Safety, feasibility, and quality of thulium laser en-bloc resection for treatment of non-muscle invasive bladder cancer

BACKGROUND

Trans-Urethral Resection of Bladder Tumors (TURBT) is a critical step in diagnosis, staging and treatment of bladder tumors. Conventional TURBT (cTURBT) involves the electro-resection of the tumor into small fragments. This technique leads to concerns about the completeness of resection, under-staging, bleeding, cancer cell implantation, and most importantly, risk of tumour recurrence. To circumvent this, laser en-bloc resection of bladder tumors has been introduced.

OBJECTIVES

Assessment of the safety, feasibility, and quality of Thulium Laser En-bloc Resection of Tumors (TmL-ERBT) for treatment of Non-Muscle Invasive Bladder Cancer (NMIBC) in various urinary bladder walls as a primary endpoint. The secondary endpoints were to investigate the feasibility of thulium laser use in the re-staging cystoscopy and to evaluate the learning curve of TmL-ERBT.

METHODS

This is a prospective observational study including all newly diagnosed patients, above 18 years old, with a urinary bladder mass ≤ 4 cm in maximal dimension (measured via bladder ultrasound or CT or MRI). All patients underwent TmL-ERBT under regional anaesthesia in a lithotomy position. All intraoperative complications such as obturator nerve reflex, bladder perforation, and significant bleeding were recorded. Postoperative variables such as the mean catheterization time, bladder irrigation fluid volume and duration, and the mean of hospital stay as well as the postoperative complications were recorded. All patients were risk stratified and managed according to EUA guidelines then followed by a surveillance regimen per 3 months for 6 months.

RESULTS

The study included 23 patients with a mean age of 53 ± 15.8 years. While 15 patients (65%) had a single tumor, the rest had multiple tumors, ranging from 2 to 3 in number with a total of 36 lesions. No cases required conversion to cTURBT and none of them experienced obturator nerve reflex or bladder perforation. Only one patient (4.3%) had an attack of clot urine retention. The mean hospitalization time was 31.2 ± 14.4 h and the mean catheterization time was 20.4 ± 13.3 h. The Detrusor muscle was present in 20 patients (87%) and the remaining 3 patients required a re-staging cystoscopy which was performed efficiently using thulium laser. None of the treated patients developed tumour recurrence during the follow-up period. In analysis, the duration of complete resection of 2-4 cm tumours was 23-27 min after the 7th case with a resection rate of 0.12-0.15 cm/min.

CONCLUSION

TmL-ERBT is safe and feasible for complete resection of NMIBC with a short learning curve and adequate cancer control.

Effect of alpha blockers on duration of urinary leakage post-percutaneous nephrolithotomy (PNL): a prospective randomized study

Background

Urinary leakage after removal of the nephrostomy tube post-percutaneous nephrolithotomy (PNL) is a common complication which could be secondary to ureteral stone fragments, blood clots, ureteral edema at the ureteropelvic or ureterovesical junction, or rupture calyx. Unfortunately, it could impact the patient’s hospital stay causing it to be lengthy, delaying time to return to work, and the negative psychological effect. The current study aimed at assessing the role and effectiveness of alpha blockers (tamsulosin) in minimizing the duration of urinary leakage post-percutaneous nephrolithotomy (PNL).

Methods

In this prospective randomized clinical study, 62 cases of PNL were included. Physical examination, laboratory investigations and radiological work up (KUB and plain computed tomography) were done. Cases were randomized into two equal groups: Group A (31 cases) received tamsulosin perioperatively; Group B (31 cases) did not receive tamsulosin. The two groups were followed postoperatively as regards duration of urinary leakage, urinary catheterization and hospital stay.

Results

Duration of urinary leakage was statistically significantly shorter in group A (10.61 ± 6.66 h) compared to group B (21.48 ± 12.41 h) (p-value ˂ 0.001). Similarly, duration of hospital stay was shorter in group A (2.52 ± 0.72 days) compared to group B (3.10 ± 0.98) (p-value 0.020).

