The evaluation of podiatrists, with knowledge and training in diagnostic musculoskeletal ultrasound, to describe sonographic images of diabetic foot wounds in the United Kingdom and Australia

AIMS

Currently, wound management decisions are based largely on visual observations such as photographs, descriptors or measurements which can lack detail and do not always capture the sub-wound area. A previous case series suggests that there is benefit in using ultrasound imaging (USI) to evaluate diabetic foot ulcers (DFU) at point-of-care, however no guidance exists to inform its use. This scoping exercise explores the capacity of podiatrists with experience in interpreting musculoskeletal structures using USI to interpret sonographic images of DFU.

METHODS

Following a short briefing session, podiatrists with previous musculoskeletal (MSK) USI training were asked to review and report on previously recorded static sonographic images (n = 8) of active DFU. Content analysis was utilised to identify recurring keywords within the podiatrists' reports which were coded and assigned to categories to gain context to the data.

RESULTS

Seven podiatrists participated in the study. Four categories were constructed for the purposes of analysis: 1) Frequency of reporting, 2) Language used in reporting, 3) Observations, 4) Clinical impression Frequently, the reported findings between podiatrists were found to be similar, especially those related to bone morphology. However greater variability was seen in the reporting of wound specific soft-tissue observations.

CONCLUSION

This scoping exercise has shown that podiatrists can translate their existing USI skills to make rudimentary reports on clinical findings in DFU. All participants were consistently able to identify and describe characteristics associated with DFU from a single b mode static wound ultrasound image. Findings from this investigation can be used as a foundation for further work to establish accuracy and reliability to validate DFU sonography. In conjunction the development of protocols and training materials will enable the adoption of USI to assess DFU in clinical practice. This will in turn, contribute to improved patient care and establish a new paradigm for wound surveillance which is translatable to other wound types.

Approaching the Gamow Window with Stored Ions: Direct Measurement of ^{124}Xe(p,γ) in the ESR Storage Ring

We report the first measurement of low-energy proton-capture cross sections of ^{124}Xe in a heavy-ion storage ring. ^{124}Xe^{54+} ions of five different beam energies between 5.5 and 8 AMeV were stored to collide with a windowless hydrogen target. The ^{125}Cs reaction products were directly detected. The interaction energies are located on the high energy tail of the Gamow window for hot, explosive scenarios such as supernovae and x-ray binaries. The results serve as an important test of predicted astrophysical reaction rates in this mass range. Good agreement in the prediction of the astrophysically important proton width at low energy is found, with only a 30% difference between measurement and theory. Larger deviations are found above the neutron emission threshold, where also neutron and γ widths significantly impact the cross sections. The newly established experimental method is a very powerful tool to investigate nuclear reactions on rare ion beams at low center-of-mass energies.

Fertility sparing management of large cell neuroendocrine tumour of cervix: A case report & review of literature

Large cell neuroendocrine cervical carcinoma (LCNEC) is a rare and aggressive cancer that tends to spread and recur early despite intensive multimodal treatment. Conventional treatment strategies for early stage neuroendocrine tumour (NET) include radical hysterectomy followed by adjuvant chemotherapy. There are only 2 reported cases of fertility sparing treatment for NET. We report on the first case of successful conception and delivery at term following radical trachelectomy for early stage LCNEC.

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First reported case of delivery at term following radical trachelectomy for LCNEC

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3 year recurrence free survival following radical trachelectomy in LCNEC

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Continue data collection on both oncologic and fertility outcomes in LCNEC

Diagnosis of tuberculous lymphadenitis using fine needle aspiration biopsy

BACKGROUND

Tuberculous lymphadenitis is the commonest form of extrapulmonary tuberculosis. However, the optimal approach to diagnosis, employing biopsy by either fine needle aspiration (FNA) or surgical excision, remains uncertain.

AIMS

To evaluate the diagnostic value of biopsy using each of the component diagnostic modalities of FNA (microscopy, cytology and culture), and compare these with excision biopsy in the diagnosis of tuberculous lymphadenitis in a predominantly migrant population in Melbourne.

METHODS

A retrospective examination of tuberculous lymphadenitis cases presenting to Western Health over 12 years was conducted. Using a reference method of positive culture of Mycobacterium tuberculosis, the diagnostic sensitivities of each modality employed in FNA were determined.

