Clinical hepatology and pharmacoepidemiology: a pending multidisciplinary approach

A healthy 19-year-old United States college student volunteer in a clinical research program underwent a bronchoscopy and died as a result of acute lignocaine toxicity. The major contributing factor in the tragedy was that the research protocol failed to specify an upper dose limit for lignocaine spray, although previous versions of the protocol had done so. We look at the implications of this case for Australian institutional ethics committees.     

Collaborative problem-solving in telemedicine and evidence interpretation in a complex clinical case

The objective of this study was to evaluate the effect of different infection levels of Ostertagia ostertagi and Cooperia oncophora in a simulated 'first grazing season' on the resistance of calves to an artificial challenge infection. The infection levels were determined by the infection schedules and the chemoprophylaxis used. Thirty six 7-11-month old Holstein-Friesian bull calves were randomly divided into four groups. The animals of group B received an ivermectin sustained release bolus (ISRB) on day 0. The calves of group D were treated on days 0 and 56 with a subcutaneous injection of doramectin (0.2 mg kg(-1) BW). Group C was the untreated control group. The calves of group N were used as helminth-naive controls, while the animals of groups B, C and D were trickle infected for 24 weeks. The infection schedules were designed to simulate the expected infection pattern for each treatment group under set-stocked conditions in temperate climate areas. After the last infection, all animals were treated with oxfendazole. One week later, all animals received a challenge infection of 50,000 O. ostertagi L3 and 100,000 C. oncophora L3, spread over 10 consecutive days. During the primary infection period the faecal egg output and the serum pepsinogen and antibody levels reflected the different levels of host-parasite contact between the groups (group C > group D > group B > group N). After the challenge infection, faecal egg counts, total Ostertagia burden, size of the adult worms and abomasal globule leucocyte counts all indicated a positive relationship between the level of Ostertagia infection during the primary infection period and the level of acquired resistance. A reduction of host-parasite contact during the primary infection period, as a consequence of the infection schedule and the chemoprophylaxis used, resulted in a diminished level of resistance to the artificial challenge infection with O. ostertagi. Faecal cultures and small intestine worm counts indicated that all previously infected groups had acquired a high degree of resistance to the Cooperia challenge infection.     

Paracoccidioidoma: case record and review

The ulcer resulting from snake-bite injury was characterized by deep and wide tissue necrosis and secondary infection. The patient was at high risk of loss of function of his extremity. From 1989 to 1996, 16 cases with deep ulcer of the upper extremity resulting from snake-bite injury were treated with different types of axial thoraco-abdominal skin flaps, depending on the location of the ulcer. Thoraco-umbilical skin flap was used in 2 cases, lateral thoracoabdominal skin flap in 1 case, iliolumbar skin flaps in 5 cases, lower abdominal skin flaps in 6 cases, lower abdominal divided foliated skin flap in 1 case and Y-shaped hypogastric skin flap in 1 case. Reparative operation was carried out within 3 weeks after injury and primary repair were undertaken in 6 of them. The pedicles were divided in 17 to 24 days after operation. Twelve flaps survived. Three of the 6 flaps had mild signs of inflammation which disappeared after administration of antibiotics. One had necrosis of the distal part of the flap, and was healed with split skin graft. This type of skin flap was an ideal method for the treatment of snake-bite injury of the upper extremity.     

Madelung's disease. Clinical case and review of the literature]

Symmetrical benign lipomatosis (Madelung's disease) is extremely rare. Approximately 200 cases have been reported in the literature. SLB is a syndrome characterized by the occurrence of symmetric lipomas of the neck. No clear etiology has been recognized while a frequent association with systemic metabolic abnormalities has been described. The only effective therapy is the palliative surgical removal of the fatty tissue by lipectomy or liposuction. Experience with surgically treated patients shows the tendency of this disease to recur.     