Conclusions

In patients undergoing PNL for renal stones and receiving tamsulosin, the duration of urinary leakage, and eventually hospital stay was shorter compared to those not receiving tamsulosin.

Diaphragmatic hernia after radiofrequency ablation of liver tumor case report and literature review

INTRODUCTION

Radiofrequency ablation is an effective management modality for irresectable primary and secondary liver tumors. Some serious complications have been reported including diaphragmatic hernia. Diaphragmatic hernia is the protrusion of abdominal viscera into the thoracic cavity through a diaphragmatic defect and usually classified into congenital and acquired. After RFA, diaphragmatic hernia is a rarely-reported complication.

CASE REPORT

A 62-year-old male patient, known to have liver cirrhosis on top of hepatitis C virus, presented to the emergency department with generalized abdominal pain and vomiting four months after having a RFA procedure for a liver tumor in segment VIII. Computed tomography showed diaphragmatic hernia with strangulated terminal ileum in the chest. Emergency laparotomy was performed with resection of an ileal segment and creation of double barrel ileostomy. The patient was discharged in a good condition after tolerating oral intake.

CONCLUSION

Radiofrequency ablation is an effective modality for management of the primary and secondary liver tumors. Despite its safety, some complication may happen owing to its thermal effect and the associated patients general condition. Many techniques have been described to decrease its thermal injury. Diaphragmatic hernia is a rare complication after RFA. Its clinical presentation may be confusing and it may occur as early as one month after RFA. Its diagnosis depends mainly on computed tomography. Emergency surgical management is the standard approach.

Laser lithotripsy using dusting technique (low energy, high frequency) for symptomatic upper urinary tract stones

Background

A prospective study to assess the feasibility of stone dusting technique (low energy and high frequency) during laser lithotripsy in symptomatic upper urinary tract |(UUT) stones.

Methods

Sixty patients with symptomatic single or multiple UUT stones less than 3 cm in diameter were included. Patients with coagulation disorders and active UTIs were excluded. All patients were clinically evaluated and underwent non-contrast spiral CT (NCSCT) to detect stone site, size, number, Hounsfield unit. A rigid or flexible ureteroscope was used with stone dusting using the Ho: YAG laser at low-energy and high-frequency (0.5 J & 20 Hz) set. Operative and fluoroscopy time, total energy delivered, type of stent, hospitalization time, complications and its grade, and stone-free rate using NCSCT after 4 weeks were recorded.

Results

The mean stone size ± SD (range) was 1.55 ± 0.55 (0.5–3) cm; out of sixty patients (50 with single stone and 10 with multiple stones), fifty-five patients were stone-free at 4 weeks. Complications had occurred in 11 patients (eight with grade I, one with grade II, and two with grade IIIa) according to Clavien–Dindo grading of surgical complications. Stone size was the only parameter which correlated significantly with stone-free rate. No significant correlation was found between incidence of complications and other parameters (stone size, site, BMI, age and operative time).

Conclusions

Stone dusting technique is feasible, safe and effective in management of UUT stones.

Impact of clinical stage on the outcome of laparoscopic radical cystectomy: a prospective cohort study

Background

Some authors recommend not to perform laparoscopic radical cystectomy (LRC) for large bulky bladder cancer (BC) as the laparoscopic manipulation will be difficult. As there were no prospective studies focusing on the effect of the tumor stage of BC on the outcome of LRC, the aim of this prospective cohort study was to evaluate the effect of tumor stage on the outcome of LRC.

