Helping families of homicide victims: A multidimensional approach

Homicide inflicts massive injury upon the intrapsychic and interpersonal realities of the surviving kin of murder victims. A New York City pilot program of outreach and counselling to 1182 families of Brooklyn homicide victims suggests that surviving kin undergo the symptoms of traumatic stress disorder. Recovery is prolonged by knowledge that the perpetrator is usually alive and in some cases unpunished, by repetitive confrontations with the criminal justice system and by the multiple losses endured: loss of a family member, loss of illusions of safety and invulnerability, loss of a sense of trust in the surrounding community, and loss of a belief system. Effective help to survivors requires interventions that respond to all aspects of the survivors' losses.     

Surgery for fistula-in-ano: an audit of practise of colorectal and general surgeons.

Objective Some conditions, previously managed by general surgeons, may be treated more successfully by colorectal specialists. This argument is well established for rectal cancer but does it also apply to benign conditions? This study compares the treatment strategies and outcomes for fistulae‐in‐ano by general and colorectal surgeons in a district general hospital. Method Patients who had surgery for fistula‐in‐ano from January 1992–October 2003 were identified from theatre records. Case notes were reviewed for data on type of fistula, aetiology, surgery performed and recurrence. All patients were sent a questionnaire requesting details of recurrence and incontinence. The severity of incontinence was assessed using the Faecal Incontinence Quality of Life Scale (FIQOLS) and the Faecal Incontinence Severity Index (FISI). Results Eighty four patients (male = 53) were identified. Colorectal surgeons performed surgery in 34 and general surgeons in 50 patients. These groups were comparable with terms of age, gender, aetiology (colorectal: IBD = 5, cryptoglandular = 21: general IBD = 14, cryptoglandular = 24; P = 0.28; Chi‐squared test), and type of fistulae (colorectal: inter‐sphincteric = 20, trans‐sphincteric = 13: general inter‐sphincteric = 30, trans‐sphincteric = 18: P = 1.0; Fisher's exact test). Colorectal surgeons carried out fewer fistulotomies (47.1%vs 84.0%; P < 0.001; Fisher's exact test), more staged fistulotomies with Setons (44.1%vs 10.0%: P < 0.001; Fisher's exact test), and had fewer recurrences (9.7%vs 30.0%: P < 0.05; Fisher's exact test) when compared with general surgeons. Five patients with recurrence from the general surgery group were subsequently referred to the colorectal surgeons; four patients had further surgery (fistulotomy = 2; staged fistulotomy = 2) with no recurrence to date; one patient required proctectomy. Forty seven (64.4%) patients answered the questionnaire. There was no difference between patients operated on by colorectal or general surgeons with regards the frequency (43.5%vs 62.5%: P = 0.25; Fisher's exact test) or severity [FISI 26 (21–38); median (inter‐quartile range) vs 26 (17–38); median (inter‐quartile range: P = 0.85; Mann–Whitney test) of faecal incontinence. There was no difference between the groups with regards any of the four scales that comprised the FIQOLS. Conclusions The number of included patients is far too low to draw any conclusions but there were some interesting trends. For similar patient samples, colorectal surgeons seem to adopt a more conservative approach and have fewer recurrences than general surgeons. These differences are not reflected in the frequency or severity of postoperative incontinence.     

多聚酶链反应检测细菌DNA对大鼠空、回肠吻合口瘘的早期诊断价值

目的:探讨PCR检测大鼠外周血及腹水中细菌DNA对空肠-空肠、回肠-回肠吻合口瘘的早期诊断价值。方法:健康Wistar雌性大鼠50只，随机分成5组，每组10只：A组为假手术组;B组为空肠-空肠吻合组;C组为空肠吻合口瘘组;D组为回肠-回肠吻合组;E组为回肠吻合口瘘组。采集手术前后外周血及术后腹水，抽提DNA, 比较lacZ基因和16SrRNA基因的PCR阳性率，并观察各组的病理学情况。结果:（1）C，E组术后外周血lacZ基因PCR阳性率与B，D组无显著性差异（P>0.05）;C，E组术后外周血16SrRNA基因PCR阳性率显著高于B，D组（P<0.05）。（2）C，E组腹水lacZ基因和16SrRNA基因PCR阳性率均显著高于B，D组（P<0.05）。（3）C，E组腹水lacZ基因阳性率显著高于外周血（P<0.05）;C，E组腹水16SrRNA基因阳性率与外周血无显著性差异（P>0.05）。结论:（1）PCR检测术后外周血16SrRNA基因对空、回肠吻合口瘘的早期诊断有一定意义;（2）检测术后腹水lacZ基因和16SrRNA基因对空肠-空肠、回肠-回肠吻合口瘘的早期诊断也有一定意义。     

Three-dimensional magnetic resonance myocardial motion tracking from a single image plane.

Three-dimensional imaging for the quantification of myocardial motion is a key step in the evaluation of cardiac disease. A tagged magnetic resonance imaging method that automatically tracks myocardial displacement in three dimensions is presented. Unlike other techniques, this method tracks both in-plane and through-plane motion from a single image plane without affecting the duration of image acquisition. A small z-encoding gradient is subsequently added to the refocusing lobe of the slice-selection gradient pulse in a slice following CSPAMM acquisition. An opposite polarity z-encoding gradient is added to the orthogonal tag direction. The additional z-gradients encode the instantaneous through plane position of the slice. The vertical and horizontal tags are used to resolve in-plane motion, while the added z-gradients is used to resolve through-plane motion. Postprocessing automatically decodes the acquired data and tracks the three-dimensional displacement of every material point within the image plane for each cine frame. Experiments include both a phantom and in vivo human validation. These studies demonstrate that the simultaneous extraction of both in-plane and through-plane displacements and pathlines from tagged images is achievable. This capability should open up new avenues for the automatic quantification of cardiac motion and strain for scientific and clinical purposes.     

