Please, no more deaths from neglect

BACKGROUND: High resolution computed tomography (HRCT) is highly efficient in demonstrating the anatomy of the temporal bone. This study evaluates its application to temporal bone fractures (TBF). METHODS: We collected data from 26 cases of TBF in the past two years. All cases underwent HRCT examination. The clinical information was reviewed and correlated with the imaging findings. RESULTS: Eighty-six percent of the cases had longitudinal fractures. Axial scans were the most useful in identifying the fracture line. Mastoid opacification on routine head computed tomography (CT) was also useful in indicating possible TBFs. Complications of TBF, such as ossicular chain disruption, facial nerve damage or otorhino-liquorrhea, were identified clearly using HRCT. CONCLUSIONS: To minimize or prevent the sequelae of TBF, accurate radiologic evaluation is necessary as soon as possible after injury. HRCT of the temporal bone delineates the bony and soft tissue anatomy with high accuracy and we recommend it as the diagnostic modality of choice.     

Intestinal anastomosis with the biofragmentable anastomosis ring

BACKGROUND: The fear of anastomotic complications prevents the spread of the use of the biofragmentable anastomosis ring (BAR) in intestinal surgery. PATIENTS AND METHODS: A total of 453 patients underwent intestinal resection and anastomosis with the BAR. RESULTS: In all, 514 anastomoses have been carried out, 424 (83%) in elective settings, and 90 (18%) in emergency. Fifty-one patients had multiple anastomoses. Reoperation was performed in 4 patients (1%) who had a complete anastomotic leakage. In 13 patients (3%), anastomotic leakage was partial, and only 1 patient required reoperation. No postoperative intestinal obstruction occurred. Four patients (1%) developed late anastomotic strictures, which have been treated by endoscopic dilation. CONCLUSIONS: The results of our experience and those of other large clinical series definitely confirm the effectiveness of the BAR method, which seems to be a standard, easy, rapid, and safe technique either in elective or emergency surgery.     

The obstructed bladder syndrome in the neonate

Eleven neonates with bladder obstruction, causing retention of urine, and a large, palpable lower abdominal mass were treated at the Yale-New Haven Hospital during a five year period. Intrinsic and extrinsic lesions, including urethral atresia, posterior urethral valves, ectopic ureteroceles, hydrocolpos and a neuroblastoma of the pelvis, were diagnosed by cystography, vaginography, pyelography and barium enema examination or a combination of these reoentgenographic methods. The multiplicity of underlying lesions make the obstructed bladder syndrome in the neonate a unique condition.     

Pneumothorax in the neonate

Dynamic cardiomyoplasty has been performed to reinforce the myocardium in the treatment of patients with severe cardiomyopathies. At the Heart Institute of S?o Paulo University Medical School, 36 patients were submitted to cardiomyoplasty between May 1988 and December 1993. The indications were idiopathic dilated cardiomyopathy in 31, ischemic cardiomyopathy in 3, and Chagas' disease cardiomyopathy in 2 patients. Twenty-eight patients were categorized in New York Heart Association (NYHA) Class III and 8 in Class IV despite the use of maximal medical therapy. There were no hospital deaths, and patients were followed up from 2 to 70 months (mean, 24 months). Besides the improvement of NYHA functional class from 3.2 +/- 0.6 to 1.6 +/- 0.9 at 6 months of follow-up, patients also presented significant changes in the left ventricular systolic and diastolic functions. Nevertheless, 16 patients died, and 2 patients were submitted to heart transplantation during late follow-up. Actuarial survival rates were 82.3% at 1 year, 61.5% at 2 years, and 38.8% at 5 years of follow-up. Otherwise, the analysis of factors influencing the outcome showed that long-term survival was significantly affected by preoperative functional class and by pulmonary vascular resistance. The 26 patients operated in NYHA functional Class III and with pulmonary vascular resistance below 4 Wood units presented survival rates of 72.7% at 2 years and of 63% at 5 years of follow-up. In conclusion dynamic cardiomyoplasty improves functional class and left ventricular function in patients with severe cardiomyopathies. However, the long-term survival after this surgical procedure may be limited by the patients' condition before the operation.     

Thrombocytopenia in the neonate

Pediatricians caring for newborns will eventually be confronted with the problem of thrombocytopenia in the neonatal period. Familiarity with the differential diagnosis of neonatal thrombocytopenia and understanding the pathogenesis of the more common entities allows physicians to design a selective diagnostic and therapeutic plan to benefit these thrombocytopenic infants.     

The king with no clothes.

Posits that a theory is required which treats of generosity, love, joy, sadness, and the willingness to die. Theories which appreciate the thrill and exuberance of life as well as the shadows are required. It is stated that we have a hoard of molecular theories which pretend to molar status. We are as a King with no clothes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neurodevelopmental consequences associated with the premature neonate

Changes in neonatal care have resulted in an increased survival rate among low birth weight infants. Because their neurologic system is immature, these infants are vulnerable to neurologic injury. Major and minor neurodevelopmental consequences can result. Most preterm infants survive without serious difficulties; however, the lower the birth weight, the higher the likelihood that problems will occur. Numerous factors can increase a preterm infant's risk for disease and impairment, and the neonatal nurse can perform a significant role in minimizing this risk.     

