Metopic synostosis: Defining the temporal sequence of normal suture fusion and differentiating it from synostosis on the basis of computed tomography images

Only the metopic suture normally fuses during early childhood; all other cranial sutures normally fuse much later in life. Despite this, metopic synostosis is one of the least common forms of craniosynostosis. The temporal sequence of normal physiologic metopic suture fusion remains undefined and controversial. Therefore, diagnosis of metopic synostosis on the basis of computed tomography images alone can prove misleading. The present study sought to determine the normal sequence of metopic suture fusion and characterize both endocranial and ectocranial suture morphology. An analysis of computed tomography scans of 76 trauma patients, ranging in age from 10 days to 18 months, provided normative craniofacial data that could be compared to similar data obtained from the preoperative computed tomography scans of 30 patients who had undergone surgical treatment for metopic synostosis. Metopic suture fusion was complete by 6 to 8 months in all nonsynostotic patients, with initiation of suture fusion evident as early as 3 months of age. Fusion was found to commence at the nasion, proceed superiorly in progressive fashion, and conclude at the anterior fontanelle. Although an endocranial ridge was not commonly seen in synostotic patients, an endocranial metopic notch was virtually diagnostic of premature suture fusion and was seen in 93 percent of synostotic patients. A metopic notch was not seen in any nonsynostotic patient. The morphologic and normative craniofacial data presented permit diagnosis of metopic synostosis based on computed tomography images obtained beyond the normal fusion period.     

Massive hemospermia: a new etiology and simplified treatment

Hemospermia is a common urologic symptom that is usually benign and self-limited, and required no clinical investigation. Massive hemospermia causing hematuria, with clot formation and occasional urinary retention, occurs in a subset of patients. Three patients are reported in whom cystourethroscopy demonstrated nonvaricose abnormal posterior urethral vessels. Treatment consisted of fulguration of the vessels. One patient was cured, 1 had no symptoms for 3 years and 1 improved slightly. Endoscopically, this is a safe simple outpatient surgical procedure that is recommended for massive hemospermia due to abnormal posterior urethral vessels.     

Gradual cranial vault expansion for the treatment of craniofacial synostosis: a preliminary report

To treat craniosynostosis, skull reshaping (such as fronto-orbital advancement) is widely performed. Surgical techniques have improved, however several problems still remain, such as postoperative relapse, late resorption, and infection. The main reason for this is probably (1) that the "craniotomized" bone for changing skull contour is used as free bone grafts and (2) that dead space between the reshaped bone and dura is created. We have developed a new method in which cranial bone is expanded gradually, together with the dura, using expansion devices. With this approach there is no extradural dead space postoperatively and the cranial bone segment remains vascularized. We have performed this procedure in 2 patients with Crouzon's disease and in 1 patient with sagittal synostosis. In the Crouzon's patients, osteotomies were performed to form a one-piece fronto-orbital bony complex without detaching the bone from the dura, and three expansion devices were applied. In the patient with sagittal synostosis, bilateral temporoparietal osteotomies were done in the same fashion and two expansion devices were applied. Expansion was started on the fourth postoperative day at a rate of about 1 mm per day. After obtaining the proper expansion, the devices were removed and the bone segments were fixed with miniplates and screws. All patients showed good results without any complications.     

Atypical mycobacterial infection in childhood: a "surgical disease''

Frequency data for the STR system HumFGA were obtained from a North Italian population sample (Milano area) of 201 unrelated individuals. PCR products were detected by horizontal polyacrylamide gel electrophoresis and a total of 15 alleles were identified by side-by-side comparison with a commercially available sequenced allelic ladder. The observed genotype distribution showed no significant deviation from Hardy-Weinberg equilibrium. The high information content (discrimination power > 0.96, polymorphism information content > 0.84) render this system a useful tool in forensic routine casework both in criminal and paternity cases.     

