Wheat bran- but not oat bran-enriched diets increase the mucosal height of the cecum and colon of newly weaned and aged rats

BACKGROUND: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. METHODS: 1100 patients in the age group 5-88 years who underwent ambulatory surgery during a period of 6 months were asked to complete a questionnaire 48 h after the end of the operation. In the case of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature and severity of postoperative complications. RESULTS: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with management of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. CONCLUSION: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.     

Pilot study on the prevalence of Ornithobacterium rhinotracheale infections in food chickens in northwest Germany

Nasosinusal polyposis in the pediatric population is uncommon and its etiology is unclear. In this eleven-year retrospective study, we describe the etiologic features and evaluate the effectiveness of endoscopic sinus surgery in 49 children. Patients were divided into three groups according to whether nasosinusal polyposis was either isolated (n = 14), or associated with either asthma (n = 5) or cystic fibrosis (n = 30). An allergy was present in 10% of patients with isolated polyposis, 80% of patients with polyposis associated with asthma, and 19% of patients with polyposis associated with cystic fibrosis. The indications for surgery were disabling symptoms, specially chronic nasal obstruction, rhinorrhea and mouth breathing, and failure to respond to medical treatment. No surgical complications were encountered. Most patients reported improvement in quality of life with reduction of nasal obstruction in 83% of cases and rhinorrhea in 61%. Minor asymptomatic recurrence (i.e. a few micropolyp localized on the roof of the ethmoid cavity) was observed in 22.7% of the cases in this series, and major recurrence with the same functional symptoms as before surgery in 13.6%. However, recurrences were higher in patients with cystic fibrosis, since minor recurrence with no clinical manifestation was observed in 28.6% of cases and major recurrence in 17.8%. Endoscopic sinus surgery must be decided in collaboration with the pediatric and pulmonary physicians, and must be performed skillfully. With a mean follow-up of 4 years, results in this series are encouraging.     

A model to meet the strategic information needs of dentistry in England

INTRODUCTION: A retrospective review of patients undergoing feeding jejunostomy (FJ) was undertaken in order to evaluate procedure related complications and their impact on final outcome. PATIENTS AND METHODS: Ninety six patients had FJ at the department of Surgical Gastroenterology, SGPGIMS from January 1989 to December 1995. RESULTS: FJ as an adjunct was performed in 89 patients with predominantly oesophageal (n = 62) and pancreatic surgery (n = 17). Seven patients had FJ as the only procedure. Fifteen patients (15.2%) had complications related to FJ. Minor complications (7.2%) included dislodgement (n = 3), blockage of the tube (n = 2) and pericatheter leak (n = 2). Major complications (8.3%) which needed surgical intervention were, detachment of the jejunostomy from the abdominal wall (n = 3), leak into the peritoneal cavity (n = 3), jejunal perforation by the tip of the catheter (n = 1) and peritonitis after removal of the tube (n = 1). Procedure related mortality was 3.2%. CONCLUSIONS: FJ should not be treated as a minor procedure and due attention to the technical details is required in its performance, otherwise it may well become the cause of a poor result following a very successful major operation.     

Current status of pediatric home mechanical ventilation in Japan]

The first nationwide survey of pediatric home mechanical ventilation (HMV) was conducted. From 35 out of 149 medical centers investigated, 49 cases of HVM were reported. The patients ranged in age from 1 to 20 years, and the causes of respiratory failure were neuromuscular diseases (51%), central hypoventilation (33%), respiratory disorders (10%) and cervical cord injury (6%). Since 1983 when 2 patients were discharged home on mechanical ventilation, more and more ventilator-dependent children have been sent home every year. However, home mechanical ventilation is not yet well recognized in Japan as an option for pediatric patients with chronic respiratory failure, and there are many problems to be solved. Firstly, very few, if any, hospitals have a designated home care team composed of physicians and other specialists. Secondly, the current health insurance system scarcely covers the cost of home ventilation. Thirdly, development of home use equipment, in particular, portable ventilators and monitors is imperative. There are 107 hospitalized patients in 56 institutions who are reportedly able to go home if a support system is established. A program for pediatric home mechanical ventilation should be urgently developed on a national basis.     