Subgaleal hemorrhage in the neonate

Subgaleal hemorrhage in the neonate, a possible complication of vacuum extraction, is a medical emergency. Neonates delivered with the assistance of vacuum extraction and displaying any signs of neurologic disturbance, blood loss, or anemia should be evaluated promptly for the possibility of hemorrhage. A case report is provided in this article to describe recognition and management of a neonate in hypovolemic shock after vaginal birth assisted by vacuum extraction.     

Intestinal sleeve anastomosis: a comparative study with end-to-end anastomosis

This study examines the utility of a sleeve anastomosis with comparison to conventional end to end anastomosis. Thirty New Zealand white rabbits were randomized to sleeve (n = 15) or end-to-end (n = 15) small bowel anastomosis. Five rabbits of each group were sacrificed at 3 days, 7 days, and 6 weeks. Anastomoses were assessed for integrity, bursting strength, and stenosis and examined histologically. Ten control specimens of small bowel were tested for bursting pressure. Three rabbits died postoperatively (1 sleeve and 2 end-to-end). A fourth rabbit (sleeve) was sacrificed early at 3 weeks and had a total stenosis at the anastomosis. The remaining 26 rabbits were reoperated at the prescribed times. There was no evidence of infection or dehiscence in any of these rabbits. Both end-to-end and sleeve anastomoses were equivalent for bursting pressure at all times and, at 7 days and 6 weeks, were similar to controls. The stenotic index revealed no evidence of proximal dilation suggestive of obstruction in the 26 rabbits. For sleeve anastomoses the length of the projected bowel into the lumen persisted at the 6-week stage. Histologically there was good evidence of healing in both the sleeve and end-to-end anstomoses and the serosal surface of the sleeved bowel had epithelialized. Sleeve anastomosis has been demonstrated to heal well and to be as strong as conventional end-to-end anastomosis. Further studies are warranted to determine its role in intestinal anastomosis and potential as a valve.     

Surfactant treatment in the neonate with severe respiratory distress syndrome

Eighteen preterm infants severely ill with respiratory distress syndrome who required assisted ventilaton were given modified natural surfactant (Survanta) endotracheally. They had a mean +/- SEM gestational age of 31.2 +/- 0.4 weeks (range 28-34) and a mean +/- SEM birthweight of 1562 +/- 71 g (range 1160-2010). Average time of initial surfactant administration was 15 +/- 1.7 hour (range 5-24). No significant side effects were found during surfactant instillation. Post surfactant, the air entry was improved, oxygenation and arterial/alveolar gradients increased, and the levels of inspired oxygen could be reduced. Some of the radiological abnormalities were resolved. In 13 infants, patent ductus arteriosus became clinically evident, seven of whom received Indomethacin. There were 4 cases of pulmonary air leak, 5 cases of pulmonary hemorrhage and 8 cases of bronchopulmonary dysplasia. Four infants expired, two were due to severe asphyxia/shock and two died of unrelated causes. Among the 14 survivors who came for follow-up, two cases of retinopathy of prematurity had gradually regressed, one had cerebral palsy and delayed development. Surfactant rescue therapy is a supplemental beneficial treatment for severe respiratory distress syndrome while newborn intensive care concept is necessary for efficient diagnosis and treatment of RDS.     

Treatment of sepsis in the neonate

Angiotensin is an important regulator of blood pressure and exerts both pressor actions and influences growth in the cardiovascular system via the AT1 receptor. This review describes a number of signalling mechanisms involved in vasoconstriction and growth in response to AT1 receptor activation in vascular smooth muscle.     

Aortic arch thrombosis in the neonate

Two cases of neonatal aortic arch thrombosis are reported. One patient, who had ascending aortic thrombosis, died preoperatively. The other had reoperation and is alive and well at 6 months' follow-up. No obvious cause was found.     

Present morality in parkinson's disease: the ratio of observed to expected deaths with a method to calculate expected deaths

Excess mortality, i.e. more deaths than expected in a similar normal population, has been reduced in Parkinson's disease by levodopa. A California series and a large collaborative study throughout the United States show the ratio of observed to expected deaths to be normal. In contrast, a New York study was similar patients and a Montreal group of much more severely disabled patients showed greater mortality. The reasons for these differences are unclear, but some variations in results may be attributed to different methods of calculating expected deaths to derive the ratio of observed to expected deaths.     

Endocrinology of the neonate

Endocrine disease in the neonate is uncommon, but, if it is not promptly recognised and treated, may be life-threatening or have profound long-term consequences. This article covers congenital adrenal hyperplasia, hypothyroidism, neonatal thyrotoxicosis and hypopituitarism. Other endocrine problems with which the MRCP(Paeds) candidate should be familiar are also listed.     

Pulmonary arteriovenous malformation in the neonate

Pulmonary arteriovenous malformation (AVM) is a congenital condition, but because the symptoms usually do not occur until middle age, the diagnosis is often delayed. The authors report on a neonate, diagnosed at 2 weeks of age, who was treated by lobectomy at 35 months of age. This prompted a review of the diagnosis, pathophysiology, and treatment of pulmonary AVM. In the literature there are approximately 500 cases of pulmonary AVM. Special attention is given to the reports involving children. Eight cases have been reported in which the diagnosis was made in the first year of life. In two series, a chest roentgenogram showed abnormalities in all affected patients. Because of the strong association of pulmonary AVM with hereditary telangiectasia (Rendu-Osler-Weber syndrome), it is recommended that family members of affected patients be screened by chest roentgenograms for pulmonary AVM.