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Unlabelled: Nitrous oxide (N2O) has been shown to decrease the solubility (lambdaB:G) of volatile anesthetics in human blood and, consequently, affect their rate of uptake. If this is true, then carbon dioxide (CO2) may also have an effect, which is important because methods that measure the tension of volatile anesthetics in blood washout CO2 in the process. Blood samples were obtained from fasted, healthy volunteers and patients undergoing major surgery. Each sample was divided into two aliquots: one was equilibrated at 37 degrees C in a closed glass tonometer with a mixture of isoflurane 1% and sevoflurane 2% in a test gas mixture of either 50:50 N2O/O2 or 5:95 CO2/O2; the other aliquot was equilibrated with isoflurane and sevoflurane in O2 alone as a control. Using a two-stage headspace technique using gas chromatography, we measured the lambdaB:G of isoflurane and sevoflurane in the presence and absence of the test gas in each subject. There was no significant difference between the lambdaB:G of sevoflurane and isoflurane obtained from the N2O group and their controls or between the CO2 group and their controls. We conclude that neither N2O nor CO2 has an effect on the lambdaB:G of sevoflurane or isoflurane in the concentrations tested., Implications: The blood solubilities of sevoflurane and isoflurane were measured with and without nitrous oxide and carbon dioxide. No differences were found. Nitrous oxide does not affect the kinetics of other anesthetics by altering their solubility. Carbon dioxide tensions need not be controlled when measuring anesthetic tensions in blood.

The case notes of children undergoing video-assisted thoracoscopic ligation of a patent ductus arteriosus were reviewed with particular emphasis on the anaesthetic management. All children were managed using one-lung ventilation with no serious adverse sequelae. The lungs could be isolated easily in all cases and no special equipment was required. We describe our initial series of 13 cases and discuss the anaesthetic implications arising from this surgical technique. We also discuss the different ways of monitoring duct closure.

The gastrocnemius muscle remains the workhorse for providing soft tissue over the knee and upper tibia. Nevertheless, we have found the island posterior calf fasciocutaneous flap to be a valuable alternative. We describe 10 cases in which an island posterior calf fasciocutaneous flap was used to cover defects over the knee and tibia. Three cases were after knee arthroplasty wound dehiscence, three cases were of traumatic soft-tissue loss, three cases involved replacement of unstable skin, and one case required closing a synovial fistula. This series is compared with 10 contemporaneous consecutive cases of soft-tissue loss around the knee that were reconstructed with a gastrocnemius muscle flap. Nine posterior calf fasciocutaneous flaps survived completely, and one flap had to be replaced because of poor flow. Although this flap is technically more demanding, we have found that it offers some advantages over the gastrocnemius. These include a greater flexibility of size and shape, a longer arc of rotation to reach suprapatellar defects, the provision of sensate skin with protective though crude sensation, less bulk, and the avoidance of a twitch. The flap is also easy to re-elevate from the recipient site for subsequent orthopedic work.

A retrospective analysis of tibial diaphyseal fractures caused by football was undertaken to establish the epidemiology and severity of these common injuries. Analysis showed that the commonest fracture types were Tscherne C0 and C1 fractures and that only 73.9 per cent of the patients had unimpaired sporting function after the injury. The time to return to football was significantly related to the severity of the fracture but there was no correlation with the skill of the player. The time to return to football for the C0 fractures averaged 7-8 months and it is therefore suggested that it is unlikely that any player will return to football in the same season.

Objectives: To establish the incidence and clinical effects of anterior knee pain after intramedullary nailing of the tibia., Design: A retrospective study., Setting: The Royal Infirmary of Edinburgh, Scotland., Patients: 169 patients who presented with a tibial diaphyseal fracture and were treated by intramedullary nailing., Intervention: All patients were treated with a reamed Grosse Kempf tibial nail., Main Outcome Measurements: Anterior knee pain was assessed with an analogue scale and functional outcome was examined using a series of routine daily activities., Results: Anterior knee pain was found in 56.2% of patients. The only distinguishing feature between patients with and without pain was that the patients who had pain were significantly younger. Most patients had mild pain but there was considerable functional impairment with 91.8% of patients experiencing pain on kneeling and 33.7% having pain even at rest. Nail removal resolved or improved the symptoms in almost all cases., Conclusions: Anterior knee pain is a significant complication of intramedullary nailing of the tibia.