Ileoanal reservoir dysfunction: a problem-solving approach

BACKGROUND: Many technical difficulties of the ileoanal reservoir operation have been overcome, allowing acceptable morbidity in the hands of both the frequent and less frequent operator. However, a minority of patients have persistently unsatisfactory pouch function, which can be a difficult problem to manage. METHODS: A Medline search was carried out to identify relevant papers published from November 1996 to January 1978. For clinical information more emphasis was given to recent publications with larger numbers. Where appropriate, information from other sources and some local data were included. RESULTS: Most patients empty the pouch four to eight times a day with perfect continence and no urgency, and are considered to have acceptable function with which they are satisfied. Patients who have poor function beyond an easily treated episode of pouchitis require the expertise of a multidisciplinary team offering some understanding of the anatomy, physiology and pathology of the gastrointestinal tract in general and of the ileal reservoir in particular. A thorough and persistent approach to difficult cases is often rewarded with a good outcome, with the exception of problems arising from postoperative sepsis. The temptation to use pouchitis as a waste-basket diagnosis for poorly understood dysfunction should be avoided. Problems causing poor function may originate in the pouch (including pelvic sepsis), the pouch outlet, or the small bowel above the pouch, and these areas need to be considered in each case. CONCLUSION: To optimize the benefits of restorative pouch surgery, both patients and physicians need to understand aspects of fine tuning of pouch function, including diet, medication and lifestyle. In managing ileoanal reservoir dysfunction the temptation to procrastinate should be resisted; an approach that is systematic and sympathetic should be adopted.     

Clinical case of the month. Metastatic endocarditis: clinical observation and review of the literature

The authors describe a case of metastatic endocarditis associated with a gastric carcinoma. The diagnosis was made early and the treatment by surgery and chemotherapy allowed a survival of 18 months, which is unusually long. The differential diagnosis is discussed and includes nonbacterial thrombotic endocarditis, infectious endocarditis and primary tumors of the heart.     

A review of the problem-solving literature and its relationship to the counseling process.

Analyzes the problem-solving process within counseling by extending a problem-solving model proposed by T. J. D'Zurilla and M. R. Goldfried (1971). It is maintained that the counseling process can be viewed as a problem-solving event, a perspective that may lead researchers into new research problems and greater specificity. Selected research from psychological, industrial, and counseling fields is used to delineate essential problem-solving skills as well as hypotheses regarding techniques to develop such skills. It is concluded that more research is needed to analyze the behavior of successful problem solvers and to determine the most efficacious manner to facilitate problem-solving skills in a counseling context. Several areas of research are suggested in terms of specific problem-solving skills as well as research problems in general. (83 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Streptococcal pyomyositis: case report and review

Pyomyositis is most often associated with Staphylococcus aureus infections after trauma. We describe an unusual presentation of pyomyositis of the chest wall secondary to group A betahemolytic streptococcus infection in a 15-month-old child with acute abdominal symptoms. In addition, the patient had no history or evidence of trauma to the affected area. Pyomyositis presenting in this manner secondary to group A beta-hemolytic streptococcus infection in the absence of a primary varicella infection has not been previously reported.     

MURCS association: case report and review

We report on a 25 year old woman with aplasia of the Müllerian duct, unilateral renal agenesis, and anomalies of the cervicothoracic somites (MURCS association). Growth retardation and facial asymmetry were also present. A review of published reports allows MURCS association to be distinguished from related associations, sequences, and syndromes. Moreover, sporadic occurrence, the broad spectrum of associated anomalies, and the involvement of different organ systems closely related in early embryogenesis are arguments for considering MURCS association as the consequence of a developmental field defect.     

Adolescent problem-solving thinking.

Tested the hypothesis that adolescent psychiatric patients would be deficient with respect to normal controls in their interpersonal problem-solving skills by comparing 33 patients and 53 high school student controls on 7 tasks reflecting different aspects of problem solving. With IQ covaried out, controls obtained significantly higher scores on the tasks evaluating optional thinking, social means-ends thinking, and role taking, but not on the tasks measuring problem recognition, causal thinking, emotional means-ends thinking, and consequential thinking. Findings are interpreted within a developmental framework of interpersonal problem-solving thinking. (27 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)