Elective cervical discectomy in California: postoperative in-hospital complications and their risk factors

STUDY DESIGN: A retrospective cohort study of short-term outcomes after elective cervical discectomy in California hospitals. OBJECTIVES: To compare the frequency of elective cervical discectomy across population strata, to determine the frequency of adverse outcomes in the early postoperative period, and to identify risk factors for such outcomes. SUMMARY OF BACKGROUND DATA: Previous cervical discectomy series have been too small to analyze risk factors for early complications, and have originated from centers that may not adequately represent the population. METHODS: Computerized hospital discharge abstracts were obtained from the California Office of Statewide Health Planning and Development. Inclusion and exclusion criteria were applied to identify 10,416 routine discectomies at 257 hospitals in 1990-1991. Several categories of postoperative complications were identified, along with inpatient deaths, early reoperations, and nursing home transfers. Logistic regression was used to estimate the independent effects of patient characteristics on short-term outcomes. RESULTS: After adjustment for age and gender, blacks were 51% and Hispanics were 24% as likely as whites to undergo elective cervical discectomy. Overall, 6.7% of patients had one or more reported postoperative complications: 1.8% had noninfectious surgical complications, 1.8% had infectious complications, 4.0% had other medical complications, and 0.35% had unplanned reoperations before discharge. Fourteen inpatient deaths were reported (0.13%). Congestive heart failure, alcohol/drug abuse, chronic lung disease, previous spine surgery, psychological disorders, and chronic musculoskeletal disorders were independently associated with postoperative complications. Even after adjustment, risk was higher with advancing age, higher among women than among men, and higher after posterior fusion than after discectomy without fusion. CONCLUSIONS: The ethnic disparity in cervical discectomy rates suggests overuse among whites or underuse among minority populations. The complication rates reported here are similar to those synthesized from previous literature, except that the lower incidence of neurologic complications reflects our inability to distinguish preoperative from postoperative deficits. Important comorbidities should be identified and treated, if appropriate, before cervical spine surgery.     

Pedicle screw fixation for arthrodesis of the lumbosacral spine in the elderly. An outcome study

STUDY DESIGN: An analysis of the outcome and effectiveness of instrumented arthrodesis of the lumbosacral spine in elderly patients conducted using a review of records, assessment of fusion via plain radiographs, and a two-part questionnaire. OBJECTIVE: To ascertain the outcome and efficacy of instrumented arthrodesis of the lumbosacral spine in patients 60 years of age and older. BACKGROUND DATA: From 1987 to 1991, 38 patients of at least 60 years of age underwent instrumented arthrodesis of the lumbosacral spine using the Wiltse or Selby pedicle screw fixation system (Advanced Spine Fixation Systems, Inc., Irvine, CA). Patients were considered for surgery only after attempts at conservative management, including physical therapy, medication, injection blocks, and home exercises, had proven unsuccessful. METHODS: Follow-up examinations were performed 3 months, 6 months, 1 year, and 2 years after surgery. Fusion was assessed using plain radiographs, including flexion-extension films. Inpatient and outpatient records were reviewed, and a two-part questionnaire was used to establish the effect of surgery on function and lifestyle. Thirty patients responded to the questionnaire. Follow-up observation of the patients ranged from 25 to 56 months. The mean age was 73.8 years (range, 60-90 years). RESULTS: The mean co-morbidity was 1.7. Based on the authors' method of evaluation of fusion, the fusion rate was 92%. Fifty-seven percent of the patients reported excellent or good results, 26% reported fair results, and 17% reported poor results. Functional gains of 50% or more were reported by 71% of the respondents. Female patients had significantly more complications than male patients, but reported comparable outcomes. CONCLUSION: Despite the increase in age, co-morbidity, and associated risk of perioperative complications inherent in this population, an outcome comparable with that of younger patients is reported.     