Hepatocellular carcinoma: surgical treatment

Worldwide the hepatocellular carcinoma (HCC) is one of the most common malignancies. There is a coincidence with liver cirrhosis or chronic hepatitis B/C in most cases. HCC can be suspected by ultrasound and by rise of the tumor marker (AFP). Further investigations, like biopsies, are not necessary if angiography or computed tomography in combination with patient history and elevated AFP levels are positive. The prognosis of untreated HCC is extremely poor. Live expectancy of symptomatic patients is only a couple of weeks. Radical tumor removal by liver resection or transplantation is the only treatment with curative intent. However these options are only suitable for patients with limited disease. Five year survival after curative liver resection depends on the tumor stage, ranging from 25% to 67%. The results after liver transplantation are similar for small cancer. Large, symptomatic tumors are in most cases only suitable for palliative treatment (chemoembolisation, ethanol injection, chemotherapy, immunotherapy). The strong dependence of prognosis on tumor extent underlines the importance of screening patients with elevated risk of developing an HCC. The early recognition of small tumors allows curative therapy with good results.     

Circumcision no longer a "routine" surgical procedure

Nonmedical circumcision can no longer be considered routine in a new era of children's rights and more careful scrutiny of the medical necessity of surgical procedures. Although the minor procedure has been practised for centuries, custom and cultural factors may have had greater influence on the incidence of circumcision than the prevalence of problems such as penile cancer and urinary-tract infection that it was thought to prevent.     

Surgical treatment of congenital metacarpal synostosis of the ring and little fingers

Eighteen cases of traumatic dislocations of the hip in children under 15 years of age presenting between 1985 and 1995 were reviewed. Fifteen of the dislocations were posterior. There were two groups: a younger group dislocating with minimal trauma and an older group whose injuries involved significantly more trauma. All patients were treated by closed reduction, but two required open reduction because of intraarticular fragments preventing a full reduction. On long-term follow-up of the 16 available patients (average length of follow-up, 5 years 10 months; range, 17-132), there were no cases of avascular necrosis or early degenerative change.     

Monobloc craniomaxillofacial distraction osteogenesis in a newborn with severe craniofacial synostosis: a preliminary report

Severe craniofacial synostosis can be a devastating problem for a newborn infant. Reasons for early surgical intervention include cranial stenosis, hydrocephalus, inadequate globe and corneal protection, compromised airway patency, and feeding problems. In this preliminary report, we describe the management of severe craniofacial synostosis in a newborn infant by means of cranial and midfacial distraction osteogenesis.     

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.     

Surgical treatment of Wolff-Parkinson-White syndrome: a "retrospectroscopic" view

The surgical treatment of the Wolff-Parkinson-White syndrome made its appearance in 1968 when Dr W. C. Sealy performed the first direct surgical intervention for ablating an accessory connection in a patient with incessant atrioventricular reentrant tachycardia. The surgical approach fell into disfavor in 1990 when catheter ablation using radiofrequency energy was adopted into widespread use. In this presentation, I will attempt to assess the scientific value of the surgical experience using the scholarly tool, the "retrospectroscope," and also to answer the questions, Was it worth it? What was learned? and What was achieved? We conclude that a large body of scientific knowledge and skill was brought to light by this experience and, of even more importance, passed on for best use to the catheter surgeons.     

Closed humeral shaft fractures: a prospective evaluation of surgical treatment

OBJECTIVE: We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid Ender nail (EN) in the treatment of closed humeral shaft fractures. DESIGN: A prospective, randomized clinical study was performed with detailed comparison parameters. MATERIALS AND METHODS: Ninety-one closed humeral shaft fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54 months). MEASUREMENTS AND MAIN RESULTS: In the group with DCP without BG, the average blood loss was 270 mL, operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was 6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was 54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fisher's exact test were used to evaluate the statistical significance. CONCLUSION: In our experience, for humeral shaft fractures fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic BG is recommended, especially in cases with more comminution.     

