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A case of chainsaw injury to the neck is described. Previous reports in the English language are exceedingly rare. A brief discussion of safety features on chain saws is followed by a review of selective vs. mandatory surgical exploration in penetrating neck trauma, including the role of ancillary diagnostic tests.
One third of HIV-infected individuals worldwide suffer from chronic hepatitis C virus (HCV) infection. Two main reasons justify considering HCV therapy as a priority in HIV-coinfected patients. First, these patients have more rapid liver disease progression, and second, they have a higher risk of developing hepatotoxicity following the initiation of antiretroviral therapy. Unfortunately, HCV therapy is associated with lower response rates and higher rate of side effects in HIV-coinfected patients. However, recent evidence suggests that when HCV therapy is administered adequately (to optimal candidates; using full doses of ribavirin; at least for 12 months irrespective of the HCV genotype; and with satisfactory drug adherence), treatment responses may not differ much from those seen in HCV-monoinfected individuals. Treatment should be considered up front in antiretroviral-naive subjects with stable HIV infection. In patients already on antiretroviral therapy, HCV therapy should not be administered before replacing didanosine by another antiretroviral, given the increased risk of mitochondrial toxicities. If possible, zidovudine should be avoided as well, given the high risk of anemia. The histological information provided by either non-invasive procedures (FibroScan, Fibro-test, etc.) or liver biopsy is useful but should not be considered as mandatory before prescribing HCV therapy. In summary, liver disease associated to HCV is a growing problem among HIV-positive individuals. The relatively low efficacy of current anti-HCV medications and their low tolerability clearly indicated the need for new drugs with more potent and direct antiviral activity against HCV.
Clinical reasoning learning (CRL) sessions stem from an educational reform brought about since 1987 at the Faculty of Medicine of the Université de Sherbrooke. This reform is student-centered and based on situated learning and teaching. The objective of the CRL sessions, designed and implemented at the clerkship level, is to help students develop problem solving competencies through the use of effective general clinical reasoning strategies and the development of a highly organized network of specific knowledge. These sessions also strive to offset the difficulties of random clinical exposure and often highly complex cases encountered by trainees during clinical rotations in teaching hospitals. Formed of small groups, sessions recreate a clinical consultation setting focused on a specific priority problem and clinical condition identified among the mandatory objectives of the rotation. Emphasis is placed on early generation and subsequent testing of diagnostic hypothesis, and the active search and gradual disclosure of clinical data using hypothesis-driven inquiry strategy. Students are asked to verbalize their reasoning process under the close supervision of a clinical expert in the field under discussion. Implemented in 5 different clinical disciplines since 1990 in Sherbrooke, assessment data are now available and support the relevance and usefulness of CRL sessions.
Gastro-esophageal reflux disease is regarded as the single most common foregut disorder mainly in Western countries. The pathophysiological background of the disease is multifactorial. The primary aim of the management of gastro-esophageal reflux disease is relieving heartburn and healing esophagitis. The therapeutic objectives are alleviating symptoms, preventing complications and avoiding recurrence. Besides the effective medical treatment nowadays we possess the minimal invasive anti-reflux surgery which gives comparable, even better results than medical therapy does, in cases of patients who are suitable for anti-reflux surgery. The key question is the appropriate patient selection. In order to achieve the most adequate patient selection, diagnostic tools like endoscopy, radiotherapy, esophageal body and sphincter manometry, 24-hour esophageal pH monitoring and occasionally 24-hour bile exposure monitoring and gastric emptying studies are mandatory to carry out preoperatively. On the basis of the results of these tests the tailored concept of anti-reflux surgery can be applied. The importance of experienced surgeon should be pointed out, too.
Frequency and dangerousness of falls in elderly people are a public health problem because of its prevalence and its consequences. Because of its high frequency a program designed to avoid the risk of fall and to restore the balance is of importance. Nowadays in Belgium, only the ones belonging to the F-pathology list are reimbursed for the walking functional reeducation. The troubles of walking and balance increasing the risk of falls, are evaluated by different tests like: Tinetti's test (POMA), Time-up-and-go tests. To screen the patient in its physical psychological and environmental sides is mandatory. The physiotherapist is the key to evaluate the patient globally. The main aim is to restore the patient's independence after a fall and to ensure an optimal quality of live. A functional reeducation including the relearning of walking, balance, standing up and proprioception is a must. A preventive way should be more adequate for the patient at risk and the society. A prevention program for fall involving a multidisciplinary team could be the solution of the public health's problem. A lost still remains to be done! In some countries such programs do exist. They inform the elderly about falls' risks and the sometimes tragic consequences. To prevent falls, GP's, ergotherapists, physiotherapists, nurses and social workers have to work together.