Reflections on the management of cerebral arteriovenous malformations

BACKGROUND: The authors report their personal experience in the management of cerebral arteriovenous malformations (AVMs), using the three techniques now available: surgical resection, endovascular embolization, and radiosurgery. They review the recent literature on this topic and present their current management algorithm based on this experience. METHODS: A series of 90 patients treated for cerebral AVMs is reported (68% Grade I-III and 32% Grade IV-V, Spetzler scale). The three methods of treatment were used, either individually or in combination, based on the size and the location of the malformation. The first intervention was surgical resection in 26% of cases, endovascular embolization in 57%, and radiosurgery in 17%. Surgery and embolization were followed by another technique in some cases and eventually single modality treatment was used in 58% of cases (surgical resection 21%, endovascular embolization 20%, radiosurgery 17%) and multimodality treatment in 42% (embolization + resection, 21%; embolization + radiosurgery, 17%; resection + radiosurgery, 4%). Embolization was used as reductive therapy in 38% of the overall series (65% of all embolized patients), and was followed by surgery in 56% of cases or by radiosurgery in 44%. Angiography was used to assess the cure rates. RESULTS: The following cure rates were obtained, when each technique was used as a first treatment: surgical resection, 82%; embolization, 6%; and radiosurgery, 83% (2-year angiographic follow-up). After combined treatment, embolization and resection resulted in a 100% cure rate, embolization and radiosurgery produced a 90% cure rate. The clinical outcome was evaluated in terms of deterioration attributable to treatment. Seventy-one percent of patients had no complication, minor complications were observed in 18%, and severe complications in 11%. Treatment mortality was 3%. All deaths were attributable to hemorrhage during the embolization procedure. CONCLUSIONS: In this management algorithm, AVMs submitted directly to surgery or to radiosurgery were considered "good risk" malformations, and the outcome for these cases was good in terms of clinical result and cure rate. AVMs submitted first to endovascular embolization were considered "poor risk" malformations, including a majority of Spetzler Grade IV-V lesions. Not surprisingly, the majority of severe complications occured in this group during embolization. Thus, the major risk of the treatment of AVMs has now shifted from surgery to endovascular techniques. Endovascular embolization as sole treatment gave a low rate of complete occlusion, but proved to be very useful as a reductive therapy, in preparation for further surgery or radiosurgery. Partial embolization permitted high rates of complete cure in difficult AVMs. Embolization should be used to the maximum extent possible as a reductive technique, despite the risks of the procedure. Because of its risks however, this technique of reductive embolization should be used only if absolutely necessary to allow the complete cure of the malformation. Thus, the use of embolization should be considered very cautiously in small malformations as well as in very large and complex AVMs in which partial embolization will not be sufficient to allow complete cure with either endovascular or surgical techniques.     

A randomized controlled trial of home care: clinical outcome for five surgical procedures

The clinical function of patients receiving home care after five surgical procedures was assessed. Hospital patients who normally would have received minimal nursing care at the end of their hospital stay were randomly assigned to an experimental home-care group or a control group who were discharged from hospital after the normal length of stay. Comprisons of "untoward events" (discomfort, infection, delayed healing, or complications) are reported for the two groups in five surgical categories (varicose vein stripping, herniorrhaphy, cholecystectomy, anal and rectal operations and abdominal hysterectomy) where the home-care program operated efficientyl. No apparent differences in the rates of untoward events were noted between hospital and home-care groups. It is concluded that home care should be considered for reasons other than clinical function, such as socio-economic functioning, the wishes of the patient, or more efficient use of hospital space.     

Bronchogenic cysts and esophageal duplications: common origins and treatment

BACKGROUND/PURPOSE: Bronchogenic cysts and esophageal duplications are usually considered as separate foregut malformations. Yet, both are thought to arise from the same embryological event, division of the embryonic foregut, and they share common histological characteristics, often making their clinical differentiation difficult. METHODS: A retrospective review of the cases of 68 children treated at a single institution between 1937 and 1995 was performed. Thirty children were girls (44%) and 38 were boys (56%). Ages ranged from newborn to 24 years. Complete records were available in all children. Fourteen of these 68 children were asymptomatic. RESULTS: Respiratory (54%) or gastrointestinal (13%) symptoms were the most frequent presenting problems. The majority of children were treated by resection of the cyst (52 of 68; 76%), while 9 of 68 (13%) required lobectomy for intraparenchymal lesions. Three children underwent marsupialization, with all of these children requiring additional surgery for recurrent disease. Five children (5 of 68; 7%) had multiple cysts. The mortality rate from this series was 10% (7 of 68). Two deaths were caused by perioperative exsanguination, one related to bleeding from a cyst lined with gastric mucosa with subsequent ulceration and hemorrhage into the esophagus. Two deaths occurred secondary to septic complications, one from an esophageal leak and the other from an intraparenchymal abscess. Two deaths were caused by respiratory failure; one was unrelated (SIDS). The majority of cysts found on histological review were lined by respiratory epithelium or bronchial glands (51 of 68; 75%). Gastrointestinal epithelium was present in cysts of nine children, only two of which were clinically diagnosed as esophageal duplications. Twenty-one cases (21 of 68; 31%) were classified as esophageal duplications based on the intramural location of the cyst, yet 15 of 21 (71%) contained respiratory epithelium, substantiating the hypothesis of the common origin of these lesions. CONCLUSIONS: The histological similarity and anatomic proximity of the "bronchogenic cysts" and the intramural "esophageal duplications" supports their common origin. The possible complications of bleeding, ulceration, infection, and obstruction of the esophagus or airway, should generally lead to prompt resection.     

