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(1) To highlight the significance of carotid artery pseudoaneurysm as a rare complication following neck dissection, and (2) to suggest endovascular coiling as management, in the presence of infection, previous radiotherapy and a grafted blood supply.
A 66-year-old man diagnosed with squamous cell carcinoma of the hypopharynx and upper oesophagus underwent pharyngolaryngectomy with reconstruction of a neo-pharynx using a free jejunal graft. The patient had previously received radiotherapy for a soft palate squamous cell carcinoma. Two months after surgery, computed tomography demonstrated a bilobed pseudoaneurysm of the left external carotid artery just distal to the arterial branch supplying the jejunal graft. This mycotic pseudoaneurysm was successfully treated with endovascular coiling, while maintaining the patency of the superior thyroid artery supplying the jejunal graft anastomosis.
In this patient, endovascular coiling of the external carotid artery was considered to be the only definitive treatment for a life-threatening mycotic pseudoaneurysm.
Epistaxis can be caused or exacerbated by anticoagulant and antiplatelet therapy. This prospective study assessed the prevalence of epistaxis in patients taking anticoagulant and antiplatelet medication, and monitored differences in patients’ clinical courses.
Prospective data were collected for consecutive patients referred with epistaxis from the emergency department over a seven-month period. Emergency department records were used to investigate prevalence and referral rates.
Over the study period, 290 patients presented to the emergency department with epistaxis; this represented 0.9 per cent of all emergency attendances. Of these patients, 119 (39 per cent) were referred on to the ENT department, 62 per cent of whom were currently taking anticoagulant or antiplatelet medication. Patients taking anticoagulant and antiplatelet medication were a significantly older group (relative risk 1.50 (1.08–2.28), p = 0.01) requiring longer in-patient stays (relative risk 2.50 (1.01–4.97), p = 0.01) and more aggressive local haemostasis measures. Most patients taking warfarin had an international normalised ratio outside the appropriate range for their disease. Hypertension was not a factor in these patients’ clinical course.
Increasingly, emergency and ENT departments are being presented with epistaxis in patients taking anticoagulant or antiplatelet medication. A better understanding of such medication and its effects may enable more effective management of these patients.
To describe an outbreak of invasive methicillin-resistant Staphylococcus aureus (MRSA) infection after percutaneous needle procedures (acupuncture and joint injection) performed by a single medical practitioner.
A medical practitioner's office and 4 hospitals in Perth, Western Australia.
Eight individuals who developed invasive MRSA infection after acupuncture or joint injection performed by the medical practitioner.
We performed a prospective and retrospective outbreak investigation, including MRSA colonization surveillance, environmental sampling for MRSA, and detailed molecular typing of MRSA isolates. We performed an infection control audit of the medical practitioner's premises and practices and administered MRSA decolonization therapy to the medical practitioner.
Eight cases of invasive MRSA infection were identified. Seven cases occurred as a cluster in May 2004; another case (identified retrospectively) occurred approximately 15 months earlier in February 2003. The primary sites of infection were the neck, shoulder, lower back, and hip: 5 patients had septic arthritis and bursitis, and 3 had pyomyositis; 3 patients had bacteremia, including 1 patient with possible endocarditis. The medical practitioner was found to be colonized with the same MRSA clone [ST22-MRSA-IV (EMRSA-15)] at 2 time points: shortly after the first case of infection in March 2003 and again in May 2004. After the medical practitioner's premises and practices were audited and he himself received MRSA decolonization therapy, no further cases were identified.
This outbreak most likely resulted from a breakdown in sterile technique during percutaneous needle procedures, resulting in the transmission of MRSA from the medical practitioner to the patients. This report demonstrates the importance of surveillance and molecular typing in the identification and control of outbreaks of MRSA infection.
Areas of coastal marshland formed an important and distinctive part of the landscape of Roman Britain, and current work is showing that different wetlands were utilised in very different ways. Some areas, for example in Essex and Kent, were simply exploited for their natural resources to produce salt and support seasonal grazing. Parts of Fenland were also used in this way, though the higher coastal siltlands were modified through the creation of drainage systems in order to improve agricultural opportunities within a landscape that was still liable to tidal flooding. A third strategy towards wetland exploitation is reclamation: a major transformation of the natural environment, involving the construction of a sea wall along the coast to keep tidal waters out and a system of drainage ditches cut into the surface of the former saltmarsh to lower the water table and remove surface run-off from the surrounding uplands.
A protocol is described to enable the production of reliable genetic fingerprints of lichen-forming fungi using randomly amplified polymorphic DNA (RAPD) markers. Key features of the method are the use of mycobiont DNA extracted from axenic cultures by a phenol-chloroform procedure, and PCR amplification using DyNAzyme II DNA polymerase. RAPD-PCR fingerprints of Graphis scripta, G. elegans and Phacographis dendritica were successfully generated using this protocol and individual isolates could be identified on the basis of differences in banding patterns produced. DNA extracted from whole thalli of G. scripia was also subjected to RAPD-PCR but the fingerprints produced differed from those given by axenic cultures of the mycobiont. Therefore difficulties of interpretation may arise when whole thalli are used in RAPD analysis.
Raman scattering experiments on silicon-doped GaN show that donor impurities quench the Al(LO) Raman line at 735 cm−1. This is due to interaction between lattice vibrations and the free carrier plasma. The spatial variation of the Al(LO) signal has been imaged directly using newly developed instrumentation. Features with dimension under on micron are observed in faceted GaN crystallites. The variation in free carrier concentration is attributed to preferential incorporation of donor impurities during growth.