Sinus of Valsalva aneurysms: 20 years' experience

BACKGROUND: Aneurysms of sinus of Valsalva are rare. Here, we analyze retrospectively patients operated on at our center during the last 20 years. PATIENTS AND METHODS: One hundred four cases of congential aneurysm of sinus of Valsalva were operated upon between January 1977 and April 1996. Only 12 aneurysms were unruptured. The majority (76.9%) arose from the right coronary sinus. The right ventricle was the most common chamber of rupture (58.6%). Ventricular septal defect was associated in 46 patients (44.2%), of which 28 (60.9%) were supracristal. Ventricular septal defect was more common in aneurysms arising from the right coronary sinus (91.3%). Aortic incompetence was found in 45 patients (43.3%). The defect was closed through the aortic root alone in 24 patients (23.1%) and through both the aortic root and the chamber of rupture in the remaining 80 patients. Six patients underwent aortic valve repair, and 21 an aortic valve replacement. RESULTS: There were two hospital deaths (1.92%). Morbidities were few. Follow-up ranged from 1 to 20 years (mean 8.2 +/- 1.1). There was one late noncardiac death, and in the majority, the long-term follow-up was uneventful. CONCLUSION: Surgery for aneurysm of sinus of Valsalva yields gratifying results, and it should be undertaken as soon as the condition is diagnosed.     

Penile cancer in Taiwan--20 years' experience at National Taiwan University Hospital

To analyze the characteristics and prognostic factors of penile cancer in Taiwanese, we retrospectively reviewed the clinical data of patients with a diagnosis of penile cancer treated during a 20-year period (1977-1996) at National Taiwan University Hospital (NTUH). Of 71 patients treated for penile cancer during the study period, 17 were referred from other hospitals or clinics. Our analyses focused on the 54 previously untreated patients. Growth on the penis was the main symptom in all cases. Palpable inguinal lymph nodes were found only in 14 patients. All 54 patients with primary tumors were treated surgically. Pathologic examination showed squamous cell carcinoma (SCC) in 43 cases, extra-mammary Paget's disease in three, verrucous carcinoma in three, Bowen's disease in two, cutaneous lymphoma in two and basal cell carcinoma in one. Twenty-six (48%) patients had stage I penile cancer, 13 (24%) had stage II, seven (13%) had stage III, and eight (15%) had stage IV cancer. The five-year survival rate was 78% among patients with SCC and 84% among those with nonsquamous malignancies (p = 0.80). The five-year cumulative survival rates according to Jackson's cancer stage were 100% for patients with stage I, 88.9% for those with stage II, 66.7% for those with stage III, and 0% for those with stage IV (p < 0.001). Tumor staging (p = 0.027) and adjuvant chemotherapy (p = 0.042) were found to be the most significant prognostic factors. Penile cancer accounted for 0.254% of all malignancies among male patients at the NTUH during the study period. Our findings indicate that penile cancer is uncommon in Taiwanese and its prognosis is closely related to tumor staging and management. Early diagnosis and appropriate treatment may lead to prolonged survival.     

Management of enuresis in children

A postal survey was conducted to gather information on the enuresis service of Oxfordshire Health Authority Community Unit. This article discusses the size of the problem, treatment and knowledge and expertise. The findings are summarized in the form of a list of recommendations.     

Nocturnal enuresis in children]