Dobutamine stress echocardiography for assessing coronary artery disease after transplantation in children

OBJECTIVES: The purpose of this study was to determine the feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography (DSE) for evaluating posttransplant coronary artery disease (TxCAD) in children, and to determine the frequency of selected cardiac events after normal or abnormal DSE. BACKGROUND: Posttransplant coronary artery disease is the most common cause of graft loss (late death or retransplantation) after cardiac transplantation (CTx) in children. Coronary angiography, routinely performed to screen for TxCAD, is an invasive procedure with limited sensitivity. The efficacy of DSE for detecting atherosclerotic coronary artery disease is established, but is unknown in children after CTx. METHODS: Of the 78 children (median age 5.7 years, range 3 to 18) entered into the study, 72 (92%) underwent diagnostic DSE by means of a standard protocol, 4.6 +/- 1.9 years after CTx. The results of coronary angiography performed in 70 patients were compared with DSE findings. After DSE, subjects were monitored for TxCAD-related cardiac events, including death, retransplantation and new angiographic diagnosis of TxCAD. RESULTS: No major complications occurred. Minor complications, most often hypertension, occurred in 11% of the 72 subjects. The sensitivity and specificity of DSE were 72% and 80%, respectively, when compared with coronary angiography. At follow-up (21 +/- 8 months), TxCAD-related cardiac events occurred in 2 of 50 children (4%) with negative DSE, versus 6 of 22 children (27%) with positive DSE (p < 0.01). CONCLUSIONS: DSE is a feasible, safe and accurate screening method for TxCAD in children. Positive DSE identifies patients at increased risk of TxCAD-related cardiac events. Negative DSE predicts short-term freedom from such events.     

Skin lesions in children with tuberous sclerosis complex: their prevalence, natural course, and diagnostic significance

BACKGROUND: Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by widespread cutaneous and visceral hamartomas. METHODS: The prevalence of cutaneous lesions in 106 children with TSC (47 boys and 59 girls) aged 1 month-18 years was evaluated from 1984 to 1995. Assessing the diagnostic usefulness of each National Tuberous Sclerosis Association skin criterion was an aim of this study. RESULTS: Hypopigmented macules were the most frequent finding, seen in 103 of 106 children (97.2%). In 66 children they were evident at birth, and in 20 others their presentation was delayed until the first months of age. Facial angiofibromas were seen next most often (79 of 103, 74.5%), followed by a shagreen patch in 51 of 103 (48.1%), "cafe-au-lait" macules in 30 of 103 (28.3%), molluscum fibrosum pendulum (24 of 103, 22.6%), a forehead fibrous plaque (20 of 103, 18.9%), periungual fibromas (16 of 103, 15.1%) and "confetti-like" macules (3 of 103, 2.8%). The hypomelanotic macules were seen within the first 2 years of life in 95 children, as were café-au-lait spots in 24, facial angiofibromas in eight, shagreen patches in six, and forehead fibrous plaques in six, whereas molluscum pendulum and periungual fibromas were not evident. Seizures were seen in 102 of 106 children (98%), with 80 (75%) occurring during the first year of life. CONCLUSIONS: Hypomelanotic macules were the overwhelmingly most common early finding in TSC. Infants with seizures or other possible stigmata of TSC should be carefully evaluated for these hypomelanotic macules, as well as for other associated findings.     