RESULTS

Forty-two subjects having FNA and 30 having excision biopsy as the initial investigation were compared. Among specimens obtained by FNA, sensitivity of microscopy was 18% (95% confidence interval (CI): 5–40%) and sensitivity of cytology was 38% (95% CI: 20–59%). For specimens obtained by excision biopsies, sensitivities for microscopy and histology were 17% (95% CI: 2–32%) and 96% (95% CI: 88–100%) respectively. Sensitivity of culture performed on FNA specimens was 86% (95% CI: 65–97%).

CONCLUSIONS

Given the relatively high sensitivity of mycobacterial cultures from FNA, this study supports its routine use as the initial investigation in most patients with suspected tuberculous lymphadenitis. Microscopy and cytology add relatively little to the clinical utility of FNA

General practice career intentions among graduate-entry students: a cross-sectional study at Ireland's newest medical school

Increased care provision and clinical activity in General Practice in Ireland will have important manpower implications. Recent developments in medical education policy including the introduction of graduate-entry medical degree programmes may help address this issue. The aim of this study was to determine GP career intentions among students on an Irish graduate-entry medical degree programme and to identify factors that influence these. An electronic cross-sectional study of students at University of Limerick Graduate-Entry Medical School (UL-GEMS) was undertaken. We received 139 replies (78% response rate). 41 (29%) reported GP was their current preferred career choice, while 29 (19%) reported it was their preferred career choice on entry to medical school. This first study to present data on GP career intentions among graduate-entry students in Ireland highlights the specialty as a popular preferred career choice among students, both on entry to, and during medical school. The study also identifies factors which are likely to be important in determining career intentions. Further research to examine this issue at other graduate-entry medical schools in Ireland and to determine whether our findings are pursued over time amongst graduates is a priority.

Women with peritoneal carcinomatosis of unknown origin: efficacy of image-guided biopsy to determine site-specific diagnosis

OBJECTIVES

To evaluate the use of image-guided biopsy (IGB) in routine clinical practice to obtain site-specific diagnoses in women presenting with peritoneal carcinomatosis (PC).

STUDY DESIGN

Retrospective case study.

SETTING

Tertiary referral centre.

POPULATION

A total of 149 consecutive women with PC who underwent IGB.

METHODS

Biopsy was performed in women considered unsuitable for primary surgery because of poor performance status or disease unlikely to be optimally debulked, with a prior history of malignancy or where there was clinicoradiological uncertainty about primary tumour site. Standard haematoxylin-eosin histological analysis was supplemented with immunohistochemistry.

MAIN OUTCOME MEASURES

The rate of site-specific diagnosis.

RESULTS

A total of 149 women underwent IGB using computed tomography or ultrasound over a 6-year period. The only complication was one rectus sheath haematoma. In 138 (93%) women, a site-specific cancer diagnosis was made on the IGB (including 111 müllerian tract, 8 gastrointestinal tract, 4 breast and 3 lymphoma); in ten women, a repeat biopsy was necessary, giving an overall failure rate of 7%. In a further six women, malignancy was confirmed but a site-specific diagnosis could not be made, and in four women, biopsy showed benign tissue. A site-specific diagnosis was obtained in 29 of the 32 women (94%) with previous malignancy, of which 18/32 (56%) showed a new primary cancer.

CONCLUSIONS

IGB is a safe and accurate technique for providing site-specific diagnoses in women with PC in routine clinical practice, including those with a previous relevant malignancy. IGB can replace laparoscopic or open biopsy in defining primary therapeutic options. The data would suggest that the biopsy should be performed with ultrasound where feasible.

Image-guided biopsy in women with breast cancer presenting with peritoneal carcinomatosis

When women with a history of breast cancer present with peritoneal carcinomatosis, the differential diagnosis lies between recurrent breast cancer or a new primary tumor. This scenario is of particular relevance to women with a BRCA gene mutation, who have a genetic predisposition to develop second primary tumors of the ovary, fallopian tube, and peritoneum. We describe the use of image-guided core biopsy as an alternative to laparoscopy or exploratory laparotomy in providing minimally invasive diagnosis in this increasingly common clinical dilemma.