The fear of fear concept: evidence in favour of multidimensionality

In recent years, questions have been raised regarding the dimensionality of existing measures of fear of fear. This is an important issue that needs to be addressed if the dimension(s) of any scale purporting to assess fear of fear are to guide theory and research. One of the most widely used measures of fear of fear comprises a set of two scales: the Agoraphobic Cognitions Questionnaire (ACQ) and the Body Sensations Questionnaire (BSQ). In the present study, the dimensional nature of both measures was empirically examined using a confirmatory approach. It was also determined whether the dimensions are differentially related to a variety of state and trait measures of psychological functioning. The results pointed to multi- rather than unidimensionality of the fear of fear construct. Correlational and scale-level confirmatory analyses across time-points indicated that (a) fear of fear dimensions are elements of a replicable higher order Negative Affect/Neuroticism/General Emotionality/Instability component; (b) this superfactor emerges orthogonal to the stable higher order factors of Positive Affect, Phobic Fear (excluding Agoraphobic Fears), and Agoraphobia; and (c) anxiety and fear are distinct phenomena. Implications for the conceptualization and measurement of fear of fear are briefly discussed.     

A simplified surgical approach to the incomplete form of testicular feminization

A simplified surgical approach to the intersex child with the incomplete form of testicular feminization is presented. The procedure is particularly useful in patients where the gonadal tissue is located in the scrotolabial folds and eliminates the necessity for exploratory laparotomy. Representative drawings of the procedure are shown.     

Internal pancreatic fistula: surgical treatment

The authors present 13 cases of internal pancreatic fistula, of which 11 were secondary to a chronic pancreatitis and two were caused by an abdominal trauma. Beside the clinical picture, the diagnosis was anticipated by the high amylase levels present in the fluid obtained by paracentesis or thoracocentesis. The diagnosis was confirmed by the radiological analysis of the pancreatic duct system, when an endoscopic retrograde pancreatography was performed in seven patients, one pancreatography was carried out during surgery in five cases, and one patient underwent an injection of hydrosoluble contrast in the pleural cavity. The treatment was a latero-lateral pancreaticojejunoanastomosis in five cases, associated with a corpora-caudal pancreatectomy in four patients; a cephalic duodenopancreatectomy was performed in one case. Two patients underwent a cystoenteroanastomosis, while the option chosen in the last four cases was an external drainage. One patient refused to undergo surgical treatment. Operation mortality was null. The conclusion was that an adequate surgical treatment results in the occlusion of the internal pancreatic fistula and, furthermore, allows for the definitive resolution of underlying pancreatic affection.     

Placement of screws in subtalar arthrodesis: a simplified technique

Risk factor for invasive pulmonary aspergillosis in HIV-negative patients include neutropenia, corticosteroid therapy, and chemotherapy. Corresponding risk factors in HIV-positive patients have not yet been reported. A case-control study was conducted at the Bichat-Claude Bernard Teaching Hospital, Paris, France, between 1991 and 1996. Eight cases were identified. In three cases, the diagnosis was documented histologically. Of the remaining five patients, four had a de novo lung cavity with a positive bronchoscopy sample, and one had a pulmonary infiltrate with a positive bronchoscopy sample in the absence of any other potential pathogen. Each case was matched with three controls who were admitted during the same period and had CD4 counts lower than 50/mm3. Median age was 38.1 years in the cases and 38.4 years in the controls. Median CD4 counts were 12.5 +/- 19.2 in the cases versus 19.3 +/- 16.3 in the controls (P = 0.14). No case-control differences were found for AIDS duration, neutrophil counts at diagnosis or during the previous six months, history of corticosteroid therapy or chemotherapy, or number of previous opportunistic infections. Cases were more likely than controls to have a preexisting lung cavity (3/8 versus 0/24; P = 0.01) and had spent more time in the hospital during the previous year (7 +/- 4.5 versus 2.8 +/- 3.2 weeks; P = 0.02). These data do not support a role for neutropenia or immunosuppressive treatments as risk factors for invasive aspergillosis in AIDS. They suggest that AIDS patients with a lung cavity or frequent hospital stays are at increased risk for invasive aspergillosis.