Thirty-two patients were admitted to the South-East Scotland Burn Unit over a 4-year period (1990-94), with burns sustained as a consequence of chip-pan fires. This represented 7 per cent of all admissions to the unit. Fourteen patients came from the Edinburgh city area, and 18 from surrounding countries. There were 14 males and 18 females, and an average age of 51.6 years. The average burn surface area was 4.7 per cent. Eighteen patients had burns to their hands, this being the most common area involved. Fourteen patients were managed conservatively, and 18 needed operative intervention. The patients spent an average of 19.4 days in hospital, and they required 46.3 days for complete healing to take place. Prevention by increased community awareness and widespread education is necessary to minimize the incidence, morbidity and cost of this relatively common and preventable type of burn.

The Surgeons' knot is both technically complex and difficult for junior surgeons to tie, especially when using heavy monofilament material. Knot slippage or breakage can pass unrecognized as a cause of wound dehisence, and it has been suggested that the Aberdeen knot and the Half-blood knot are easier and safer than the Surgeons' knot for tying these materials. The effect of different knots upon the breaking strain of common monofilament sutures was assessed using an Instron Tensiometer. The Surgeons' knot significantly reduced the breaking strength of all materials (P < 0.001). Using the Half-blood knot to commence closure had no significant effect upon strength. The Surgeons' knot, tied using the penultimate loop as at termination of closure, was associated with a significant risk of slippage, most noticeably with looped nylon. The Aberdeen knot, used for closure, showed no such slippage, and did not significantly weaken the suture (P < 0.05), except for polydiaxanone. In view of the ease of tying, security of knot and non-weakening properties, we recommend starting midline closure with a Half-blood knot and terminating with an Aberdeen knot.

In an analysis of vascular audit data on upper limb vascular trauma over a 10 year period in a major UK injury centre it was found that 15 patients required operation for subclavian or axillary artery injuries. Eleven cases were the result of blunt injury. Twelve patients had an ischaemic arm on presentation, all of whom had an associated brachial plexus lesion. Subclavian or axillary artery transections, irrespective of limb viability, also were found to have associated plexus trauma. Twenty-eight patients had brachial artery injuries repaired, 46 per cent of whom had an associated nerve injury. A good functional result was achieved in only half of the patients who underwent repair of a peripheral nerve injured in association with the brachial artery. Vascular reconstruction was successful in all cases. The long-term outcome of brachial plexus lesions was very poor and the role of exploratory surgery is discussed. The long-term outcome of upper limb injury is not dependent on the vascular injury which can be successfully managed, but upon the recognition, treatment, and outcome of the associated nerve injuries.

Between 1.1.88 and 31.12.91, 349 consecutive patients had an x-ray localization excision of a non-palpable breast lesion less than 10 mm in diameter detected by 2-view mammography performed as a result of self-referral for screening (133), breast symptoms (164), or follow-up for breast disease (52). All lesions greater than 11 mm were excluded. 250 had benign and 99 (28%) had malignant lesions. 37 of 99 (37%) patients with malignancy were aged 49 or under. 133 patients requested screening, 33 (25%) had carcinoma of whom 11 (33%) were aged 49 or less. 164 patients presented with breast symptoms; 47 (29%) had cancer and 15 (32%) of these were aged 49 or less. 52 patients requested follow up for breast diseases including previous cancers, 19 (37%) had carcinoma of which 11 were 49 years or less (58%). 223 had microcalcifications, of which 68 (31%) were positive for cancer, and 126 had no microcalcification, of which 31 (25%) patients had cancer. The specific spiculate radiological lesions yielded 16 carcinomas in 31 cases (52%). Microcalcification was seen in 110 patients under 49 with 27 (25%) carcinomas detected. Microcalcification was a significant diagnostic criterion in the patients aged 49 or less, accounting for 27/37 (73%) patients. Dutal carcinoma in situ accounted for 18/37 (49%) in patients aged 49 or less, and 19/62 (31%) in patients over 50 years. Mammography should not be withheld from patients who are seeking screening, have symptoms, or who wish to be followed up, irrespective of age.

Gastric mucosal tonometry was used to determine the adequacy of gastrointestinal perfusion in 10 patients undergoing elective myocardial revascularization. Patients were prospectively randomized to receive either pulsatile or nonpulsatile flow during cardiopulmonary bypass. All patients showed a reduction in gastric mucosal perfusion during bypass, manifested by a reduction in the gastric mucosal pH, which occurred independently of variations in the arterial pH. In the group of patients receiving nonpulsatile flow, this reduction was significantly greater (p < 0.05). Cardiopulmonary bypass using nonpulsatile flow is associated with the development of a gastric mucosal acidosis, which may have implications for the development of postoperative complications.