显微外科技术治疗复杂膀胱尿道阴道瘘(附五例报告)

目的 总结显微外科技术修补复杂性膀胱尿道阴道瘘的经验。方法 膀胱尿道瘘患者4例，膀胱阴道多发瘘1例，均在手术放大镜下用细线行瘘修补，膀胱颈缺损多层缝合或利用阴道壁修补尿道缺损。结果 5例均一次修补成功，随访6～12个月，排尿均通畅。1例膀胱颈全尿道缺损者咳嗽时有轻微尿失禁，余4例无尿失禁、无漏尿，性生活满意。结论 多层缝合膀胱颈缺损可恢复膀胱颈括约肌功能，显微外科技术组织对合好、反应小，有利于尿瘘愈合。     

Use of endoscopy in the management of postoperative ureterovaginal fistula

The aim of the study was to evaluate endourological techniques in the management of iatrogenic ureterovaginal fistula. Seventeen patients referred to us after gynecologic surgery were diagnosed as having iatrogenic ureterovaginal fistula. First, retrograde double-J stenting was tried. If this failed, percutaneous nephrostomy using an antegrade double-J stent was performed. If this also failed, open surgical repair was performed. The retrograde double-J stent bypassed the fistula in 2 patients (11.8%). Percutaneous nephrostomy was performed in the remaining 15. The antegrade double-J stent bypassed the fistula in another 2 of these patients (11.8%). Open surgical repair was performed in the remaining 13 patients (67.5%) (direct ureteroneocystostomy) with nipple valve in 11 patients and Boari flap with psoas hitch in 2 patients). Of all patients, 2 had ureteral stricture, one after antegrade double-J stenting and the other after open repair. It was concluded that early intervention is recommended in the treatment of iatrogenic uretrovaginal fistula, causing minimal morbidity and discomfort, and being less expensive. EDITORIAL COMMENT: This is an interesting paper that is worthy of mention because of an important concept in the management of an iatrogenic ureterovaginal fistula. The traditional management of these fistulas has been ureteroneocystostomy [1]. However, recent urologic literature suggests that modern endoscopic treatment is highly successful if the passage of an internal stent is possible [2,3]. This is a concept that must be shared with our urogynecologic colleagues. In this paper, 4 of 14 patients with an iatrogenic fistula underwent placement of an indwelling stent. Of these, two were placed cystoscopically, whereas the other two were placed percutaneously. All four ureterovaginal fistulas healed successfully. However, 1 patient developed a ureteral stricture. It is noteworthy that in the combined series of Selzman [2] and this Tulane group not only were all ureterovaginal fistulas successfully treated with a stent, but only 1 of 11 patients (9%) developed a stricture. Although the sample size is small, this paper supports the conclusion that successful endoscopic placement of a double-J stent does allow the ureterovaginal fistula to heal spontaneously. Therefore, initial endoscopic management of an iatrogenic ureterovaginal fistula is a reasonable recommendation. However, equally important is the development of a ureteral stricture causing ‘silent hydronephrosis’. After stent removal the patient may develop a distal ureteral stricture with a completely asymptomatic hydronephrosis — ‘silent hydronephrosis’. Although the patient may be clinically asymptomatic, the renal units remain in jeopardy. Therefore, routine periodic follow-up with radiologic studies is warranted after stent removal.     

Percutaneous transcatheter occlusion of coronary artery fistulas using detachable balloons

Three pediatric patients underwent successful transcatheter coronary artery fistula occlusion using the Debrun system. This latex balloon system offers several advantages over other occlusion systems. First, the balloon delivery and release is controlled. Second, “test occlusions” can be performed that allow simultaneous balloon inflation, coronary cineangiography, and electrocardiographic monitoring. Third, because the balloons are flow-directed, they are easily positioned in properly chosen locations. Finally, the balloons can be constructed to suit the size of the fistula. In this study, two patients received only one balloon; in the other patient two balloons were placed in the same fistula. All fistulas drained into either the right atrium or ventricle and were successfully occluded. After a follow-up period of up to 3 years, no local or systemic reactions to the balloons were recognized. We conclude that detachable balloon occlusion of coronary artery fistulas is a safe, effective alternative to surgical ligation in selected pediatric patients.     

癌性食管-气管瘘的带膜内支架治疗

目的评估食管带膜内支架治疗癌性食管-气管瘘的疗效。资料与方法20例癌性食管-气管瘘,15例合并肺部感染。共置入20枚食管带膜自膨式支架。结果18例一次性堵瘘成功,进食改善。14例肺部感染治愈,1例于术后1周大出血死亡。先期失败的2例,其中1例因持续肺部感染死亡,另1例禁食12天后自愈。结论食管带膜内支架置入是治疗癌性食管-气管瘘的有效方法。     

湘西自治州1995～2002年男性劳教人员法定性病监测报告

目的 了解湘西自治州重点人群性病患消长趋势，为性病防治工作提供科学依据。方法 从1995年起，采用统一的表格，每年对湘西州劳教所新入教人员进行一次法定性病监测。结果 三种法定性病平均患病率为14．64％(4．96～26．7％)，以1995年最低，1997年最高，8年未发现HIV／AIDS，患病率以20～39岁的性跃期人群为最高，汉族患病率高于其它民族；化程度越高，患病率越低。结论 男性劳教人员作为性病患病的高危人群，是哨点监测理想的目标人群。