Background: It is controversial whether regular changes of external ventricular drains can reduce cerebrospinal fluid (CSF) infection. Objective: To carry out a randomised controlled clinical trial over a two year period to determine whether a regular change of ventricular catheter every five days could reduce CSF infection and improve outcome. Methods: 103 patients requiring external ventricular drains for more than five days and with no evidence of concurrent CSF infection were studied. The patients were randomised to regular change of ventricular catheter (every five days) and no change unless clinically indicated. Results: The CSF infection rates were 7.8% for the catheter change group and 3.8% for the no change group, respectively (rate ratio = 1.80, 95% confidence interval 0.33 to 9.81, p = 0.50). No significant difference was found in intensive care unit stay, ward stay, or clinical outcome between the two groups. Conclusions: Regular changes of ventricular catheter at five day intervals did not reduce the risk of CSF infection. A single external ventricular drain can be employed for as long as clinically indicated.

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Single board spectrum antibiotic prophylaxis with Cefepime was an effective alternative regimen for neurosurgical patients with an EVD in situ.

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The role of laparoscopic cholecystectomy in management of acute cholecystitis remained controversial. Unless contraindicated or refused, early laparoscopic cholecystectomy was offered to patients suffered from acute cholecystitis in our department. Patients data and outcome were collected and analyzed to assess the safety and efficacy of the procedure and to identify predictive factors for conversion.From January 1999 to December 2000, a total of 78 patients with diagnosis of acute cholecystitis were operated. 18 patients had immediate open operation due to previous upper abdominal surgery, or presence of septic shock/peritonitis.Laparoscopic cholecystomy (LC) were successful in 41 (68.3%) of the remaining 60 patients and converted in 19 (31.7%). No mortality was found in the successful or attempted laparoscopic group but 3 patients died in the open group, probably due to poorer premorbid state. The successful LC group had the best outcome in terms of shorter postoperative stay (mean 8.2 days) and less complication rate (7.3%). The only statistically significant predictive factor for conversion are WBC count >19 ¥ 10 9 /L and duration of symptoms of more than 72 hours after onset. Conclusion: Early laparoscopic cholecystectomy for acute cholecystitis is safe and effective when operated within 72 hours of symptom onset before significant sepsis occur. 2.A consecutive series of 26 free fibular flaps in 25 patients performed by the Division of Plastic Surgery in Kwong Wah Hospital between 1995-2000 was presented. There were 15 male and 10 female patients. Age ranged from 11 to 84 years old (median 56). Pathology involving the mandible included 18 squamous cell carcinoma, five radiation-induced sarcoma, one radionecrosis and one ameloblastoma. After surgical ablation, all these oromandibular defects were reconstructed using free fibular flaps with closing wedge osteotomies and double-miniplates fixation. Concerning the fibular flaps, there were one straight osteal flap, 12 osteo-cutaneous flaps, and 13 composite osteo-myo-cutaneous flaps. Among the composite osteo-myo-cutaneous flaps, there were eight stacked bone flaps, three double skin islands composite flaps and two double muscles composite flaps. Hospital mortality of these advanced cancer patients was 7.7%. Success rate of free fibular graft was 96.2%. There was one total loss (3.8%), two flaps skin necrosis (7.7%) and three re-operations for major complications (11.5%). Minor complications that included wound infection and selflimited salivary fistula was 23%.The additional craftsmanship for the complex oromandibular reconstruction required careful three-dimensional planning and meticulous protection of individual components of the osteomyo-cutaneous flaps so as to restore the lower face with form and function. 3.