Image-guided biopsy in women with breast cancer presenting with peritoneal carcinomatosis

When women with a history of breast cancer present with peritoneal carcinomatosis, the differential diagnosis lies between recurrent breast cancer or a new primary tumor. This scenario is of particular relevance to women with a BRCA gene mutation, who have a genetic predisposition to develop second primary tumors of the ovary, fallopian tube, and peritoneum. We describe the use of image-guided core biopsy as an alternative to laparoscopy or exploratory laparotomy in providing minimally invasive diagnosis in this increasingly common clinical dilemma.

Efficacy of fibrinolysis in the emergency department for acute myocardial infarction

BACKGROUND

Patients with an acute myocardial infarction require a rapid response to their symptoms and the earlier fibrinolysis is given (where indicated), the better the outcome.

AIMS

The aim of this study is to compare 'door to needle times' for fibrinolysis in Acute Myocardial Infarction (AMI) in three phases of one year each, at Letterkenny General Hospital.

METHODS

In the PREINTERVENTION year all fibrinolysis was performed in the Coronary Care Unit (CCU). In the INTERVENTION year Emergency Department (ED) fast track fibrinolysis was introduced and in the POST INTERVENTION year most fibrinolysis was performed on fast track in the ED.

RESULTS

The time saved by the introduction of ED fibrinolysis was significant, 41 minutes on average per patient. Elderly, female patients were more likely to bypass ED fast track fibrinolysis and to be brought to CCU for fibrinolysis, with attendant delays. This has educational implications in relation to the variation in clinical presentation of AMI with age and sex.

CONCLUSION

The ED fast track fibrinolysis system is recommended as an effective, safe, achievable and worthwhile intervention towards improving 'door to needle times' for fibrinolysis in AMI.

Octupole vibration in superdeformed 152(66)Dy86

Nine transitions of dipole character have been identified linking an excited superdeformed (SD) band in 152Dy to the yrast SD band. As a result, the excitation energy of the lowest level in the excited SD band has been measured to be 14 238 keV. This corresponds to a 1.3 MeV excitation above the SD ground state. The levels in this band have tentatively been determined to be of negative parity and odd spin. The measured properties are consistent with an interpretation in terms of a rotational band built on a collective octupole vibration.

Direct decay from the superdeformed band to the yrast line in 15266Dy86

The excitation energy, spin, and parity of the yrast superdeformed band in 152Dy have been firmly established. The evidence comes mainly from the measured properties of a 4011 keV single-step transition connecting the yrast superdeformed level fed by the 693 keV transition to the 27- yrast state. Four additional, weaker, linking gamma rays have been placed as well. The excitation energy of the lowest superdeformed band member is 10 644 keV and its spin and parity are determined to be 24+.

Peritoneal carcinomatosis: image-guided peritoneal core biopsy for tumor type and patient care

PURPOSE

To assess image-guided peritoneal core biopsy for the diagnosis of tumor type and treatment of patients with peritoneal carcinomatosis.

MATERIALS AND METHODS

Thirty-five women (age range, 47-85 years; mean age, 69 years) prospectively identified in a gynecologic oncology center underwent 18-gauge core biopsy in omental cake (n = 25), peritoneal (n = 7), or adnexal (n = 3) sites. No complications of biopsy occurred. Standard hematoxylin-eosin analysis of the biopsy cores was supplemented by immunohistochemical markers to CA-125, carcinoembryonic antigen, cytokeratin 7, and cytokeratin 20. Diagnoses were validated with further multidisciplinary review, subsequent surgery, and response to specific chemotherapy.

RESULTS

In 27 (77%) of the 35 women, a confident primary site diagnosis was obtained with standard hematoxylin-eosin analysis of core biopsy material from the following sites: ovary (n = 22), breast (n = 2), colon (n = 2), and lymphoma (n = 1). The finding at hematoxylin-eosin analysis in another seven (20%) women was poorly differentiated adenocarcinoma with no definite primary site but with an immunohistochemical profile suggesting ovarian cancer (CA-125 positive, carcinoembryonic antigen negative, cytokeratin 7 positive, cytokeratin 20 negative). There was one false-negative biopsy result.

CONCLUSION

Image-guided peritoneal core biopsy with hematoxylin-eosin analysis supplemented with immunohistochemical analysis is a simple, safe, and accurate technique for providing site-specific diagnoses in women with undiagnosed peritoneal carcinomatosis.

Bladder transplantation in rats using FK-506

PURPOSE

We created viable bladder tissue by transplantation with immunosuppression.