Patient recovery after infrainguinal bypass grafting for limb salvage

PURPOSE: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. METHODS: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. RESULTS: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. CONCLUSIONS: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent.     

Tissue radiation dosages using the RVG-S with and without niobium filtration

Twenty-five free tissue transfers for reconstruction after lower limb trauma or release of scar contractures were performed in 23 children over an 8-year period. The ages ranged from 2 to 14 years (mean 7.1 years). Fourteen (61%) patients had major associated injuries. The reconstruction sites were all in the distal leg. The overall vascular success rate was 96%. Three patients underwent re-explorations because of vascular insufficiency. One flap failed and two were salvaged. The causes of vascular complications were considered to be inadequate debridement of an avulsed vessel, venous kinking and inadequate protection of the vascular pedicle. The three cases with vascular insufficiency were children with associated injuries on the ipsilateral leg proximally. Postoperative complications were not uncommon (28%). Six of the seven complications occurred in patients with major associated injuries. The mean follow-up was 57 months. Long-term problems such as a limping gait, frequent flap ulcers, toe contracture or a bulky flap were common. Our results suggest that free tissue transfer is reliable and safe for the reconstruction of major leg injuries in children. Associated injuries proximal to the reconstructed defects on the ipsilateral leg predispose to more vascular complications. Since postoperative complications and long-term morbidity are common in children, special precautions should be taken with the preoperative assessment, planning, execution of surgery and postoperative care to achieve better results.     

Management of ophthalmic complications of homocystinuria

OBJECTIVE: To determine the safety and efficacy of surgical versus medical management in the treatment of ophthalmic complications of homocystinuria, and also to document ocular complications of homocystinuria other than lens dislocation. DESIGN: Retrospective case series. PARTICIPANTS: Forty-five patients with ophthalmic complications of homocystinuria participated. INTERVENTION: Eighty-four surgical procedures were performed on 40 patients. There were 82 procedures done with the patients under general anesthesia and 2 with the patients under local anesthesia. Medical therapy was attempted initially in all patients with lens dislocation and was the sole therapy used for five patients. MAIN OUTCOME MEASURES: Complications resulting from medical or surgical treatment and final visual acuity were studied. RESULTS: All patients had a history of lens subluxation or dislocation. Fourteen (31%) were receiving dietary treatment at the time of presentation and 29 (64%) were mentally retarded. Eighty-two procedures were performed with the patients under general anesthesia with 2 surgical complications and 1 postsurgical complication. Lens dislocation into the anterior chamber was the most frequent indication for surgery (50%) followed by pupillary block glaucoma (12%). Prophylactic peripheral iridectomy was not successful in preventing lens dislocation into the anterior chamber in five patients. Anesthetic precautions such as stockings to prevent deep venous thrombosis, preoperative hydration, or aspirin were given in 85% of cases. Other common ophthalmic complications found include optic atrophy (23%), iris atrophy (21%), anterior staphylomas (13%), lenticular opacities (9%), and corneal opacities (9%). CONCLUSION: Laser iridectomy was unsuccessful in preventing lens dislocation into the anterior chamber. With appropriate anesthetic precautions and modern microsurgical techniques, the risks associated with the surgical management of ocular complications of homocystinuria are reduced. Surgical treatment should be considered, especially for cases of repeated lens dislocation into the anterior chamber or pupillary block glaucoma. If a conservative, nonsurgical approach is undertaken, these patients must be observed carefully for repeat episodes of lens dislocation.     

Use of 123I-BMIPP single-photon emission tomography to estimate areas at risk following successful revascularization in patients with acute myocardial infarction