Results

LRC was completed for 47 patients. All patients were followed for at least 1 year, and there was no recurrence. COPD, DM, hypertension and renal impairment were detected, respectively, in 57.4%, 36.2%, 44.7% and 10.6% of patients. Transitional cell carcinoma and squamous cell carcinoma were found, respectively, in 91.5% and 8.5% of patients. Complications were reported in 29.78% including 29.78% Clavien grade 1, 17.02% grade 2 and 6.38% grade 3. There was no significant difference between cT2 and cT3 in perioperative criteria including demographic features, operative time, estimated blood loss, blood transfusion, pain score, hospital stay and complications. Upon final pathological assessment, 44.68% of patients were upgraded to higher pathological stages. Additional comparison was performed according to pathological stage and revealed no significant difference in the outcome of LRC between pT2 and higher stages except the pain score at first postoperative day which was higher in patients with pT3 stage.

Conclusion

LRC is a feasible and safe technique for both T2 and T3 clinical and pathological stages.

Modified R.E.N.A.L nephrometry score for predicting the outcome following partial nephrectomy

Background

It was difficult to compare the outcome of partial nephrectomy among different studies due to the absence of standardized description of different renal masses. This problem led to the development of nephrometry scoring systems. R.E.N.A.L. is among the commonest nephrometry scoring systems; however, some studies failed to find any relation between R.E.N.A.L. with perioperative outcome. We evaluated our designed newly modified nephrometry score in prediction of outcome following partial nephrectomy and compared its predictability versus original R.E.N.A.L.

Methods

Fifty-one patients with cT1-2N0M0 renal masses amenable for partial nephrectomy were included prospectively. Different perioperative outcome variables were compared according to complexity level in R.E.N.A.L. and the newly modified nephrometry score.

Results

Clinical staging was T1a (21.6%), T1b (49%), T2a (25.5%), T2b (3.9%). Median R.E.N.A.L. was 9 (4–12). Hilar position and intrarenal pelvis were detected in 19.6% and 68.6%. Low, moderate and high complexity masses were found in 21.6%, 39.2% and 39.2%. Complications and rate of conversion to radical nephrectomy were 17 (33.3%) and 4 (7.8%). The only significantly affected variable (p = 0.039) by R.E.N.A.L. was rate of secondary intervention, but it was higher in low than in high complexity level. In the newly modified nephrometry score, complications (p = 0.037) and rate of positive surgical margin (p = 0.049) were significantly higher with increased complexity level. Although other variables (pelvi-calyceal system entry, operative time, blood loss, hemoglobin loss, blood transfusion and conversion to radical nephrectomy) did not show statistically significant difference according to both scores, they were better associated with the complexity level in the newly modified nephrometry score with their remarkable increase in the high when compared to the low complexity level.

Conclusions

The newly modified nephrometry score was associated with better prediction of outcome of partial nephrectomy when compared to R.E.N.A.L.

[Surgical management of suburethral sling complications and functional outcomes]

OBJECTIVES

To identify various clinical presentation leading to the diagnosis of mid-urethral sling (MUS) complications and to analyze the functional outcomes after surgical management of these complications.

METHOD

Retrospective observational monocentric study of all patients treated by MUS section or removal, between December 2005 and October 2019, in a pelviperineology centre.

RESULTS

During this study, 96 patients were included. MUS complications surgically managed were vaginal mesh exposure (48 %), urethral mesh exposure (17 %), bladder mesh exposure (10 %); dysuria (30 %), pain (6 %), and infection (3 %). The mean time to diagnosis was 2 years. This diagnosis delay was caused by a non-specific and heterogeneous symptomatology. Surgical management consisted in MUS partial removal (79 %) and MUS simple section (21 %) with low perioperative morbidity. At three months follow-up, 36 patients (53 %) had stress urinary incontinence (SUI), including 13 (19 %) de novo (meaning no SUI before MUS section/removal) and 19 (28 %) had overactive bladder, including 9 (13 %) de novo. Half of the patients with SUI after MUS section/removal were able to be treated by a second MUS with a success rate of 83 % at 3 years.

CONCLUSION

Clinical presentation of MUS complications is heterogeneous. Surgical treatment was associated with low morbidity in our study. Post-operatively, half of the patients had SUI and a second MUS was a relevant treatment option after proper evaluation.

