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This case report highlights the present threat and challenges with treatment and transmission of infections caused by carbepenem-resistant enterobacteriaceae (CRE) within in-patient spinal rehabilitation units. The setting is within the Spinal Cord Injury Unit, Royal North Shore Hospital, Sydney, Australia. We report the case of a 45-year-old female with T9 complete paraplegia who developed CRE urinary tract infection (UTI) and sepsis 1 month post injury while in an in-patient spinal rehabilitation unit. We describe the challenges in treatment with colistin, the implications of infection on her rehabilitation and challenges in containing the spread of CRE to other patients in the unit. We present our experience with the management of CRE bactaeraemia in a spinal rehabilitation unit and the enhanced importance of infection control and surveillance strategies required to successfully contain risk of transmission.

Introduction The purpose of this study was to quantitatively investigate the effect of magnification on fine motor skills used in endodontics. Methods This study used a novel manual dexterity test that was performed with and without magnification. An 8× operating microscope and 2.5× dental loupes were used for the magnification tests. Forty subjects, 20 with microscope experience and 20 without, participated in the study. Performance on the test was evaluated by using an accuracy scoring system, and the time needed to complete the test was recorded for each subject. Results A significant increase in accuracy score with each level of magnification was demonstrated (P ≤ .05). In addition, the use of operating microscope significantly increased the time needed to complete the test among subjects with less than 3 years of microscope experience. Conclusions The use of magnification to enhance fine motor skills was supported in all age groups and experience levels.

The management of a fistula following retrosternal esophageal reconstruction proves particularly challenging. Two distinct tissue deficits must be considered for satisfactory reconstruction. The defect in the anterior wall of the colonic replacement and that of the adjacent soft tissues of the anterior chest wall can be closed simultaneously with a single, well-planned radial forearm free flap. A patient is presented who illustrates the design and implementation of a bivalved radial forearm free flap that provides two separate epithelial surfaces.

We determined the incidence of voiding symptoms, urodynamic etiology and satisfaction with therapy in a large cohort of men with prostatism during a 12-year period.We retrospectively analyzed the records of 2,845 consecutive men who underwent urodynamic evaluation between January 1982 and December 1994. Patients were divided into groups 1 and 2 according to the years of study (between 1982 and 1988, and between 1989 and 1994, respectively). Parameters of evaluation included prevalence and distribution of voiding symptoms, urodynamic etiology of symptoms and satisfaction with therapy (medical or surgical).There was 843 evaluable patients 50 to 94 years old (mean age 63.2) Group 2 patients were younger, and had a 22% higher prevalence of nocturia and a 12% higher prevalence of daytime frequency. The prevalence of all other symptoms was the same in both groups. On urodynamics 523 patients (62%) had demonstrable evidence of bladder outlet obstruction of whom 345 (66%) had concomitant detrusor instability. Of the 843 patients 647 (77%) had detrusor instability, which was the sole diagnosis in 199 (24%). We noted low pressure/low flow in 137 patients (16%) and impaired detrusor contractility in 152 (17%), including 57 (7%) in whom the latter condition was the only diagnosis. Urodynamic findings remained the same during the entire 12-year period. Global satisfaction and symptomatic improvement were better with surgical than medical therapy, although the degree of satisfaction was independent of the urodynamic etiology of symptoms.Symptomatic men with prostatism are presenting with a greater prevalence of significant nocturia and daytime frequency than in the past with no change in urodynamic findings. In addition, patient level of satisfaction remains greater with surgical than medical therapy regardless of the urodynamic presence of bladder outlet obstruction.

Hemangiopericytoma (HPC) is an uncommon tumor which was first described in 1942. There are no unique radiological or clinical identifiers that can reliably aid in preoperative diagnosis. Surgery is the only reliable therapy as both chemotherapy and radiotherapy have proven ineffective in several series. The outcome is difficult to predict; the only reliable predictor is the presence or absence of metastasis. We report on a 63-year-old female with a large left renal HPC.

In the period 1972 to 1989, 92 sports men and women were treated for stress fracture. Symptoms included localized bony pain aggravated by activity. Physical examination demonstrated point tenderness and pain on loading the bone. The majority of fractures were in the lower limbs but axial skeleton and upper limb bones were also affected. Radiographs showed evidence in only 49% of fractures. Bone scanning, on the other hand, was found to be very accurate and indicative immediately. Therefore, patients with a clinical history of stress fracture and a normal radiograph should undergo a bone scan.

The clinical features of melanoma and various regimens of treatment have been studied throughout the years. A melanoma can be cured if it is discovered early and adequately removed surgically. Survival decreases progressively as tumors recur locally, satellite nodules develop, and regional lymph nodes become involved.