After allergic disorders, nocturnal enuresis is the most common chronic childhood condition. Recent research has yielded abundant new knowledge about the condition, especially about its aetiology and pathophysiology, and the psychological consequences. A hereditary background has been substantiated by the identification in genetic linkage studies of areas in chromosomes 12 and 13 that are manifestly associated with bedwetting, though genotype expression in the phenotype appears to be complex and heterogeneous. Pathophysiologically, findings in current intensive research suggest three interactive factors to be involved: (i) relative nocturnal polyuria, due to insufficient antidiuretic hormone release during sleep in pre-teenagers, and due to renal tubular dysfunction in adolescents and adults; (ii) reduced nocturnal bladder capacity, especially in the 33 per cent of cases which do not respond to desmopressin treatment; and (iii) the patient's inability to waken in response to signals from a full bladder. Recent findings have also confirmed previous reports that with very few exceptions bedwetting is not caused by psychological factors. On the contrary, the condition causes psychological problems manifested in reduced self-esteem, shame and guilt, though self-esteem is restored by successful treatment. Active treatment should be started as soon as the child is ready to receive it, the main options being an enuresis alarm, desmopressin, or a combination of the two. If reduced bladder capacity is suspected, treatment with a detrusor relaxant should be included.     

Epidemiology of enuresis in Turkish children

The treatment and favorable outcome of a bitch with uterine torsion and two retained fetuses are described. The condition was corrected surgically by ovariohysterectomy. Complications (i.e., septic shock, peritonitis, and hemostatic abnormalities) were managed with aggressive medical therapy. Torsion of the gravid uterus in dogs is a life-threatening condition which can have a successful outcome if medical complications encountered in the pre- and postoperative periods are treated quickly and effectively.     

Pediatric annular pancreas: twenty years' experience

Characterization of pediatric annular pancreas is provided by this analysis of 24 cases (22 neonates, 1 infant, 1 child). Salient observations include: (1) Presentation is affected by the degree of duodenal obstruction at birth and by coexistent anomalies. (2) Polyhydramnios usually accompanies complete high intestinal obstruction by annular pancreas. (3) Primary biliary interruption was not encountered and jaundice was not unusually prevalent. (4) There is a high incidence of associated anomalies. (5) Duodenal bypass by duodenoenterostomy was employed with excellent results.     

Zone therapy of children with nocturnal enuresis

The purpose of the study was to clarify whether reflexology is a relevant treatment for enuresis nocturna, and to test a research design applicable to controlled experiments with reflexology. An unblinded method was used comparing a treatment group (1) receiving reflexology to a non-treatment group (2) keeping the same record of symptoms. At the start of the study, the volumes of night urine in the two groups were comparable. By the end of the study, there was no significant decrease in the volume of night urine in either of the groups. Two children in the treatment group and one in the non-treatment group became dry during the night in the course of the study. In conclusion, reflexology given as 14 treatment sessions over a period of four months did not result in a significant fall in enuresis nocturna in children aged seven to eleven years old. It must be concluded that the treatment result can not be distinguished from the conditions in the non-treatment group even though the average night diuresis in group one showed a slightly decreasing tendency while morning diuresis increased, in contrast to group two which exhibited a slight increase in night diuresis. As the total diuresis remained constant, this could be interpreted as an increased urinary bladder capacity, but in both cases the changes were far from significant.     

Thymic carcinoma. Ten years' experience in twenty patients

Thymic carcinoma is a rare neoplasm with extremely poor prognosis. To evaluate the outcome of treatment in thymic carcinoma, we reviewed a 10-year (1982 to 1992) experience with 20 consecutive patients in Taichung Veterans General Hospital. There were 9 men and 11 women: ages ranged from 34 to 70 years old (mean 51.4 years). None of these patients had concomitant myasthenia gravis. All of the patients received surgical intervention, and the diagnosis was made by pathologic study. Postoperative staging was made according to the modified Masaoka staging system. None of our patients were in stage I. One patient (5%) had stage II disease, 12 (60%) stage III, and 7 (35%) stage IV. The pathologic subtypes of thymic carcinoma included eight squamous cell carcinomas, seven undifferentiated carcinomas, one lymphoepithelioma-like carcinoma, one clear-cell carcinoma, 1 mucoepidermoid carcinoma, and two carcinoid tumors. Curative resection could be done in seven patients (35%). The overall cumulative survival was 45.9% at 3 years and 34.4% at 5 years. The median survival times for patients with complete and incomplete resection were 39.0 months and 14.3 months, respectively (p = 0.1752). The median survival times of patients with postoperative radiotherapy and without postoperative radiotherapy were 39.3 months and 15.0 months, respectively (p = 0.0738). The median survival times of patients with squamous cell carcinoma and undifferentiated carcinoma were 25.4 months and 11.3 months, respectively (p = 0.1464). Our data show that complete resection, postoperative radiotherapy, and squamous cell carcinoma do not indicate a significantly favorable result, even though they result in longer median survival times. Yet a positive trend of favorable outcome in patients who received postoperative radiotherapy is ambiguously shown.     