MATERIALS AND METHODS

For bladder transplantation the bladder of newborn Brown-Norway rats was excised and each was transplanted into a pouch created in the distal omentum of a 5-week-old Lewis rat. In 15 group 1 rats no immunosuppressive agent was used. In 20 group 2 rats 0.6 mg./kg. FK-506 daily were given intramuscularly until a predetermined day of harvest. Recipient rats were sacrificed on day 3, 5, 7 or 14 after bladder transplantation, and the bladder grafts were harvested and formalin fixed. Hematoxylin and eosin staining was done to examine bladder graft survival and the degree of rejection, and immunohistochemical testing was performed for assessing the vesical nervous system. In 5 rats in the control group bladder augmentation was performed by anastomosing the bladder graft to the native bladder. Each augmented bladder was harvested 21 days later for histopathological assessment.

RESULTS

Overall bladder graft survival was 96.4%. Each successfully transplanted bladder graft appeared macroscopically as a thin walled cyst. In group 1 all bladder grafts showed rejection with cellular infiltration. In group 2 there was mild rejection in 5 rats and no evidence of rejection in the remaining 15. All group 2 bladder grafts had intact nerve distribution. Bladder augmentation was successful in all 5 cases and the mucosa was normal throughout each augmented bladder.

CONCLUSION

Because FK-506 successfully prevents rejection, our technique would appear to have the potential for creating viable bladder tissue that may be used for bladder augmentation in cases of vesical exstrophy or neurogenic bladder.

Use of Abdominoplasty Technique and Marlex for Closure of a Major Abdominal Wall Defect

Surgical resection of extensive primary or secondary abdominal wall tumours leads to major defects requiring reconstruction. The present case report describes the use of Marlex (polypropylene) mesh (CR Bard Inc, USA) with Mitek GII suture anchors (Mitek Products, USA) and an abdominoplasty technique to close a defect involving the entire lower half of the abdominal wall.

Benefits of pravastatin on cardiovascular events and mortality in older patients with coronary heart disease are equal to or exceed those seen in younger patients: Results from the LIPID trial

BACKGROUND

The effect of cholesterol-lowering therapy on death from coronary heart disease in older patients with previous coronary heart disease and average cholesterol levels is uncertain.

OBJECTIVE

To compare the relative and absolute effects of pravastatin on cardiovascular disease outcomes in patients with coronary heart disease who are 65 years of age or older with those in patients 31 to 64 years of age.

DESIGN

Subgroup analysis of a randomized, placebo-controlled trial.

SETTING

87 centers in Australia and New Zealand.

PATIENTS

3514 patients 65 to 75 years of age, chosen from among 9014 patients with previous myocardial infarction or unstable angina and a baseline plasma cholesterol level of 4.0 to 7.0 mmol/L (155 to 271 mg/dL).

INTERVENTION

Pravastatin, 40 mg/d, or placebo.

MEASUREMENTS

Major cardiovascular disease events over 6 years.

RESULTS

Older patients were at greater risk than younger patients (31 to 64 years of age) for death (20.6% vs. 9.8%), myocardial infarction (11.4% vs. 9.5%), unstable angina (26.7% vs. 23.2%), and stroke (6.7% vs. 3.1%) (all P < 0.001). Pravastatin reduced the risk for all cardiovascular disease events, and similar relative effects were observed in older and younger patients. In patients 65 to 75 years of age, pravastatin therapy reduced mortality by 21% (CI, 7% to 32%), death from coronary heart disease by 24% (CI, 7% to 38%), coronary heart disease death or nonfatal myocardial infarction by 22% (CI, 9% to 34%), myocardial infarction by 26% (CI, 9% to 40%), and stroke by 12% (CI, -15% to 32%). For every 1000 older patients treated over 6 years, pravastatin prevented 45 deaths, 33 myocardial infarctions, 32 unstable angina events, 34 coronary revascularization procedures, 13 strokes, or 133 major cardiovascular events, compared with 22 deaths and 107 major cardiovascular events per 1000 younger patients. Among older patients, the numbers needed to treat were 22 (CI, 17 to 36) to prevent one death from any cause, 35 (CI, 24 to 67) to prevent one death from coronary heart disease, and 21 (CI, 17 to 31) to prevent one coronary heart disease death or nonfatal myocardial infarction.