LEVEL OF EVIDENCE

4.

Asthma Device Calibrator (ADC)

Spirometer testing is considered the most common method used to evaluate the pulmonary system. It diagnoses asthma, chronic obstructive pulmonary disease (COPD) and other conditions that affect breathing. Nowadays many pharmaceutical companies produce spirometer devices for patients with asthma, designed for home use. However, the machines are replaced annually due to the lack of control and results' reproducibility. Lacking a reliable mean of calibration leads to unnecessary replacement of expensive devices and/or inaccurate measurements. The objective of this work is designing and prototyping a controlled air flow machine, which will simulate the exhalation of a human based on correlations and predefined graphs found in medicine. This prototyped machine will be used to control and/or calibrate the spirometer device of the physician. The simulation of the human's exhalation was accomplished by varying the rotational speed of an AC single phase motor using a Variable Frequency Drive in addition of a hardware device. The motor is connected directly to a centrifugal fan with forward curved blades. Using the digital pitot tube anemometer/manometer, the flow rate was measured by taking an average value of 40 frequency samples in the range 0 Hz to 100 Hz. After obtaining a relationship between the flow rate and the frequency, the data were implemented in a hardware controller, to adequately control the motor. The control was made from an Android mobile application as follows: Manual and Automatic. The Manual feature enables the user to control the flow rate manually by choosing the required maximum peak flow values to run the test. By adding an air flow sensor, the automatic feature runs automatically and the results of the test shall be obtained as a feedback on the application's screen.

One week stenting after pediatric laparoscopic pyeloplasty; is it enough?

INTRODUCTION

The use of ureteric stents for urinary diversion after pediatric dismembered pyeloplasty and its duration remain debatable. Classically, an indwelling Double J ureteric stent has to be left for 4-6 weeks. However, such a duration is not free of stent-related complications, in addition to the need to remove it under general anesthesia in the pediatric age group.

OBJECTIVES

This study aims to evaluate the outcome of short-term stenting after laparoscopic pyeloplasty in pediatric sector.

METHODS

A prospective randomized study of 37 children (less than 16 years-old) with pelvi-ureteric junction obstruction (PUJO) were managed by laparoscopic pyeloplasty by the same surgeon in the period between April 2015 and September 2017. In group A (18 patients), the DJ was removed after 4 weeks under general anesthesia, while in group B (19 patients), the DJ was fixed to the urethral catheter by a stitch, and it was removed with the urethral catheter after one week in the outpatient office. All patients were followed regularly for symptomatic improvement. Urine culture and sensitivity was done 1 month postoperatively. Abdominal ultrasound was done at 3, 6, 12 months and annually thereafter, while renal isotope scanning was done after 6 months.

RESULTS

There were no significant differences between both groups regarding operative duration, postoperative leakage, hospital stay, early postoperative complications. Both groups improved after pyeloplasty with no significant differences regarding symptoms, follow-up ultrasound, and renal scanning. The incidence of irritative symptoms and need for anticholinergics after catheter removal as well as urinary tract infection after 1 month were significantly higher in group A (P-value: 0.004 and 0.029, respectively) (Table).

DISCUSSION

To the authors knowledge, this is the first prospective controlled randomized study comparing short-term stenting with the classic 4 weeks stenting after laparoscopic pyeloplasty in the pediatric age group. In addition, the used technique of stenting not only allows stent removal on outpatient basis without anesthesia but also benefits from the pre-operative retrograde study so as not to miss any associated pathology in the ureter.

CONCLUSION

Short-term ureteric stenting after laparoscopic pyeloplasty in pediatric age group is safe and not inferior to the standard 4-week stenting. It also avoids the stent-related complications.

Enhanced recovery protocol versus standard protocol for patients undergoing radical cystectomy: results of a prospective randomized study

Background

To assess patients undergoing radical cystectomy using enhanced recovery protocol and standard protocol in terms of intraoperative and postoperative outcomes and complications.

