Biomedical subjects
Publications and source records attributed to J S Lumley.
A case of cervical glossopharyngeal schwannoma presenting with gagging dysphagia is presented. Treatment was by total excision of the schwannoma following which the patient made a good recovery. To our knowledge, this is the first report of gagging dysphagia associated with a glossopharyngeal schwannoma.
Fifteen patients under the age of 20 years underwent transcranial revascularisation surgery: 13 presented with acute strokes or recurrent transient neurological events, one with progressive dementia and one with recurrent syncope. Five underwent unilateral and seven bilateral anastomosis of the superficial temporal artery to a branch of the middle cerebral artery (STA-MCA bypass). One patient aged 22 months underwent bilateral encephaloduroarterisynangiosis (EDAS). Three patients deteriorated postoperatively: one died from a probable cardiac cause, one had subarachnoid haemorrhage and the patient who underwent EDAS suffered further permanent ischaemic damage. No further permanent ischaemic events occurred following STA-MCA bypass (median follow-up 41 months). Transient ischaemic events persisted postoperatively in four cases, but with reduced severity. The results suggest that STA-MCA bypass may be effective in protecting young patients from further permanent ischaemic events in the treated vascular territory.
Approximately 50% of diabetic hospital admissions in the United Kingdom are for foot problems. These relate primarily to neuropathic and vascular disease, often presenting as separate entities. Added to these problems is an impairment of the inflammatory response to intercurrent infection. Arterial lesions are those of arteriosclerosis, occurring at a young age. The lesions are more prominent in the calf vessels and distal profunda artery than across the adductor canal or the aorta-iliac segment. Surprisingly, microangiopathy does not present a major problem in digital vessels. Classification of foot problems is based on foot deformity and the degree of ulceration, infection and gangrene. Management is most effectively directed at educating doctors, nurses, patients and their carers, on foot care. Established foot lesions are best managed by a team, including chiropodists, orthotists, physicians and surgeons. This combined approach ensures optimal treatment of the diabetes and associated risk factors, such as hypertension. Patients usually have sufficient autonomic neuropathy to negate any advantages of sympathectomy, but temporary improvement of severe ulceration and pain may be obtained by prostaglandin E2 infusions, allowing time for angiographic assessment. Angioplasty provides the first line of vascular reconstruction. Surgical reconstruction may involve bypass to the level of the shin and ankle. Such revascularisations may reduce foot surgery to local amputation and debridement. Major amputation should not be delayed if it provides the most effective means of rehabilitation and return to community life.
The explosive expansion of scientific knowledge over recent decades has made it difficult for individuals to stay abreast of a single specialty. This, together with specific developments within certain fields, has established a need for expertise at a subspecialist level. The advantages of this development are that clinicians can concentrate their efforts, linking with experts of similar interests, by journals, meetings and networking databases. Similarly, provided a patient reaches the appropriate subspecialist, they can be sure of up-to-date skilled management by a recognised expert in a centre of excellence. The disadvantages of this trend are the obligatory early entry into specialist training and the inevitable decline of the generalist clinician, increasing the risks of inappropriate diagnosis and inappropriate referral. The introduction of a subspecialty will usually increase overall costs and therefore has to be justified by improved quality of care, while not being detrimental to other aspects of health care delivery. The implications at a national level are on undergraduate as well as postgraduate training, and also on the provision of appropriate funding for the sub-specialty and its infrastructure. Although there are many potential pathways for achieving standards of excellence in medical care, subspecialisation provides one of the most appropriate ways of developing, promoting and expanding a field. Such expansion, however, must be accompanied by thorough audit, to justify its independent existence.
Studies on the natural history of cerebrovascular disease have shown that patients with symptomatic tightly stenosed and occlusive disease of the internal carotid artery are at high risk of subsequent stroke. However, carotid endarterectomy is still unpredictable in its outcome and morbidity and mortality levels do not support surgery in asymptomatic mild or moderate stenosis. The prime indications for surgery are transient ischaemic attacks (TIAs) and transient stroke with focal lesions of the origin of the internal carotid artery. Combined severe stroke morbidity and mortality should be less than 4%. Extra-intracranial bypass is indicated when cerebral symptoms are associated with low cerebral perfusion. Symptomatic smooth tight stenoses of the origin of the aortic arch branches are effectively treated with angioplasty and occlusion of these origins with bypass surgery. More research is required into the prevention of atheroma, methods of reducing thrombo-embolism and means of undertaking safe surgery. With this must be linked the study and management of acute ischaemia and post-stroke rehabilitation.
A case is described of a neurilemmoma of the first thoracic nerve. Its presentation as a Horner's syndrome in combination with thoracic outlet syndrome is unique.
Over the past 10 years, 13 patients presented with operable renal carcinoma and tumour extension within the inferior vena cava. This was diagnosed accurately in all but 1 patient, using ultrasound. Radical nephrectomy with removal of tumour within the inferior vena cava was performed in all 13 cases, 2 requiring cardiac bypass. There were no operative deaths and 6 patients remain alive and well with a mean follow-up of 2 years. The presence and level of vena caval extension did not appear to have an adverse affect on prognosis.