CONCLUSIONS

In older patients with coronary heart disease and average or moderately elevated cholesterol levels, pravastatin therapy reduced the risk for all major cardiovascular events and all-cause mortality. Since older patients are at greater risk than younger patients for these events, the absolute benefit of treatment is significantly greater in older patients.

Venous aneurysm of the dorsal venous arch

Clinically, a venous aneurysm is seen as a nonpulsatile mass with shrinkage upon elevation and enlargement with dependency. Confirmation of the diagnosis is best made by venography. In the case presented here of a rare aneurysm of the dorsal venous arch, the diagnosis of venous aneurysm was based on the histopathologic and intraoperative findings. If a venous aneurysm is symptomatic, it should be excised, with ligation of all feeder veins. In all cases, accurate preoperative diagnosis and evaluation allows for appropriate surgical planning.

Effects of pravastatin in 3260 patients with unstable angina: results from the LIPID study

BACKGROUND

The LIPID study is a major trial of secondary prevention of coronary-heart-disease events that includes hospital admission with unstable angina (as well as myocardial infarction) as a qualifying event. In this substudy of LIPID, we compared subsequent cardiovascular risks and the effects of pravastatin in patients with previous unstable angina or previous myocardial infarction.

METHODS

3260 patients diagnosed with unstable angina and 5754 with acute myocardial infarction 3-36 months previously were randomly assigned 40 mg pravastatin daily or placebo over a mean of 6.0 years. The risk reduction of a range of cardiovascular events was estimated by means of the hazard ratio in Cox's proportional hazards model.

FINDINGS

Among patients assigned placebo, survival in the two diagnosis groups was similar. The relative risk reduction for mortality with pravastatin was 20.6% in the myocardial infarction group and 26.3% in the unstable angina group (p=0.55). Pravastatin significantly reduced the rates of all prespecified coronary endpoints in the myocardial infarction group. In patients with previous unstable angina, coronary heart disease mortality, total mortality, myocardial infarction, a need for coronary revascularisation, the number of admissions to hospital, and the number of days in hospital were significantly lower with pravastatin. Overall, hospital admission for unstable angina was the most common endpoint (24.6% of the placebo group; 22.3% of the pravastatin group).

INTERPRETATION

Patients who have survived acute myocardial infarction or unstable angina have a similar long-term prognosis, a high occurrence of subsequent unstable angina, and benefit similarly from therapy with pravastatin.

Neural networks in the diagnosis of malignant ovarian tumours

OBJECTIVE

To assess the role of neural networks in predicting the likelihood of malignancy in women presenting with ovarian tumours.

DESIGN

Retrospective case study.

SETTING

University Department of Obstetrics and Gynaecology, St James's Hospital, Leeds.

METHODS

Information from 217 cases with histologically proven benign, borderline or malignant tumours was extracted for study. Four variables (age, ultrasound findings with and without colour Doppler imaging and CA125) were entered in the neural network classifier. The neural network results were compared with logistic regression analysis.

RESULTS

When used in the neural network the variables of age, CA125 and ultrasound score produced the best result with a sensitivity of 95% and a corresponding specificity of 78% in predicting malignancy. Logistic regression gave a sensitivity or 82% for a specificity of 51%.

CONCLUSION

The neural network is a good method of combining diagnostic variables and may be a useful predictor of malignancy in women presenting with ovarian tumours. A comparison of the performance of the neural network with conventional diagnostic methods would be warranted prior to use in clinical practice.

Port-site metastasis following laparoscopic lymphadenectomy for adenosquamous carcinoma of the cervix

Although incisional metastases following surgery for cervical cancer are extremely rare, port-site disease following minimal-access surgery is becoming increasingly reported. We report a case of a metastasis which occurred at a port site following laparoscopic removal of lymph nodes affected by cervical adenosquamous carcinoma. This report adds to the literature suggesting that cutaneous tumor deposition may be enhanced by this method of surgery.

CT appearances and prognostic significance of splenic metastasis in ovarian cancer

DESIGN

A retrospective review of women undergoing computed tomography (CT) as part of the investigation and management of pathologically proven ovarian cancer in a single specialist gynaecological cancer centre.

OBJECTIVE

To ascertain CT appearances and prognostic significance of splenic involvement in ovarian cancer.