Results

All operative and postoperative complications were recorded. In group B, time to normal bowel activity ranged from 1 to 4 days, and the mean was 1.8 days (± 1.02), while it ranged from 1 to 5 days, and the mean was 3.17 days (± 1.14) in group A which was statistically significant (p value < 0.001). The length of hospital stay in group B ranged from 6 to 50 days, the mean was 13.16 days (± 7.83), while it ranged from 8 to 35 days, and the mean was 14.71 days (± 5.78) in group A which was statistically significant (p value = 0.033). Postoperative mortality was similar in both groups.

Conclusion

In patients undergoing radical cystectomy, enhanced recovery protocol is considered as a safe procedure and not associated with any increase in intraoperative and postoperative complications compared to standard protocol. The length of hospital stay and time to return to full diet are reduced.

Promoting Smoking Cessation Through New Media Tools Facebook, Instagram and WhatsApp

Background and context: Tobacco use is a devastating problem all over the world and in the Middle East. In Egypt 20% of the adult populations are using any type of tobacco and the problem is increasing among youth especially waterpipe. Tobacco industry is targeting the youth through many ways and using indirect ways in drama and points of sale. Raising the awareness of the public about smoking hazards and benefits of quitting is one important strategy to control the epidemic. Providing support and help material is very important. Behavioral support and promoting change is very important using coaching strategies and using new tools is very helpful to reach youth. Aim: Motivating current smokers to quit through the effect of role model using new tools for behavioral support. Strategy/Tactics: Providing the message and support through new tools as WhatsApp, Instagram and Facebook where smokers who is able to quit provide information about their smoking experience and how they overcome it. Program/Policy process: Tobacco treatment specialist worked in collaboration with few young medical students to develop a Facebook page on the World No Tobacco Day 2016 and developed different posts about smoking problem and inviting viewers to add their inputs. During the early days of the campaign the team used the Facebook ads tool to promote for the page and this was sponsored by few supporters. The team who is in charge of managing the Facebook page then thought about new ideas to increase the reach and impact of the page where inviting smokers who was able to quit or take a selfie with a piece of paper writing how many days they were able to abide from smoking. The page during few months made a trend on social media. Outcomes: The reach of the page was 3 million and the reactions were 500 thousand engagement with 52 thousand members. About three thousand smokers were able to quit with following the stories sent on the page. What was learned: Using social media tools is very good way to reach out and mobilize the public to change the behavior.

A smart spirometry device for asthma diagnosis

In this paper an innovative prototype for smart asthma spirometry device to be used by doctors and asthma patients is presented. The novelty in this prototype relies in the fact that it is destined to subtend not only adults but offers an efficient and attractive manner to accommodate children patients as well thus, making it efficient for doctors, patients and parents to detect and monitor such intricate cases at stages as early as six years old. Moreover, the apparatus used enables us to integrate a vital parameter representing the Forced Expiratory Volume to the final diagnosis. Besides, the presented device will automatically diagnose those patients, assess their asthma condition, and schedule their medication process without excessive visits to medical centers whilst providing doctors with accurate and pertinent and comprehensive medical data in a chronological fashion. Zooming into under the hood of the device, a fully reliable hardware digital system lies along with a flowmeter detector and a Bluetooth emitter to interface with a user-friendly GUI-based application installed on smartphones which incorporates appealing animated graphics to encourage children to take the test. Furthermore, the device offers the capability of storing chronological data and a relevant resourceful display for accurate tracking of patients' medical record, the evolvement of their asthma condition, and the administered medication. Finally, the entire device is aligned with the medical requirements as per doctors' and telemedicine specialists' recommendations; the experiments carried out demonstrated the effectiveness and sustainable use of such device.

Five-year results of sleeve gastrectomy

OBJECTIVE

Our purpose was to evaluate the efficacy and safety of sleeve gastrectomy (SG) at 5 years after surgery.

