolol had lower serum high-density lipoprotein cholesterol levels and higher low-density lipoprotein/high-density lipoprotein cholesterol ratios, whereas patients treated with celiprolol showed no contrasting changes. These differences in lipoprotein levels between drug treatment groups were statistically significant at weeks 9 and 12. The difference between drug treatments was also significant if the values of the 9- and 12-week visits were averaged. Patients taking atenolol had statistically significantly higher serum levels of total cholesterol, triglycerides and apoprotein B at 9 weeks. These divergent directional changes were consistent throughout and statistically significantly different between drugs.

Relief of posttraumatic headache by intravenous chlorpromazine.

We report the case of an 18-year-old male with a vascular-type headache occurring 3 days after a minor closed-head injury. The headache resolved completely, without recurrence, with a single dose of intravenous chlorpromazine. This case and the few others reported in the literature illustrate that the response of a headache to antimigraine therapy cannot be relied upon to diagnose or confirm a diagnosis of migraine headache, or to rule out other intracranial pathology.

Isolated bladder rupture after minor trauma in a patient with alcohol intoxication.

We report the case of an intoxicated male patient who presented with an isolated intraperitoneal urinary bladder rupture, with a history of minor trauma. A review of the literature reveals that isolated bladder rupture after minimal or no trauma in association with alcohol or drug ingestion is an infrequently reported, but recognized, injury. The diagnosis of bladder rupture should be considered in an intoxicated patient with lower abdominal pain, even without a history of trauma. A history of voiding or bladder dysfunction should increase the suspicion for this injury. If suspected, a retrograde cystogram should be obtained promptly. Failure to consider and recognize this injury may lead to significant morbidity.

Placental angiogenic and growth factors in the treatment of chronic varicose ulcers: preliminary communication.

A short-term clinical study on the effect of purified angiogenic and growth factors from human term placenta in the treatment of chronic varicose ulcers was carried out in 18 patients. Patients were randomly allocated to receive a maximum of two dressings containing or not containing these factors. The amount of granulation and epithelial tissue was clinically estimated 48 hours after each application. Patients treated with placental angiogenic and growth factors showed increased granulation and epithelial tissue. These results indicate that placental factors may be used for acceleration of wound healing.

The wizard and the gatekeeper: of castles and contracts.

The wizards and the gatekeepers were unhappy. There were many reasons for their unhappiness. They worked hard but felt that too much was being demanded of them. The poorly people's charter was resulting in unrealistic expectations, and changes in the apprenticeship for wizards were putting great strain on their mentors. The wizards enjoyed their work less and less, and it was getting difficult to find new gatekeepers. On the other hand, the way the system worked meant that there had to be plenty of goblins and the number of scrolls that had to be filled in was rising sharply. The wizards and gatekeepers tried to point out ways to improve things that would ensure that poorly people were better treated, but there was no easy solution. With the ominous sign that the recruitment of wizards and gatekeepers was becoming more difficult, an answer was needed--and soon.

Current management of acute ischemic stroke. Part 1: Thrombolytics and the 3-hour window.

OBJECTIVE: To help family physicians who care for patients with acute stroke or who are involved in planning service delivery or resource allocation to understand recent developments in acute stroke care. QUALITY OF EVIDENCE: A MEDLINE search indicated that most data were derived from well designed, randomized, double-blind, placebo-controlled trials, including all the largest international studies and large systematic reviews. MAIN MESSAGE: Treatment of acute stroke with tissue plasminogen activator seems beneficial for certain patients with certain kinds of stroke. Because thrombolytic therapy is not without risk and requires substantial resources, it should be administered only by physicians trained in its use and in centres with the necessary experience and resources. Because time is important, an organized and efficient system of stroke care with collaboration between hospital and prehospital care providers and help from ordinary citizens is essential. CONCLUSION: Management of acute stroke is an emerging discipline; many potential therapies are still experimental.

Current management of acute ischemic stroke. Part 2: Antithrombotics, neuroprotectives, and stroke units.