RESULTS

We found a 10.3% frequency of splenic metastasis in a series of 321 patients with ovarian cancer. Thirty-three women had splenic metastases demonstrated on CT. Twenty-three women had surface lesions with an irregular scalloped shape and broad contact with the splenic surface; 17 of these women had lesions at presentation. Ten women had parenchymal lesions, five at presentation and five at relapse, typically with a rounded shape surrounded by normal splenic tissue. Four out of 10 cases with parenchymal involvement showed lesion progression during chemotherapy. However, lesion progression occurred in only one of 23 cases with surface disease (P < 0.025, Fisher's exact test). In 16 cases with disease involving both spleen and liver, the response to chemotherapy was the same in both organs.

CONCLUSION

We have found a higher frequency of splenic metastasis from ovarian cancer during life than previously reported. Parenchymal lesions are significantly less likely to respond to treatment than surface lesions but are more commonly a feature of relapsed disease. We have demonstrated that splenic metastases behave similarly to liver metastases in ovarian cancer. We suggest that the presence of splenic parenchymal metastasis is indicative of FIGO stage IV disease. This finding has implications for proposed cytoreductive surgery.

Malignant melanoma metastatic to the ovary: presentation and radiological characteristics

Cutaneous melanomas rarely metastasize to the ovary; however, we have recently encountered three cases which have proved a diagnostic dilemma. All presented with a pelvic mass and a past history of cutaneous melanoma but both ultrasound examination and CT scanning proved inconclusive and neither was able to accurately characterize the lesions. Magnetic resonance imaging (MRI) was able to demonstrate the presence of melanin in one of the ovarian lesions as peripheral high signal change on T1-weighted images. The two lesions without melanin failed to show this feature. MRI may therefore be useful in the diagnosis of ovarian melanoma but only if melanin is present.

Spontaneous perforation of choledochal cyst: a study of 13 cases

Of the 187 cases of infantile choledochal cyst treated at our hospitals, we encountered 13 with spontaneous perforation. All cases were under 4 years old. Eight cases were found to have biliary peritonitis and 5 had a sealed perforation. The shape of the extrahepatic bile duct was cystic in 8 and fusiform in 5. The cyst wall around the perforation was filmy and bile was found to be oozing through the thinned wall. Nine perforations were single while 4 cases had multiple perforations. Four of 17 perforations occurred in the posterior part of the cyst wall. Only 1 case of perforation was associated with protein plugs in a common channel, while 7 of the 10 cases of choledochal cyst requiring percutaneous biliary drainage due to signs of raised intrabiliary pressure were found to have protein plugs. We consider that spontaneous perforation of a choledochal cyst is not rare in infancy. The etiology of a perforation must be epithelial irritation of the biliary tract due to refluxed pancreatic juice caused by pancreatico-biliary malunion associated with mural immaturity due to infancy, rather than an abnormal rise in ductal pressure or congenital mural weakness at a certain point.

Initial experience with non-breath-hold magnetic resonance cholangiopancreatography: a new noninvasive technique for the diagnosis of choledochal cyst in children

BACKGROUND/PURPOSE

Magnetic resonance cholangiopancreatography (MRCP) is an emerging tool for the noninvasive evaluation of the pancreaticobiliary tree.

METHODS

Non-breath-hold MRCP was used in three children to evaluate choledochal cyst; a first for this new modality of diagnostic imaging. In all cases, the intrahepatic and extrahepatic bile ducts, and the pancreatic duct were clearly visualized.

RESULTS

Two cases were found to have a fusiform choledochal cyst, and non-breath-hold MRCP demonstrated pancreaticobiliary malunion and a long common channel. In the remaining case, the size and location of the huge cyst prevented visualization of any pancreaticobiliary malunion. Endoscopic retrograde cholangiopancreatography (ERCP) in this patient failed to provide any additional information. All patients underwent cyst excision with hepaticoenterostomy, and made an uneventful recovery.

CONCLUSIONS

Our initial experience suggests that non-breath-hold MRCP is a reliable method for the diagnosis of choledochal cyst in children and could replace ERCP.