Vascular trauma. Review of 10 years' experience

The records of 82 patients with vascular trauma, treated at the Departments of General Surgery of the Sahlgren's Hospital, G?teborg, between 1969-1978 were revised. Nine patients were female and 73 male. The most common type of trauma was stab wounds. The overall mortality was 10.9%, all being patients with major vascular trauma and/or multiple injuries. Fourteen cases were due to iatrogenic lesions. Of the remaining 68 patients, minor vessels were traumatized in 40 cases, and treated with ligation. In 28 patients some kind of reconstructive procedure was attempted, 23 of these patients survived. All reconstructive procedures in surviving patients were successful. In comparison with international experience, vascular trauma in Sweden seems to be very uncommon.     

Four years' experience with the gravigard in nulliparous women

A study of the Gravigard in nulliparous patients is presented. Experience with the use of the device in 348 other patients is drawn upon for the discussion. The Gravigard is shown to be an acceptable form of contraception for nulliparous females who cannot take oral contraceptives. The failure rate was 2-6 per hundred woman-years (HWY) (corrected 1-3/HWY).     

Prepubertal ovarian cyst formation: 5 years' experience

OBJECTIVE: To document the frequency of ovarian cyst formation in the prepubertal female and to report on the clinical implications of these cysts. METHODS: We evaluated cases from a retrospective chart review of prepubertal females with ovarian cysts. RESULTS: Over a 5-year period, 1818 ultrasound studies were completed in prepubertal females, from which 99 patients were identified as having ovarian cysts. The majority (82 of 99, 83%) were small, unilocular cysts averaging 2-3 mm in diameter. The incidence of these small cysts ranged at 2-5% in females between birth and age 8. Large ovarian cysts (ie, greater than 2 cm in diameter) are rare in young girls over age 2, with most occurring within the first year of life. Of the 17 large ovarian cysts, two presented with torsion and both were complex on ultrasound examination. Five (29%) of the large ovarian cysts were treated conservatively and demonstrated regression on follow-up; these were unilocular cysts. Although functioning cysts resulting in precocious pseudopuberty are expected to be rare, we identified five cases (5%) in our series. CONCLUSIONS: Small, unilocular ovarian cysts less than 1 cm in diameter are found in prepubertal females with a frequency of 2-5% and are clinically insignificant. Ovarian cysts greater than 2 cm are rare. Unilocular ovarian cysts less than 5 cm may be followed conservatively with ultrasound surveillance until regression, without a major risk of torsion. Ovarian cysts associated with precocious pseudopuberty are generally larger than 2 cm and may be recurrent.     