Introduction: External ventricular drains (EVD) are used for intracranial pressure monitoring and temporary cerebrospinal fluid drainage in neurosurgery. Cerebrospinal fluid infection is the major complication. Previous prospective epidemiological study from Mayhall (1) had recommended that the EVD should be changed every 5 days to reduce CSF infection. However, subsequent different retrospective series had yielded conflicting results. Hypothesis: The aim was to test whether the practice of exchange of EVD every five days could reduce the CSF infection rate and subsequently improve outcome in terms of ICU stay, hospital stay, 3‐month outcome and mortality. Method: We carried out a randomized controlled clinical trial between 11/1998 and 11/2000. 103 patients who needed EVD for more than 5 days and had no evidence of CSF infection on presentation were included. The patients were randomized between change (every five days) and no change of external ventricular drain. Results: Conclusion: The practice of regular exchange of EVD did not reduce CSF infection rate and did not improve outcome. This is in agreement with the current thinking that CSF infection mainly originated from the procedure of ventriculostomy. The associated high cost with regular exchange of EVD (operations and new catheters) did not seem to be justified. Thus, the practice of regular exchange of EVD should be abandoned. (1) Ventriculostomy‐related infections: A prospective epidemiological study. Mayhall CG et al. New England of Journal of Medicine 310(9): 553–559, 1984.

We review our experience with patients harbouring putaminal intracerebral haematoma treated by intraoperative ultrasound guided aspiration and thrombolysis with Urokinase. We assessed the feasibility and safety of the procedure and compared the results with a similar group of patients previously treated in our unit by craniotomy and clot evacuation. From September 1998 to May 2000, eighteen consecutive patients with putaminal haemorrhage without suspected underlying structural aetiology or coagulopathy were included. Under general anesthesia, a catheter was inserted into the centre of the haematoma through a frontal burr hole under ultrasound guidance. An external ventricular catheter was also inserted for intracranial pressure monitoring. After maximally aspirating the haematoma, the catheter was left in place and 30 000 units of urokinase instilled. Further instillation of 20 000 units of urokinase was performed every 12 hours. The resolution of haematoma was followed with serial CT scan. The mean age was 55 years; mean haematoma size was 50 mL. The mortality rate was 11% (2/18); both deaths were not procedure related. Twenty-four patients were in the craniotomy; there were three deaths (13%). Other outcomes of the two groups were similar. We concluded that ultrasound guided aspiration and thrombolysis appears safe and effective in treating putaminal haemorrhage.Various methods and material have been used to treat cranium bifidum. We report the use of split calvarium bone graft in the treatment of the condition in a 3-year-old girl with a large bilateral parietooccipital defect. Early follow up reveals satisfactory results. 4.

pathologists' diagnosis, that is, the consensus diagnosis (CD). Kappa scores for diagnostic accuracy (benign, in situ and invasivecancer) are calculatedandtransmittedtoparticipants by National HealthService regional coordinators. NEQAS has raisedkappa scores; for example cancer grading improved fromless than0.1toover 0.65after sixyears. Implementation islogisticallycumbersome, andthe participatingpathologists' submitted diagnoses and return informationabout performance are still sent by conventional mail. Telepathology theoretically represents an alternative modality to slide circulation in histopathology NEQAS. We tested this hypothesis by assessing the technical and clinical effectiveness of robotic interactive telepathology (RITPath) in two trials. The initial study involved a single pathologist examining 87 breast cases chosen randomly froma series of 192 fromthe UKbreast pathology NEQAS file. The average time taken for telepathology (TP) diagnosis was 3.9 min. The diagnostic accuracy of TP compared with light microscopy (LM) was 100%, for all cases benign and malignant. The accuracy of TP versus LMand CDwas 91%for carcinoma in situgrading(21/23cases). TPgradingofbreast cancer achieved accuracy of 98%(43/44) compared with LMand CD. In tumour typing, TPaccuracywas97%(65/67)usingLMandCD as comparators. The second study of similar designinvolved sevenpathologists of varyingexperience, eachassessing20-33 cases. Average diagnostic times per slide were 4.5-6.5 min. Concordance with CDwas 88-96%. These data demonstrate that telepathology of the RITPath type is a clinically and technically effective modality for histopathology quality assurance schemes. In addition, all RITPathdata can be transmittedfor analysis without a 'paper trail'. This hasimplications for National HealthServicequality assurance schemes in future.