Tumor necrosis factor alpha in children with sickle cell disease in stable condition

Tumor necrosis factor alpha (TNF-alpha) is known to induce wasting in humans and animals. This study was undertaken to determine TNF-alpha concentrations in children with sickle cell disease (SCD) and whether high TNF-alpha levels are more likely to be present in children with growth deficits, infection, or pain crisis. Tumor necrosis factor alpha was measured using enzyme immunoassay in 143 blood samples obtained from 101 children. Mean TNF-alpha levels were higher in patients (50 pg/mL) than in 21 control children (19 pg/mL) and in 26 laboratory employees (20 pg/mL). During the follow-up period, 35%, 38%, and 28% of children with SCD had infection, pain crisis, or a blood transfusion, respectively. Mean TNF-alpha concentrations were higher in children who had an infection than in those who did not. No significant effect of pain crisis or blood transfusion was observed. Tumor necrosis factor alpha concentrations were above normal (> 40 pg/mL) in 15% of controls, 34% of children with SCD, and 52% of children with SCD who had an infection and 33% of those who did not. A higher percentage of children who had elevated TNF-alpha levels had weight (46% versus 31%) or height (50% versus 28.6%) deficits than children who had normal TNF-alpha levels. These results indicate that most children with SCD in stable condition have normal TNF-alpha concentrations and that those with high TNF-alpha levels are more likely to have growth deficits.

Modified Boerema technique for the closure of congenital abdominal wall defects to prevent incisional herniation and infection

Tension and infection often cause wound dehiscence or incisional herniation after the fascial closure of congenital abdominal wall defects in neonates. To overcome these problems, a modification of the Boerema technique (a method for repairing large incisional hernia in adults) was applied to repair abdominal wall defects in 14 neonates. The efficacy of this technique is discussed in this report.

Torsion of autotransplanted splenic tissue in Gaucher disease

A 12-year-old girl who underwent a splenectomy followed by heterotopic splenic autotransplantation for treatment of hypersplenism secondary to Gaucher disease at the age of 3 years presented with acute lower abdominal pain. Radiological investigations were highly suggestive of torsion of the autotransplanted splenic tissue, which was confirmed during subsequent laparotomy. This is the first known report of torsion of autotransplanted splenic tissue.

Endometrial carcinoma in a young patient with polycystic ovarian syndrome: first suspected at time of embryo transfer

Adenocarcinoma of the endometrium is a rare condition in women under 40 years of age. However, patients with anovulatory polycystic ovarian syndrome are at risk of developing endometrial carcinoma due to the unopposed and prolonged effect of oestrogen on the endometrium. This case report discusses the dilemma of various treatment options for early disease in such patients.

The Jehovah's Witness family, transfusions, and pediatric day surgery

The pediatric otolaryngologist and anesthesiologist, when encountering a family of the Jehovah's Witness (JW) faith, should be aware of the potential problems which may arise when deciding to proceed with surgery. Two case reports are presented which illustrate the difficult situations which can occur when unanticipated complications (i.e. profound bleeding) arise perioperatively. An overview of the history and common tenets of the JW faith, previous legal perspectives, pertinent clinical information from the medical literature, and the protocol of The Children's Hospital, Denver, for dealing with this sensitive issue (drafted with the cooperation of the local JW Hospital Liaison Committee) are presented.

Pancreaticobiliary maljunction associated with nondilatation or minimal dilatation of the common bile duct in children: diagnosis and treatment

It is known that the etiology of congenital biliary dilatation (CBD) is closely associated with pancreaticobiliary maljunction (PBMJ). Treatment of CBD today is primary excision of the cyst followed by hepaticoenterostomy. However, PBMJ without dilatation of the biliary tract has recently been reported and its treatment is still controversial. In adults, simple cholecystectomy without biliary reconstruction is often performed, because it usually presents as an anomaly of the gallbladder. Over 30 years, we have encountered 8 patients with PBMJ without dilatation of the common bile duct in 180 pediatric cases of CBD. The presenting symptoms of these patients were those of pancreatitis i.e. abdominal pain associated with elevation of serum amylase levels. Five cases presented with jaundice or a history of pale colored stools. Endoscopic retrograde cholangiopancreatography was performed to confirm the diagnosis. Five (62.5%) of these 8 patients were found to have dilatation of the common channel, which was seen in 50 (29%) of the 172 other cases with biliary tract dilatation. Three cases (37.5%) had proven protein plugs or debris at the level of the common channel, and this was observed in 28 (16%) of the 172 other cases. It is strongly suggested that the manifestation of clinical symptoms in these patients results from stasis or obstruction at the level of the common channel. In children who present with recurrent pancreatitis, PBMJ must be suspected even if the common bile duct appears to be normal. It is difficult to resolve these anomalies without operative repair. The authors consider that radical treatment of PBMJ is required in these children to prevent serious long-term complications.