Intraoral minor salivary gland carcinomas are relatively uncommon. The glands are concentrated in the mucosa of the mouth but occur over a wide area in the head and neck region. Little is known about the etiologic factors responsible for these tumors. Histologically, most salivary gland tumors are similar to those occurring in the parotid gland, but are more likely to be malignant. The most common presentations is an asymptomatic submucosal mass on the palate in a patient in the fifth or sixth decade, although it can occur in any age group. Neck node metastases occur in about one fourth of these patients. Surgical resection is the treatment of choice; irradiation may be a useful adjunctive method of palliation. Multiple recurrences over a long period of time are the rule, with 5 year survival for all malignant lesions being 44.5 per cent. The survival decreases another 10 per cent for each succeeding 5-year period of follow-up.

A new technique consisting of the subcutaneous insertion of molded Silastic implants in patients with pectus excavatum deformities is presented. This method of correction should be considered for patients who are devoid of cardiac and respiratory symptoms and for those in whom the only operative indication is cosmetic. The surgical technique is simple, the complication rate is low, and patient tolerance is good. The cosmetic appearance at one year appears excellent.

This report concerns a Negro infant with interruption of the aortic arch and complete transposition of the great vessels. The presenting features were congestive heart failure and differential cyanosis. The marked cyanosis of the hands was in sharp contrast to the relatively normal color of the feet. The diagnosis was established during life by detailed hemodynamic and angiocardiographic studies. These are correlated with the salient clinical features of this case and with similar cases reported in the literature.

A series of 100 patients in a general plastic surgery population were interviewed by standard format to determine their retention rate of preoperative information given to them. An overall recall, or retention rate, of 35 percent was found.

The concept of automatic threshold tracking is the most recent adaptation of artificial cardiac pacemakers to physiologic needs. Earlier pacemaker innovations were primarily in the area of timing of impulse delivery, whereas more recent changes have focused on alteration of the amplitude and duration of the pacemaker stimulus. Matching of this stimulus to the cardiac excitation threshold is important because a stimulus greater than necessary is wasteful of battery energy and may produce arrhythmias, whereas a stimulus of less than threshold intensity fails to pace the heart. Because of the wide range of clinically encountered threshold levels it is impossible to design a fixed output pacer that is efficient and safe for all patients at all times. The threshold tracking pacemaker searches for and finds the threshold level, and adjusts its stimulus to just above this level. The device ensures an adequate safety margin of stimulation, but reduces the stimulus level to the lowest safe level possible. It is fully automatic, adjusts immediately to any threshold changes and is not dependent on manual alteration.

Entirely satisfactory treatment of complete heart block has been prevented by an inability to measure pacemaker function after implantation. Two major problems can be identified in the long-term management of pacemaker patients: first, adequate prediction of when a pacemaker will fail; and second, accurate diagnosis of the type of pacemaker failure if it occurs. Observations on dogs gave precise measurements of interelectrode impedances. A method is described of externally measuring the interelectrode resistance and capacitance of implanted pacemakers. In studies on both dogs and human beings it was found that all changes in interelectrode impedance could be identified by changes in pacemaker rate and pulse width. Serial measurements of these two parameters allowed accurate diagnosis of the different types of “pacemaker failures.” The method also enabled anticipation of failures, other than wire breakage, before they were clinically evident. We think that pacemaker performance can be adequately evaluated by this method, making unnecessary prophylactic replacement of the unit.

A method for estimating myocardial threshold in patients with implanted artificial pacemakers has been described. By the external application of a calibrated suppression signal, the output of the implanted unit can be gradually reduced until the myocardial response ceases. The threshold level thus determined can be expressed as a per cent of available pulse energy by a simple calculation. This method promises to have clinical application because it is relatively simple and entirely external. It has been demonstrated to be safe, no sequelae having occurred during over 700 human studies. In combination with our previously reported method of estimating interelectrode impedance, it should provide a rational means of serially evaluating pacemaker function following implantation. It is applicable to both direct myocardial and transvenous modes of pacing, but its most important limitation at the present time is that it can be used with only one of the commercially available pacemakers. By application of quantitative threshold measurements, we have been able to confirm our clinical observations of exit block as a significant cause of pacemaker failure. This complication comprised the second most common cause of failure to pace, 14 per cent in a series of 128 implantations. It has also been possible by this means to verify the effectiveness of glucocorticoid and sympathomimetic drugs in lowering the myocardial threshold level. The implications of these observations have been briefly discussed. Threshold analysis may prove to be an important means of investigating the myocardial effects of other pharmacologic preparations in the future.