PURPOSE: To determine the frequency and nature of intraoperative complications of endocapsular phacoemulsification cataract surgery. SETTING: Dalcross Private Hospital and the Departments of Ophthalmology, Concord Hospital and Prince of Wales Hospital, Sydney, Australia. METHODS: This prospective study included the first 1000 cases of planned endocapsular phacoemulsification cataract surgery performed by an experienced surgeon. A standardized proforma was completed at the time of surgery. Data recorded included pre-existing ocular abnormalities, duration of surgery, nuclear sclerosis grade, and intraoperative complications. RESULTS: Major complications comprised posterior capsule tears with vitreous loss (1.4%), isolated posterior capsule tears (0.7%), and zonulysis (0.1%). Minor complications included anterior capsule tears (3.8%), iris prolapse (0.6%), and ciliary body incision (0.2%). There was a significant trend toward complications as the nuclear sclerosis grade increased. The incidence of major complications was 9.3% in the first 150 cases and 0.9% in the last 850. This represents a relative risk of 9.9 (95% confidence interval 4.2 to 23.0) of a major complication occurring in the first 150 compared with the later 850 cases. CONCLUSION: The frequency of major and minor complications fell sharply after the first 150 operations and was maintained. This study may provide a guide for beginning phacoemulsification surgeons and a basis for experienced surgeons to compare their performance outcomes.     

B-Myb, a repressed trans-activating protein

From April 1990 to November 1996, 313 inguinal and 14 femoral hernias were repaired in 295 subjects with a mean age of 74 years (66 to 97). Concomitant diseases increasing the operative risk were present in 206 subjects (70 per cent). A mesh repair was performed with "tension-free" or "plug" techniques in all but 23 inguinal and 2 femoral herniorrhaphies where the Bassini or the Shouldice procedures were adopted. Fifty-two inguinal hernias were recurrent, 11 emergency herniorrhaphies were performed for strangulation. Almost all operations (305), including 9 emergency herniorrhaphies, were carried out under local anaesthesia. There was no perioperative mortality. Acute intestinal bleeding occurred after surgery in a subject with colon diverticulosis. One urinary retention following emergency hernia repair under general anaesthesia and 2 following elective hernia repair under local anaesthesia in 2 subjects with hypertrophy of the prostate were observed. Some episodes of hypotension and/or bradycardia were observed either during or after surgery. Local complications following inguinal hernioplasty were 5 (1.5%) scrotal hematomas, 3 (0.9%) wound infections and 1 case (0.4%) of orchitis with atrophy after repair of a recurrent hernia. There were 1 recurrence after Bassini, 1 after Shouldice, and 1 (0.4%) after mesh inguinal hernioplasty. Using local anaesthesia and a mesh repair elective surgery of inguinal and femoral hernias can be safely and effectively performed in elderly patients. Consequently, early elective surgery should be recommended to avoid the risk of an emergency operation.     

Radiofrequency treatment of tachyarrhythmias in children and adolescents

INTRODUCTION: Radiofrequency ablation has been extensively used in adults to treat supraventricular and ventricular tachycardia. In children and adolescents few data are available on its safety and efficacy. METHODS: 28 patients (mean age 12.8) with symptomatic tachyarrhythmias underwent catheter ablation; 21 children had atrioventricular accessory pathways (11 right connections, 9 lef connections and one midseptal pathway), 3 had intranodal tachycardia, 2 had ventricular tachycardia and 2 had atrial tachycardia. Only four patients had associated structural anomalies. RESULTS: Success rate was 71.4% (20 patients). The success per cents in each group were: in intranodal tachycardias 100%; we failed in the two patients with ventricular tachycardias; in accessory pathways 76.1% and 50% in atrial tachycardia. There were no recurrences of arrhythmia in a mean chase period of 24 months (12-46). Major complications were only observed in one patient who developed a Wallenberg syndrome after ablation. CONCLUSIONS: Radiofrequency catheter ablation appears to be a safe and effective method to treat arrhythmias in children and adolescents, which in most cases can supersede surgery. Alow incidence of complications is reported, although long term damage on endocardial structures remains yet to be determined.     

Selenocysteine inserting RNA elements modulate GTP hydrolysis of elongation factor SelB