Hepaticoenterostomy after excision of choledochal cyst in children: a 30-year experience with 180 cases

In the long-term follow-up of patients with choledochal cyst, postoperative ascending cholangitis and/or stone formation in the intrahepatic bile ducts (IHBD) owing to anastomotic stricture present serious problems. To prevent the formation of anastomotic strictures, some surgeons recently have performed hepaticoenterostomy at the hepatic hilum, with a wide stoma, in all patients with choledochal cyst. The authors of the present study review the surgical procedures performed on a total of 180 children with choledochal cyst and discuss the treatment of choice, with special reference to the types of hepaticoenterostomy. The medical records and radiographs of all patients treated for choledochal cyst between January 1964 and December 1993 at the authors' institutions were reviewed. A total of 180 patients (mean age at time of surgery, 4.3 years) had follow-up for a mean of 11.1 years; 174 of them had cyst excision and hepaticoenterostomy, and six had cystoenterostomy. Of the 174 patients who underwent cyst excision, 171 had a conventional hepaticoenterostomy; two had an intrahepatic cystoenterostomy, and one had a hepaticoenterostomy at the hepatic hilum. IHBD stones with or without cholangitis developed postoperatively in four (2.3%) of the 171 patients who had conventional hepaticoenterostomy. The age at time hepaticoenterostomy of these four patients was 12, 7, 16, and 6 years. Postoperative IHBD stone formation and cholangitis were not found in 121 patients under 5 years of age. The authors recommend conventional hepaticoenterostomy as the treatment of choice for children with choledochal cyst. Hepaticoenterostomy at the hepatic hilum is indicated in only selected cases.

Sibling occurrence of biliary atresia and biliary dilatation

Familial occurrence of extrahepatic biliary atresia (EHBA) or biliary dilatation has been reported; however, the genetic influences on these disorders are still obscure. The authors previously reported the occurrence of biliary dilatation and EHBA in sisters, which is extremely rare. Recently, a similar pair of sisters was treated; one had pancreaticobiliary maljunction with minimal dilatation of the common bile duct, and the other also had EHBA. The authors' investigations suggest that there may be common etiologic factors for EHBA and biliary dilatation, such as pancreaticobiliary maljunction; however, other factors are required to complete the process and cause biliary atresia.

Carbon dioxide laser removal of polymethylmethacrylate

Polymethylmethacrylate remains an excellent method of securing orthopaedic implants. However, revision surgery may be necessary when loosening of the prosthesis has occurred with symptomatology. Removal of polymethylmethacrylate during revision surgery can be difficult. Care must be taken to avoid damage to the remaining bone and surrounding soft tissue. This study was undertaken to characterize the efficacy of the carbon dioxide (CO2) laser for cement removal in vitro and in vivo. The CO2 laser did not damage adjacent bone or soft tissue via lateral heat transfer in vitro and in vivo. The maximum bone cortex temperature during CO2 laser removal was 56 degrees C. This was lower than the 60 degrees C temperature encountered during initial cement insertion and curing. The CO2 laser preferentially penetrates polymethylmethacrylate with absorption versus apparent relative reflection with bone. The products of vaporization from CO2 laser removal of polymethylmethacrylate were removed safely (to < 12.2 ppm) with a smoke evacuator without risk to the patient or operating room personnel. Removal of polymethylmethacrylate by CO2 laser was performed in 117 patients undergoing revision operations, including 78 total hip revisions, 33 total knee revisions, 3 total elbow revisions, and 3 spine revisions. No perforation or fracture of bone occurred with the use of the laser. There was no statistical difference in surgical time, blood loss, infection rate, or hospital stay when the CO2 laser was used. There were no cases of osteonecrosis or obvious soft tissue necrosis caused by the laser. The infection rate was 3.4% (4/117) when the laser was used for cement removal.

Laser discectomy

Discectomy with lasers is a technically easy procedure and permits a surgeon to place a predictably sized and configured defect in a predetermined position in the intervertebral disc. In a small series of patients, the procedure appears effective in controlling symptoms in a high percentage of patients. The efficacy of the procedure and wider acceptance will depend on the results of multicenter clinical trials.