Bovine Spongiform Encephalopathy (BSE) is a fatal acquired neuro-degenerative disease in cattle, belonging to the group of transmissible spongiform encephalopathies (TSEs) or prion diseases. Since its first recognition in the U.K. in 1986, BSE has raised great public health concerns because the BSE agent has been shown to cause variant Creutzfeldt Jakob Disease (vCJD) in humans. With the introduction of mandatory active surveillance programmes in the European Union the need to develop rapid tests to diagnose BSE has become a high priority. Up to now, the European Union has approved twelve rapid tests for BSE monitoring in cattle, and approval for two new tests which have been evaluated in 2004 is pending. These rapid screening tests have been used in active surveillance of BSE and have greatly improved the detection of infected cattle before their entry into the human food chain. At present, no diagnostic test exists for the detection of prions in live animals or humans. New diagnostic techniques aimed at increasing the sensitivity and specificity of PrPsc detection in body fluids and at identifying novel surrogate markers are under development.
Acute renal failure related to exertional rhabdomyolysis is a medical condition that, if not diagnosed correctly and treated aggressively, can lead to serious dysfunction and may result in death. Although the history is invaluable in diagnosing this condition, it must be confirmed by laboratory testing. The sometimes subtle manifestations of exertional (non-traumatic) rhabdomyolysis make it mandatory that the health care team is able to recognize the signs and symptoms and understand the pathophysiology for prompt treatment and referral.
Legislative initiatives recently enacted in the USA will affect daily operations in the reproductive biology laboratory. These regulations affect laboratory safety, staffing, quality assurance, and record keeping. They mandate laboratory accreditation including certification, inspection, and proficiency testing. Laboratory standards of practice and costs of operation may be increased with mandatory compliance.
The quality and standards of albumin solutions (5, 10 and 20%) made in this country meet the requirements of national specification documentation. This, however, lacks some standards included into European Pharmacopoeia and mandatory for foreign manufacturers (Na and K ions, hemipigments, polymers, thermostability). The comparative tests of the albumin solutions made in Russia and abroad by conventional European standards showed that Russian solutions by some parameters are inferior to foreign samples. This urges improvement of the solution production technology as well as updating technical documents regulating the product quality.
Thyroid tumors in children continue to generate tremendous interest and controversy. Despite a frequent presentation with metastatic disease, these differentiated tumors have an excellent prognosis. Because most pediatric patients have prolonged survival, long-term follow-up is mandatory. The extent of surgery for this disease continues to be controversial. Genetic testing is changing dramatically the management of patients with multiple endocrine neoplasia and will lead to further understanding of this intriguing syndrome. Over the next decade, classification of differentiated thyroid cancers by means of more clinically useful biologic markers may affect the clinical management of children with thyroid cancer.
Pigmented villonodular synovitis (PSV) rarely involves more than one joint, and its occurrence in children is uncommon. One case of PSV with polyarticular involvement in a child is presented, and the differential diagnoses with other polyarthritis are offered. Synovial biopsy of both knees at different ages showed the presence of PSV in a fourteen years old boy with a nine years history of painless swelling of wrist, knees and ankles. Painless polyarticular swelling with few inflammatory signs, negative acute-phase laboratory tests, normal synovial fluid, periarticular soft tissue swelling on plain films and a mandatory synovial biopsy are the diagnostic clues of this rare presentation.
Haemochromatosis is an inherited, recessive trait and is among the most common genetic diseases in Norway. It is caused by a pathological increase in the absorption of iron from the intestine. This in turn leads to excessive deposits of iron in the organs of the body, e.g. in the liver and pancreas, with concomitant symptoms and frequently organ failure. The mutated gene (HFE), which causes the vast majority of cases of haemochromatosis, has recently been described in a study from the U.S. Based upon this finding, we have established a genotyping protocol for this mutation. We discuss our preliminary experiences using this test as a diagnostic tool, as well as the implications of how it will affect diagnosis. The test is of considerable value, and we suggest that its use should be mandatory in the diagnosis of haemochromatosis.