Invasive pulmonary aspergillosis (IPA) is associated with a high mortality. In 27 consecutive neutropenic patients who underwent lung resection for suspected IPA, we analyzed preoperative diagnostic evaluation, operative procedure, perioperative management, histological findings, outcome concerning recurrence of aspergillosis, and survival to evaluate the morbidity and mortality of a surgical treatment of IPA. Seventeen patients with hematologic diseases had previously undergone high-dose chemotherapy and four stem cell transplantation. Six patients with aplastic anemia were treated with antilymphocyte globulin. IPA was suspected if localized infiltrates developed on thoracic CT scan, and fever persisted under antibiotic therapy in neutropenic patients. In only one case a diagnosis of IPA could be made preoperatively. Twenty patients underwent lobectomy and seven wedge resection. At day of surgery the neutrophil count was below 500 x 10(9)/L in 78% of patients, and the platelet count below in 50 x 10(9)/L in 58% of patients. Invasive fungal infection was confirmed histologically in 22 of 27 patients (81.5%); in five patients no fungal infection was documented. The median duration of surgery was 120 min. Postoperatively, patients stayed one night in the intensive care unit, and chest tubes were removed after 2 d. Within 7 d a median of four erythrocyte packs and two platelet packs per patient were replaced. Major surgical complications occurred in two patients (bronchial dehiscence; pleural aspergillosis). Minor surgical complications included prolonged chest tube drainage (recurrent pneumothorax, n = 2; air leakage, n = 1; hematothorax, n = 1), pleural effusion (n = 4), and seroma (n = 2). Postoperatively, two patients suffered from histologically proven disseminated aspergillosis (pleural aspergillosis, renal aspergilloma) and another patient from suspected orbital aspergillosis. At 30 d postoperative mortality was 11% and 3-mo survival was 77%. After lung resection, seven patients underwent stem cell transplantation without recurrence of IPA. In conclusion, we suggest lung resection is a therapeutic option for invasive pulmonary aspergillosis in neutropenic patients with hematologic diseases and is associated with a low surgery-related morbidity and mortality.     

Pancreatoduodenectomy in abdominal trauma: a viable alternative

Accidents are the leading cause of death in children and a major factor in lost productive life. This case-control study investigates childhood accidents in the home by randomly surveying children presenting to a Dublin Accident and Emergency Department. Risk factors for home accidents are examined by comparing cases (those with accidental injuries sustained at home) with controls. Of the 174 accident attenders, 59.2% were boys; 66% of all surveyed were under 5 years. Cases were more likely to belong to Social Class 5-6 (P < 0.01), their fathers were less likely to be employed (p < 0.01) and mothers were less likely to be working outside the home (P < 0.01). Over 50% of injuries were due to falls (50.8%). Blows and cuts accounted for 22.6% of injuries, while 13% were due to burns, 7.9% were due to poisoning, and 5.7% due to foreign bodies. Children under 5 were more likely than older children to have been supervised at the time of the accident. Most of the injuries were minor. However, 34 children (19.5%) required hospital admission. Measures to prevent accidents at home should be targeted towards those at most risk-parents of pre-school children and the lower social class groups. Accident prevention requires a three-pronged approach i.e. environmental change, enforcement of legislation and educational measures.     

Clinical presentation of chronic non-infectious rhinitis in children

Chronic rhinitis is one of the commonest conditions affecting humans and there is evidence that its prevalence (and especially that of allergic rhinitis) is increasing. Although common, it is poorly recognised by doctors, parents and patients, particularly in children. AIMS: This study surveyed children with chronic non-infectious rhinitis to describe their presenting symptoms, differences in presentation between preschool and school-aged children and the prevalence of complications. SUBJECTS AND METHODS: We prospectively surveyed patients with a diagnosis of chronic rhinitis that was subsequently confirmed by response to therapy. Symptoms of rhinitis were assessed via an interview-conducted questionnaire. RESULTS: 567 children (357 boys), with a mean age (+/-SD) of 5.3 +/- 3.6 years, were studied over 14 months. Three hundred and fourteen were preschool children. Symptoms of a blocked or a runny nose were reported in 85% of patients, both symptoms occurring simultaneously in 59.9%. A blocked nose occurred more frequently in school-aged children, while a runny nose was commoner in preschool children. Sneeze and itch occurred less frequently in 56.1% and 33.6%, respectively. Complicating recurrent ear infections were reported in 46.9% of patients, more frequently in preschool children (P = 0.01); almost one-third (32.02%) had had grommets inserted. Learning problems, possibly secondary to somnolence as a result of poor sleep induced by sleep apnoea (snoring was reported in 58.4%), were reported in 24.1% of school-going children. CONCLUSION: As chronic rhinitis in South Africa commonly manifests with a blocked nose, patients display a high prevalence of associated complications. Doctors need to be aware of the presenting symptoms to diagnose and treat chronic non-infectious rhinitis earlier to prevent these complications.