PATIENTS AND METHODS

From June 2005 to January 2007, 65 obese patients underwent SG. The percentage of excess weight loss (%EWL) and excess BMI loss (% EBL), obesity-related co-morbidities, and post-SG complications were evaluated at 2 years after SG based on our database, and at 5 years after SG based on a questionnaire sent to the patients by one of the authors (IB) between May 2011 and February 2012.

RESULTS

A complete data set was obtained for 53 of 65 patients (82%), including 45 patients who had SG as the only surgical treatment, and eight patients who had a second bariatric procedure at a later date because of insufficient weight loss (five gastric bypass (GBP), three SG revision). For these 53 patients, the mean %EWL was 54.4% at 2 years and 53.7% at 5 years, and the mean %EBL was 61% at 2 years and 60% at 5 years. Three patients (5.7%) had post-operative complications (two fistulas (3.8%), one hemorrhage (1.9%)). Three trocar-site hernias (5.7%) were observed between 10 months and 34 months post-SG. Sub-group analysis of the 45 patients who underwent SG alone showed a mean %EWL of 57.1% at 2 years and 50.7% at 5 years; the mean %EBL was 64% at 2 years and 56.8% at 5 years. Of these 45 patients, 13 (28.9%) required medication to treat diabetes (DM) before SG and only five (11.1%) at 5 years after SG (61.5% decrease); 18 (40%) had antihypertensive treatment before SG, and eight (17.8%) at 5 years after SG (55.5% decrease); 12 (26.7%) took lipid-lowering medication before SG, and five (11.1%) at 5 years after SG (58.3% decrease); 24 (53.3%) had sleep apnea (SAS) before SG and six (17.8%) at 5 years after SG (75% decrease). However, while only five patients (11.1%) had GERD requiring PPI therapy before SG, 15 patients required PPI therapy (33.3%) at 5 years after SG (200% increase).

CONCLUSION

Five years after performance of SG, weight loss was satisfactory, few complications were observed, the reduction of co-morbidities was significant, but there was an increase in the frequency of GERD.

Problems and perceived needs for medical ethics education of resident physicians in Alexandria teaching hospitals, Egypt

There is a call for greater preparation for the ethical challenges encountered by physicians in their future professional duties. This study in Egypt aimed to reveal problems and perceived needs for medical ethics education of resident physicians working at University of Alexandria hospitals. In a descriptive, cross-sectional survey, 128 residents answered a self-administered questionnaire. More than half were of the opinion that their medical ethics course was ineffective; 56.3% mentioned poor curricular planning. The majority complained that the subject was not tailored to specialties, the course was too short, there was a shortage of resources to facilitate the educational process and that assessment was done for knowledge but not for skills. Problems related to staffing were low staff:student ratios and staff lack of experience. Trainees, regardless of clinical discipline, felt that there was a great need for improvement to their medicalethics education.

Laser and pneumatic lithotripsy in the endoscopic management of large ureteric stones: a comparative study

OBJECTIVE

We compared the results of holmium laser and pneumatic intracorporeal lithotripsy for large ureteric calculi in terms of efficacy, safety and complications.

METHODS

The study was conducted between April 2009 and October 2010. 80 patients divided into two equally matched groups were included in a prospective randomized trial including patients with a ureteric stone size of 0.5-2 cm. A holmium laser with a 550-μm fiber was employed in the laser lithotripsy (LL) group. The Swiss Lithoclast was used in the pneumatic lithotripsy (PL) group.

RESULTS

Mean stone size was comparable in both groups, namely 13.1 mm in the PL group and 12.9 mm in the LL group. The early stone-free rate was equal in both groups, while the delayed stone-free rate was 95% in LL and 85% in PL. Stone migration occurred in 12 PL cases and in 5 LL cases. Ureteric perforation occurred in 3 LL cases and in 2 PL cases. Ureteric stricture occurred in 1 case following LL.

CONCLUSION

Both PL and LL are effective and safe modalities in treating large ureteric stones with minor insignificant differences. A pneumatic system may be more efficient with regard to the cost-benefit ratio, which was not studied in the present work; further studies should address this issue.