A prospective study comparing two types of surgical clip, the Proximate II (Ethicon) staple and the Michel clip, was performed on 30 thyroidectomy (horizontal) and 50 carotid endarterectomy (vertical) incisions with reference to their ease of handling, patient comfort, complication rate, cosmetic result and cost. In each patient half of the wound was approximated with one type of clip and half with the other. The Proximate II staple was more comfortable for the patient in the vertical wounds (P less than 0.02), easier to remove as judged by the nurse in both horizontal (P less than 0.001) and vertical (P less than 0.02) wounds, and by the patient in the horizontal wounds (P less than 0.02) only. The incidence of inflammation was significantly higher with the Michel clip (P less than 0.001). In both the horizontal (P less than 0.05) and the vertical (P less than 0.001) wounds, when the scar was assessed at the time of discharge from hospital, the Proximate II staple achieved a significantly better result. However, assessment of the wounds by patient and researcher 6 weeks postoperatively, revealed no significant difference between the wounds with regard to cosmetic outcome. The Proximate II design, however, costs between seven and ten times more than the Michel clip depending on the size of the dispenser used, and since the late cosmetic result offers no advantage over the latter design, we feel these financial variables deserve consideration.
The study examined the influence of the Pond Report on the teaching of medical ethics in the London medical schools. A questionnaire was given to both medical students and college officers. All medical colleges reported that ethics was included in the curriculum. However, from students' replies, it seems that attendance of optional courses is low and that not all current final year medical students have had any formal teaching in medical ethics. Stronger guidelines are necessary to ensure appropriate ethical training in London medical schools.
Thirty-three impotent men underwent pharmacocavernometry and cavernography. Ten patients had a good clinical response to 60 mg papaverine, nine had a moderate clinical response and in 14, the response was judged to be a poor one. Twelve patients had evidence of abnormal venous leakage from the corpora. Subsequent investigation with isotope phallography showed six patients to have arterial insufficiency and in three of these patients this was amenable to reconstructive vascular surgery. We conclude that pharmacocavernometry provides a useful, cheap and reliable method for the investigation of impotent men which may be performed on an outpatient basis.
Penile tissue (consisting of corpus cavernosum and tunica albuginea) was obtained from 19 patients undergoing surgery for the implantation of penile prostheses. The tissue was examined for vasoactive intestinal polypeptide-like immunoreactivity in nerves, acetylcholinesterase-positive staining in nerves and noradrenaline content. Impotence was due to a variety of causes; 11 patients were classified as a 'non-neuropathic' group on the basis of their clinical history which included Peyronie's disease, vascular disease, hypertension and psychogenic impotence. Vasoactive intestinal polypeptide-like immunoreactive and acetylcholinesterase-positive nerves were present and the pattern and distribution were similar in each patient in this group. The noradrenaline content of the tunica albuginea was significantly lower than the corpus cavernosum (p less than 0.02), although there was a linear relationship between the noradrenaline contents of the two regions (r = 0.95, p less than 0.01). By comparison, a complete absence of vasoactive intestinal polypeptide-like immunoreactivity in nerves was observed in a patient with a cauda equina lesion. Five out of six diabetic patients studied revealed a marked reduction in vasoactive intestinal polypeptide-like immunoreactivity in nerves associated with the cavernous smooth muscle, while acetylcholinesterase-positive staining was reduced in three out of five diabetic patients studied. The noradrenaline content of the corpus cavernosum from diabetic patients was significantly lower (p less than 0.02) than that of the 'non-neuropathic' group. The noradrenaline content of the tunica albuginea, however, was similar in both groups. The results provide evidence that VIPergic, cholinergic and adrenergic nerves in the penis are affected in diabetes mellitus and thus may contribute to the development of impotence in diabetic patients.
We describe successful percutaneous transluminal angioplasty (PTA) of a gortex-right external carotid artery anastomotic stricture in a 49-year-old man with amaurosis fugax and occlusion of the right internal carotid artery. No neurological complications occurred during the procedure. The patient had had three previous carotid operations, and PTA enabled successful transcranial arterial bypass surgery to be carried out, with complete relief of symptoms.
Neurological symptoms in hypertensive subjects may be a reflection of intracranial vascular disease and not just a consequence of hypertension. Two hypertensive children with renovascular disease, neurological symptoms, and severe cerebral arterial disease were treated by extracranial-intracranial arterial bypass surgery with improvement of symptoms and easier control of blood pressure. Where revascularisation surgery is appropriate, this should be undertaken before neurological complications arise.
Explore the source record for details and available documents.
Thirty-eight patients had their cerebral function measured before and after extra-intracranial carotid bypass surgery using the Halstead-Reitan neuropsychology test battery. Two composite indices of cerebral function for each patient showed them to be impaired before operation. There was no improvement in the composite measures after operation to match that previously demonstrated after carotid endarterectomy. This may reflect the greater pre-operative cerebral impairment of the extra-intracranial group.
Vascular access remains the Achilles heal of haemodialysis. Fistulae are the most effective means of access, but are subject to thrombosis and infection. Bidirectional single-line systems are a useful alternative to shunting in the short-term management of acute renal failure. Attention must be given to the insertion of a patient's first fistula, and to the subsequent care of these access sites.
Analysis of the primary fellowship results showed that on average candidates were scoring a significantly higher mark in the MCQ than in the essay or viva. The level of MCQ marking has therefore been reset to the standards of the other parts of the examination. The need for continually monitoring the results of all examinations is emphasised.
Vasoactive intestinal polypeptide (VIP) has been demonstrated by immunofluorescence histochemistry in nerves in human and rat penile tissue. A reduction in VIP-like immunoreactivity in nerves was revealed in tissue from streptozotocin-diabetic rats and a human diabetic with impotence. These results suggest that an impairment in the VIP-ergic innervation in penile tissue may be an important factor in the development of impotence in diabetes. They also support the view that the streptozotocin-treated rat is a useful experimental model for diabetic autonomic neuropathy.