First-morning urine specific gravity and enuresis in preschool children

The object of the study was to determine whether a first-morning urine specific gravity of less than or equal to 1.015 was associated with enuresis in children 3 to 6 years old. Parents of preschool children seen at the Cleveland Clinic Foundation during a 5-month period completed a questionnaire concerning bed-wetting and voiding habits of their child and collected first-morning urine specimens for specific gravity analysis. Of 101 children, 12 had a urine specific gravity of less than or equal to 1.015 (11.9%), including seven of 73 (9.6%) nonbed-wetters, two of 19 (10.5%) bed-wetters by history (who did not wet their beds on the night of the study), and three of nine (33.3%) bed-wetters (who wet their beds on the night of the study). The 73 nonbed-wetters (72.3%) had a mean (+/- standard deviation) urine specific gravity of 1.022 (+/- 0.006); 19 bed-wetters by history (18.9%) had a mean urine specific gravity of 1.024 (+/- 0.006); and nine bed-wetters (8.9%) had a mean urine specific gravity of 1.019 (+/- 0.005). The groups' mean urine specific gravities were not significantly different (p = 0.10) and the enuretic children were not more likely to have first-morning-void urine specific gravity of less than or equal to 1.015 than nonenuretic children (p = 0.14). Enuretic children who wet their beds on the night of the study had lower mean urine specific gravity than nonbed-wetters although the difference was not significant. Therefore, we do not recommend routine use of first warning void urine specific gravity analysis for predicting presence or absence of enuresis.     

Routine urodynamic studies is not indicated in children with enuresis

From January 1980 to January 1992, urodynamic examinations were performed in 339 enuretic children without constipation or anatomical or neurogenic causes of incontinence. Nocturnal enuresis was seen in 178 patients, 130 children suffered from nocturnal and diurnal enuresis, and 31 had only diurnal enuresis. M. detrusor instability was found in 44% of the children and 73% showed more than 15% reduction in functional bladder capacity. In 5% an infravesical obstruction was suspected on pressure-flowmetry and in 12% dysfunctional voiding was seen. Routine urodynamic studies are not indicated in children with enuresis.     

A student-centred, problem-based curriculum: 5 years' experience

In 1987, the University of Sherbrooke's school of medicine implemented a student-centred, problem-based learning (PBL) curriculum. The experience of the first 5 years is reviewed; program goals, the schedule of learning activities, the instructional format and assessment of student learning are described. The new program is more demanding of teachers and requires better faculty training in pedagogy. No new financial resources have been available. The preclinical reform has led to revision of the clerkship, where sessions on clinical reasoning are now based on the PBL philosophy. Student reactions to the program are reported. The Sherbrooke experience has demonstrated that it is both possible and feasible to shift from a traditional to a problem-based curriculum.     

The changing pattern of intestinal tuberculosis: 30 years' experience

SETTING: Although the incidence of tuberculosis had been decreasing for many years, it has recently risen. OBJECTIVES: To investigate the changes in the pattern and distribution of intestinal tuberculosis and to alert surgeons to the importance of maintaining a high index of suspicion for this disease entity. DESIGN: Retrospective analysis of 134 patients with intestinal tuberculosis discharged from the Veterans General Hospital in Taipei from 1965 to 1995. All records, bacteriological examinations and pathological specimens were reviewed and extracted onto a standard questionnaire. RESULTS: A decline in the case numbers of intestinal tuberculosis was noted after 1975. However, there seems to be a slight rise in case numbers since 1990. The average age of those patients after 1990 (64.8 years) is higher than those before 1990 (44.4 years). None of our patients had clinical signs of human immunodeficiency virus (HIV) infection. Most patients (81.3%, 109/134) had not received a definite diagnosis until surgery. Active pulmonary tuberculosis was found in 37 patients (29.1%). CONCLUSION: The possible reasons for the rise in cases of intestinal tuberculosis in our patients may be linked to an increased life expectancy, the reappearance of some formerly 'silent' tuberculosis cases, and relapse in patients having received incomplete antituberculosis chemotherapy. Its insidious and non-specific clinical presentation makes the diagnosis of intestinal tuberculosis difficult. An increased index of suspicion and greater familiarity with the disease may shorten the time of diagnosis and may also prevent some unnecessary operations.     

Six years' experience of the prediction of severity in rhesus haemolytic disease

Prediction charts used in the management of patients suffering from rhesus haemolytic disease are presented and the accuracy investigated for two methods of amniotic fluid analysis. In 468 samples from 141 patients there were 7-9 per cent errors of prediction when both methods were used together but in only four cases (2-8 per cent) was the error thought to have possibly contributed to wrong management.