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SummaryWe report on the changes in cerebral near-infrared spectroscopy during grafting of a thoraco-abdominal aneurysm. A 58-year-old man presented with a complex dissecting aortic aneurysm. Repair of the aneurysm was performed under hypothermic circulatory arrest with retrograde cerebral perfusion. Cerebral near-infrared spectroscopy monitoring revealed a reduction in the values recorded for total haemoglobin, oxygenated haemoglobin and cytochrome aa3 along with an increase in deoxygenated haemoglobin during circulatory arrest. When retrograde cerebral perfusion was commenced the signals representing total haemoglobin, oxygenated haemoglobin and cytochrome aa3 were all restored to near baseline values. Deoxygenated haemoglobin, however, remained elevated. These changes support the hypothesis that some cerebral perfusion occurs during retrograde cerebral perfusion. Keywords ... Correspondence to: Dr T. H. Clutton-BrockNear-infrared spectroscopy (NIRS) is a technique that is used for measuring the absorption of near-infrared light by chromophores (i.e. haem-containing species). Total haemoglobin, its constituent oxygenated and deoxygenated forms and cytochrome aa3, which is the terminal enzyme in the mitochondrial respiratory chain, all absorb infrared light and can be quantified by NIRS [1][2][3]. The attraction of NIRS is in its potential to yield noninvasive information on both organ blood flow and cellular activity. We report on the NIRS changes which occurred when monitoring cerebral activity during hypothermic circulatory arrest with retrograde cerebral perfusion. Case historyA 58-year-old man was admitted for emergency graft repair of an ascending and descending thoraco-abdominal aneurysm. He presented with acute severe chest pain and had recently had a mild right-sided stroke. Chest X-ray revealed a wide mediastinum and subsequent computerised axial tomography and echocardiography confirmed a complex aortic dissection originating from just above the aortic valve and extending to just above the renal arteries. There was minimal evidence of aortic regurgitation and left ventricular function was reported to be good.The patient was premedicated with temazepam, ranitidine and metaclopromide and anaesthesia was induced with fentanyl and etomidate followed by pancuronium. The patient's trachea was intubated and anaesthesia was maintained with intravenous infusions of propofol (5 356ᮊ 1997 Blackwell Science Ltd of total haemoglobin (THb), oxygenated haemoglobin (O 2 Hb), deoxygenated haemoglobin (HHb) and cytochrome aa3 (Cyt) activity. The data from the monitor were collected via the serial port of a notebook personal computer using Critikon data logger software.After a left posterolateral thoracotomy the patient was established on cardiopulmonary bypass (CPB) with bicaval venous lines and a right femoral arterial line (Fig. 1a). Interposition grafting of the ascending aorta, including the arch of the aorta, was performed using hypothermic circulatory arrest and retrograde cerebral perfusion. To achieve this, t...

InnovAiT has previously published an article covering the physiological and clinical effects of the menopause and the indications and implications of HRT (Peet, 2009). This article will look at common menopausal problems presented to GPs and their management. This is an important topic as 80% of women experience menopausal symptoms, with 45% of them fi nding these symptoms distressing [ Royal College of Physicians of Edinburgh (RCPE, 2003) ]. In the Western societies, the commonest symptoms are hot fl ushes, night sweats, sleep disturbance and vaginal dryness. Menopausal symptoms are usually self-limiting lasting on average 2-5 years. However, some women can experience symptoms for many years. Hot fl ushes and night sweats Hot fl ushes and night sweats (the night time manifestation of a hot fl ush) affect 70-80% of perimenopausal women. They are thought to be caused by the effects of reduced oestrogen levels on the thermoregulatory nucleus in the hypothalamus, although the exact mechanism is still not fully understood. Hot fl ushes result in a sudden feeling of heat, generally in the face, neck and chest, and are often associated with fl ushing, sweating and palpitations. Hot fl ushes usually last 3-5 minutes. Vasomotor symptoms are variable in frequency, duration and severity. For 20% of women , they can be severe, causing signifi cant impact on quality of life. Hot fl ushes are most common in the fi rst year The GP curriculum and menopause GP curriculum statement 10.1: Women ' s health requires GPs to have knowledge of; Menopause and menopausal problems Mental health issues including anxiety, depression, suicide and the relationship between these and the menopause Menopause management including hormone replacement therapy (HRT) Case study 1 Elizabeth is a 52-year-old woman. She last had a period 6 months ago and is having signifi cant problems with hot fl ushes and night sweats. These occur frequently throughout the day and night. She fi nds the hot fl ushes embarrassing and disruptive at work. She is waking four to fi ve times per night with drenching sweats. As a result of her disturbed sleep, she feels exhausted and irritable and often fi nds it diffi cult to concentrate at work. She is a head teacher and her job can be very stressful at times. She has found that she often needs to drink up to six cups of coffee throughout the day at work to stay alert. She is fi nding the symptoms unbearable and is keen to try something to help them. She is not keen on the idea of HRT, remembering media coverage of concerns regarding safety. Sleep disturbance is another common symptom of the menopause and is often due to night sweats. Chronic sleep disturbance can lead to tiredness, fatigue and irritability, as well as problems with concentration and short-term memory. Controlling night sweats can improve sleep, as can maintaining a regular bedtime and avoiding exercise late in the day. Box 1 shows the management options for vasomotor symptoms. after the last period and are usually present for less than 5 years, although fo...

We report a case of tracheal stenosis in a patient with immune thrombocytopenia who presented 4 yr after splenectomy. The 20-yr progression of the stenosis and management, including resection, is charted. The period after resection was complicated by wound infection, surgical emphysema, mediastinitis and dehiscence of the anastomosis of the trachea. The management of patients with tracheal lesions is discussed, but concentrates on airway care after tracheal resection when complications developed. A laryngeal mask airway was used to stabilize an uncuffed tracheal tube at the site of dehiscence.