OBJECTIVE: To help family physicians who care for patients with acute stroke or who are involved in planning service delivery or resource allocation to understand recent developments in acute stroke care. QUALITY OF EVIDENCE: A MEDLINE search indicated that most data were derived from well designed, randomized, double-blind, placebo-controlled trials, including all the largest international studies and large systematic reviews. MAIN MESSAGE: Routine anticoagulation is not recommended except for circumstances such as cardioembolic stroke or deep vein thrombosis prophylaxis. Antiplatelet therapy with low-dose acetylsalicylic acid (or another antiplatelet agent if ASA is contraindicated) should be initiated within 48 hours of stroke onset, although benefit is modest. Dedicated care for stroke patients reduces morbidity and mortality and can be cost effective. Recent research into defibrinogenating and neuroprotective agents suggests some benefit, although none are currently licensed for use. Combination therapy might be the answer. CONCLUSION: Management of acute stroke is an emerging discipline; many potential therapies are still experimental.

Incarceration of the uterus in pregnancy.

Uterine incarceration is a rare complication of pregnancy, usually presenting between 12 and 20 weeks' gestation, when the gravid uterus normally ascends through the pelvic brim. Conditions such as pelvic inflammatory disease, endometriosis, postoperative adhesions, posterior wall leiomyomas, and pelvic contraction may lead to fixed retroflexion of the uterus, predisposing to this condition. A case of incarceration is presented. Clinical features, diagnosis, treatment, and potential complications are discussed.

An investigation into digital imaging in assessing cosmetic outcome after breast surgery.

This study investigates post-operative photographic assessment in determining the cosmetic outcome of 74 breast cancer patients who underwent a breast lumpectomy and radiotherapy. Using 10 of these patients picked at random, comparison was made between a conventional photographic print, a print produced from a digital image, and a digital image viewed on a computer screen in terms of personal preference for clinical assessment. The cosmetic outcome scores obtained on the basis of these images were compared with cosmetic outcome scores obtained by direct observation both by the clinician and by the patient. In the analysis of image preference, conventional prints scored highest, but each of the image types was considered to be acceptable for assessing breast cosmesis. Statistical analysis of the cosmetic outcome scores proved that there was a significant correlation between the scores obtained from the images and the scores obtained by direct observation both by the clinician and by the patient.

The Institute of Medical Illustrators and Glasgow Caledonian University BSc degree in Medical Illustration.

This paper relates the history leading to the validation of the Institute of Medical Illustrators (IMI) Diploma as a part-time, work-based, Bachelor of Science Degree by Glasgow Caledonian University (GCU) on the 11th June 1996. It also outlines a description of the structure and content of this degree programme. The BSc is a joint venture between GCU, who are the awarding academic institution, and the IMI, who are the professional examining body. The Institute hopes that it will become a standard qualification for the profession.

The Institute of Medical Illustrators and Glasgow Caledonian University BSc in Medical Illustration assessment system.

As a part-time work-based degree with students registered from all parts of the United Kingdom, and potentially from abroad, the Bachelor of Science (BSc) in Medical illustration does not have assessment in the conventional form as used by full-time courses undertaken in a university. It incorporates the expertise of medical illustrators actually working in the profession. The unique nature of the Institute of Medical Illustrators (IMI) and Glasgow Caledonian University (GCU) BSc has required the development of an assessment system that satisfies the quality assurance demands of both the awarding and professional body. This paper details the system devised to meet the needs of the provision and to ensure consistent assessment.

'Conversion course' to allow holders of the IMI Diploma in Medical Illustration to gain a BSc in Medical Illustration from Glasgow Caledonian University.

The 'conversion course' described in this paper has been set up following discussions between the Institute of Medical Illustrators (IMI) and Glasgow Caledonian University (GCU). The 'conversion course' will take the form of a degree triple module with a credit rating of 60 Scottish Credit and Accumulation Transfer (SCOTCAT) credits at Scottish Degree (SD) level 3. This module will require the student to undertake an extended theoretical based investigative project. The project will permit the student to study in-depth an aspect of his/her specialist interest that has a particular professional relevance. The topic of the project will be negotiated between the student and a scrutiny panel under the aegis of the department of Biological Sciences at Glasgow Caledonian University. The project will be written up in the style of an academic paper for the Institute's journal. Successful students will be awarded the BSc in Medical Illustration.