Initial staging of Hodgkin's disease must be extensive to define all initially involved sites. It includes a physical examination to look for peripheral lymph nodes. Chest X rays and CT scan are mandatory to explore deep lymph nodes and extranodal sites (e.g., lung, liver...). Biological tests look for an inflammatory syndrome. After this initial staging the disease is classified according to the dissemination of lymph nodes and to the presence of extranodal involvement. We take also in account the evolutive symptoms and the erythrocyte sedimentation rate. The staging helps for therapeutic options and must be performed after treatment to evaluate therapeutic results and search for a residual mass.
The subject of this paper is to report our experience in the determination of brain death in infants and children. We have retrospectively examined the incidence of brain death occurred in 504 consecutive children admitted to multidisciplinary pediatric ICU at "Bambino Gesù" Hospital of Rome during the years 1994 to 1997. According to current Italian Law, brain death was declared in 8 children (1.6%), whose primary diagnoses were: Meningitis (3 cases); nontraumatic intracerebral hemorrhage (2 cases); medulloblastoma (1 case); brain metastasis of neuroblastoma (1 case); SIDS (1 case). All brain death diagnoses were made using clinical criteria and confirmatory tests. A difficult problem was met in achieving the required Pa-CO2 values higher than 60 mmHg without unduly lowering O2 saturation. In order to obtain easily this objective we have recently switched the ventilator to intermittent mandatory volume ventilation at a rate of five stroke per minute using a FiO2 of 1 before starting the apnea test. In infants younger than one year the required cerebral circulatory arrest was documented in the pericallosal artery by doppler ultrasonography performed through the fonticuli cranii. The absence of cerebral blood flow was recorded for one to five days after clinical and electroencephalographic diagnosis of brain death, causing an unnecessary prolonged rianimative support. This also confirms that in young infants brain death may occur without a marked increase of intracranial pressure. Last, but not least, we believe that particular attention must be paid to psycho-emotional conditions of parents as well as of intensivists and nurses especially when brain death must be assessed in children.
EFFECT OF PREVENTIVE MEASURES: The development of reliable routine serology tests and the demonstration of the high prevalence of toxoplasmosis in France led to mandatory prospective screening of pregnant women in 1978, followed by prenatal screening in 1985. In addition, in utero diagnosis, first on fetal blood and now with the reliable and safe method using polymerase chain reaction on amniotic fluid, formally identifies the parasite. THE SITUATION TODAY: A comparison of the experience of a specialized center in Paris during three different periods over the last 40 years showed that currently 71% of all cases of congenital toxoplasmosis are infraclinical at birth and only 5% are severe. Mean incidence of seroconversion during pregnancy is 1.48%, with a 40% risk of fetal contamination if no treatment is given. The risk of overt fetopathy predominantly concerns maternal infections occurring prior to 26 weeks gestation. IN UTERO TREATMENT: Positive PCR diagnosis on amniotic fluid imposes serial ultrasound examinations to identify any fetopathy and an in utero treatment by giving the mother the pyrimethamine-sulfadiazine combination. Biological results are favorable. POST-NATAL TREATMENT: Post-natal treatment is indicated even in latent forms and should be continued for the first year of life. The pyrimethamine-sulfadiazine combination is the only pharmaceutical regimen with well-proven efficacy. New compounds should allow better prophylaxis against maternofetal contamination or improved post-natal treatment. RECURRENCE: In 70% of the cases, serology tests become positive again, but are not associated with significantly increased risk of ocular recurrence.
Screening of HIV Infection was made mandatory for every unit of blood collected for transfusion in Delhi, India since 1989. Ten Zonal Blood Testing Centres have been identified which test all the blood collected for HIV by 29 blood blanks for the city. Reports from these testing centres have been analysed yearwise to find out the magnitude and trends of HIV infection in different groups of blood donors. Although initially there was no difference in HIV Sero-reactivity in different blood donors categories (between 1 & 2 per 1000 blood donors samples tested) but subsequently there is significant increase (5.24/1000 in 1992 & 7.48/1000 in 1993) in the HIV sero-reactivity in replacement donor category possibly because professional donors donate blood in the guise of being replacement donors. The fact which comes out clearly is that HIV infection is present in all sections of the population in Delhi and mandatory HIV Screening of all blood collected for transfusion is justified.
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