Bruising of the esophagus as a cause of gastrointestinal bleeding in a case of heatstroke

Alterations in blood clotting are a frequent complication of serious heatstroke and may result in gastrointestinal bleeding. We report the case of a 26-year-old man who was admitted to our hospital with symptoms of hyperthermia associated with encephalopathy and disseminated intravascular coagulation (DIC) after prolonged exposure to sunlight. He presented hematemesis, after which he was diagnosed with having a bruising of the esophagus that took up the upper and lower thirds, there being no other lesions in the stomach or duodenum. After supportive treatment and following the resolution of the underlying pathology, the endoscopy-revealed injuries healed with a complete normalization of the esophageal mucosa. Esophageal submucosal bruising is an exceptional cause of hematemesis in serious heatstroke not previously described in the literature.

[Idiopathic thrombocytopenic purpura as an extraintestinal manifestation of Crohn's disease]

Idiopathic thrombocytopenic purpura is an infrequent extraintestinal manifestation of inflammatory bowel disease. It is particularly rare in association with Crohn's disease. In these cases it presents certain peculiarities with respect to its normal clinical features, occurring more frequently when Crohn's disease is mainly colonic and usually appearing after the diagnosis of Crohn's disease has been made. Moreover, it usually complicates the clinical course of both diseases. We present a case of idiopathic thrombocytopenic purpura in a 14-year-old girl in whom the two diseases first presented simultaneously. The clinical course was poor and both diseases were refractory to habitual treatment.

Megakaryocytes and platelets in the spleen of the dromedary camel (Camelus dromedarius)

This study was carried out on spleens of clinically healthy camels (n = 35) of both sexes (0.5-15 years) by routine histology, electron microscopy and immunohistochemistry using 12 anti-bovine platelet antibodies. Megakaryocytes were observed in the red pulp. Their number decreased with age: they were found in the spleens of all camels under 8 years old but only in 57% of camels over 8 years old. Only two antibodies (IVA37 and IVA38) cross-reacted with camel platelets. A large number of platelets were found in the splenic cords and the marginal zone. Ultrastructurally, the platelets were oval in shape surrounded by a plasma membrane, and their cytoplasm was rich in glycogen and contained less dense granules. Microtubules and microfilaments were found at their periphery. Several platelets were observed in the red pulp. There are similarities in some surface antigens of bovine and camel platelets. The presence of megakaryocytes in the camel spleen indicates a thrombopoietic function of the spleen until adulthood but that this decreases with age thereafter.

Palliative balloon valvoplasty of the pulmonary valve in tetralogy of Fallot

Balloon dilation of the pulmonary valve was performed in 54 patients with tetralogy of Fallot with severe cyanosis, high haematocrit and severe valvar pulmonary stenosis. Clinical, echocardiographic, angiographic, and haemodynamic data were analyzed before and after the procedure. After balloon dilation, the systemic oxygen saturation increased from a mean value of 66% to 85%. The mean value of the haematocrit before dilation was 55 + 13, and decreased to 47 after dilation (p < 0.002) in 2 months follow-up. Balloon dilation increased the size of the pulmonary valvar orifice from a mean value of 9 + 5 mm to 11.5 + 2 mm (p < 0.005). The mean Z score of the pulmonary valves, which was -3 + 1.3 before dilation, increased to -1.1 + 1.1 immediately after the procedure (p < 0.05). The size of the right and left pulmonary arteries increased after dilation from 9 mm to 10 mm, and from 8.7 + 2.4 mm to 9.8 + 2.3 mm, respectively (p < 0.05). The comparable mean Z scores increased from -2.8 + 1.9 SD to -1.8 + 1.4 SD, and from -2.4 + 1.9 SD to -1.5 + 1.6 SD for the right and left branches, respectively (p < 0.05). In patients with stenosis at the bifurcation of the pulmonary trunk and hypoplasia of the left artery, successful dilation of the pulmonary valve lead to an increase of flow and improvement in size of the hypoplastic segment. In conclusion, initial balloon dilation of the pulmonary valve in tetralogy of Fallot resulted in increase of the Z score for the pulmonary valve and improved antegrade pulmonary blood flow, inducing growth of the pulmonary arteries and ameliorating the anatomic and physiologic preoperative condition.

Trapezoidal keratotomy for the correction of naturally occurring astigmatism

We performed trapezoidal keratotomy, consisting of combined nonintersecting semiradial and transverse incisions, in 64 eyes of 45 consecutive patients with naturally occurring astigmatism. The central clear zone diameter and number and length of transverse incisions were determined by the refractive error. Mean preoperative refractive astigmatism was 3.18 +/- 1.16 diopters (D) (range, 2.25 to 7.00 D). At the 1-year follow-up examination, the mean surgically corrected astigmatism determined by vector analysis was 3.70 +/- 1.50 D (range, 0.75 to 8.5 D), and the mean residual refractive astigmatism was 0.85 +/- 0.72 D (range, 0 to 4.0 D), with 64% of eyes having 1.00 D or less. The smaller the clear zone diameter, the greater the astigmatic correction. Longer transverse incisions produced more steepening of the secondary meridian. The operative complications included microperforation (5%), misalignment of surgical meridian (6%), encroachment on clear zone (5%), and inadvertent crossed incisions (11%). Trapezoidal keratotomy reduced naturally occurring astigmatism, but with only fair predictability and with some irregular astigmatism due to irregular wound healing.

[Unique forms of the postthrombotic syndrome]

A prospective study was made with a view to analyse and to identify two particular forms of the post-thrombotic syndrome. The post-thrombotic syndrome of the shank can be recognized on the basis of the clinical and of the phlebographic examination. It has a serious prognosis and can be treated either conservatively or by surgery according to case. Its frequency is probably higher than it was presumed on the basis of the first observations. The post-thrombotic venous obstruction may be a cause of arterial ischemia during effort but this occurs only in very few cases. This particular syndrome is manifested as intermittent claudication which occurs in the clinical picture of chronic orthostatic venous failure. The probable mechanism is the direct effect of increased pressure in the arterial and venous circulation in vessels with normal walls, as a result of an important obstruction in the return circulation. Lumbal sympathectomy appears to improve durable claudication and hyperhidrosis.

Clinical study on the antifungal activity of griseofulvin in the presence of surfactants

Scales were taken from 128 human volunteers suffering from ringworm infections and grown on Sabourand's media to determine the type of organisms causing the disease. Groups of 32 patients each were treated for sixty days with griseofulvin tablets containing dioctyl sodium sulfosuccinate, cetyl pyridinium chloride and polysorbate 80 respectively, while another group of 32 was given tablets containing griseofulvin only for the same period. The subjects treated with griseofulvin tablets containing surfactants showed a higher rate of cure than those treated with griseofulvin alone.

[Effect of rest on the course of viral hepatitis]

Discussions having lately raised the importance of rest in the treatment of viral hepatitis the authors report some studies made on the subject. They take into account 3 personal unpublished statistics analyzing the role of effort at 3 different stages -- in the acute phase, during convalescence and as an eventual factor producing aggravation. Although their results appear to be in contradiction with those found in American studies the authors show that the importance of rest in the initial phase is unanimously recognized and that there is no statistical evidence that such a prescription should be given up before the normalization of the main biological parameters. Furthermore though it is statistically proved that a certain activity between the 30th and 60th day does not affect the later course of the disease yet there is no element which allows to authorize the patient to resume his normal professionnal activity before the 60th day. Finally the lack of controlled studies does not allow any precise determination of the impact of effort in the determinism of an eventual aggravation. However according to the authors' experience physical tiredness can legitimately be suspected to have produced this aggravation in 47.06 % of cases of a secondarily aggravated hepatitis.