Duodenogastric reflux--a current evaluation

150 years after Beaumont duodenogastric reflux is still under discussion. The cytotoxic effect of bile acids and lysolecithin is proved experimentally, its clinical role, however is called in question. Whereas a pathogenetic role is demonstrated in stress ulcer formation, its role in chronic ulcer is still questionable. Whereas its role in secondary alkaline reflux oesophagitis can be shown clinically and experimentally, the function of duodenogastric reflux in primary reflux oesophagitis still remains to be elucidated. The question of duodenogastric reflux in the operated stomach is even more difficult. A deleterious effect is discussed by some authors however it is not proved clinically. There is no doubt about the effect of intestino-gastric reflux against stomal ulceration in gastro-jejunal reconstruction after gastrectomy.     

Prevalence of chronic bronchitis in an industrial population in North India.

A survey for the prevalence of chronic bronchitis in an industrial population in North India is reported. The prevalence of chronic bronchitis is 12.5 percent in 473 subjects between the ages of 17 and 64 years. The prevalence rate of chronic bronchitis is comparable to that observed in areas of low community air pollution in Europe and North America. There is no age-related rise in the frequency of respiratory symptoms. The consumption of tobacco in these subjects is low and is comparable to tobacco consumption of light smokers. The prevalence of chronic bronchitis in smokers is five times the prevalence in non-smokers and is similar to the values reported for light smokers in other surveys. These observations suggest that cigarette smoking is associated with the development of chronic bronchitis, and the differences in the prevalence rate of chronic bronchitis between this survey and other surveys conducted in Europe and North America are mainly due to differences in smoking habits. Air pollution has a minor effect only and ethnic differences do not appear to play any part. Forced expired volume in one second shows a negative correlation with age. It is lower in asymptomatic smokers than in non-smokers and is lower in chronic bronchitis than in controls.     

Subcutaneous transposition of the proximal oesophagus in oesophagoplasty.

Experience with a new technique of oesophagoplasty is presented, in which the proximal part of the oesophagus is transposed to the subcutaneous space in front of the sternum and anastomosed to the organ replacing the oesophagus. This kind of operation has been performed successfully in five cases. The advantages are: thoracotomy is avoided; oesophageal anastomosis is easily performed; anastomotic failure in the subcutaneous space is not a serious problem; revision of the anastomosis is easily performed under local anaesthesia; and the mortality rate due to oesophageal anastomotic failure is diminished. The procedure is indicated in cases where a long graft for oesophagoplasty is not available and intrathoracic anastomosis is not desirable. It may also be used after oesophagogastrectomy or total gastrectomy. The most common complication is the development of a salivary fistula that heals spontaneously in a few days.     

VIS spectrophotometry used for quantitative determination of iodide in food products of animal origin

The spectrophotometric method used in dozing the iodides in the water, has been studied in order to use it in determining the iodides in a series of food products. This method is based on the catalyzed reduction of the iodide of Ce4+ by the arsenious acid. In order to determine the iodide in several food products of animal origin (eggs, milk and meat), the sample is first treated with a concentrated KOH solution and is maintained on a water bath until is obtained a residue; this is then subjected to calcination at temperatures of 500-600 degrees C until a perfectly white ash is obtained. After cooling, the ash is dissolved in water, concentrated H2SO4 is added and is completed with water up to a certain volume. The thus obtained solution is used for determination of the iodide in food, according to the method described above. The content of iodide (microgram%) have been calculated with the relation deduced from the equation of the regression line delineated in VIS at 459 nm. The method is selective and the procedure is widely applicable to the determination of iodide in different food products of animal origin.     

Vertebra plana and eosinophilic granuloma of the cervical spine in children

Eosinophilic granuloma of the cervical spine in children is a rare lesion which presents both diagnostic and therapeutic problems. The report describes three additional cases. Open biopsy is recommended instead of attempted needle aspiration in children. Laminectomy is likely to result in spinal deformity, and is not advised unless a second stage fusion is planned. Radiotherapy is effective in controlling the lesion. The ultimate outcome is usually good.     

Special radiographic techniques in the evaluation of arthritic disease

The radiographic modalities discussed in this article are useful adjunctive techniques in the evaluation of arthritic disease. None of these modalities should be considered for baseline study. Rather, they should be considered following plain film examination when further information is required. The one modality that may be considered for a screening examination is radionuclide imaging. It is most useful when early diagnostic information regarding the extent of pathology is required. A pattern of activity can provide important information to the clinician, enabling an accurate diagnosis. Arthrography is best reserved for the evaluation of articular cartilage of a particular joint. A double-contrast arthrogram should be performed in this case. The technique has little application in the evaluation of polyarticular disease. Tenography is most useful in differentiating tenosynovitis from stenosing tenosynovitis. The differentiation is important because a diagnosis of stenosing tenosynovitis usually necessitates surgical intervention. Spontaneous rupture can be evaluated with tenography, but is is probably best evaluated with MRI. CT may be used in the evaluation of both soft-tissue and articular pathology. It is perhaps best employed in the evaluation of articular pathology of the rearfoot. This technique should not be used as a screening examination for vague foot pain. MRI is the newest and most exciting imaging modality available. The excellent soft-tissue contrast provides an accurate means of evaluating the extraarticular manifestations of arthritic disease. MRI may aid in differentiating rheumatoid nodules from neuromas in rheumatoid patients with excessive forefoot disease. It is also useful in the evaluation of tendon pathology, particularly spontaneous ruptures. This technique is only in its infancy, but technologic advances are rapidly making it a major force in the field of diagnostic imaging.     

Kron's biliary prosthetic bypass in the treatment of neoplastic jaundice

After experimental study in the dog, which showed the material to be highly reliable, an original method of biliary bypass using a silicone prosthesis in the treatment of neoplastic jaundice is introduced. This prosthesis allows the bile duct to be bypassed regardless of the location of the obstacle. This method was used in 150 patients; recession was sufficiently good in 84 of them to confirm good tolerance and the excellence of the results. In fact, good results were recorded in 95% of cases of cancer of the hilum, which is all the more remarkable in consideration of the difficulties involved in these operations. The main postoperative complications are bile fistulas which resolve spontaneously if the precaution of extensively draining the zones of intubation is taken; postoperative comfort is excellent; no constraint is necessary and the operative risk is moderate, this is particularly desirable in patients in a poor general condition. A short prosthesis makes transtumoral intubation possible, and a long prosthesis allows implantation in the digestive tract: stomach, duodenum or first intestinal loop. Postoperative persistence of jaundice is rare if a prosthesis of sufficient diameter is used and if no major bile duct or part of the liver is excluded. Cholangitis is exceptional and indicative of an excluded biliary area.     

Urinary tract infections in the elderly

The elderly population is now increasing in the world. A higher incidence of bacteriuria and urinary tract infection (UTI) is observed in elderly patients, in both long-term care facilities and at home. The management of elderly patients with UTI is increasing in clinical significance. Almost all of UTI in the elderly is complicated UTI. Control of the underlying diseases in the urinary tract is quite important in the management of UTIs in elderly patients. For pyelonephritis, switch therapy using aminoglycosides and fluoroquinolones, carbapenems, third-generation cephalosporines, or penicillins are selections of choice. The recommended duration of treatment for patients with pyelonephritis is 14 days. Seven to 10 days of treatment using fluoroquinolones or trimethoprim-sulfamethoxazole is recommended for the treatment of elderly patients with symptomatic cystitis. Although asymptomatic bacteriuria is quite common in the elderly population, antibiotic treatment has no benefit for such patients. Intravaginal estrogen replacement is one of choice for the prevention of recurrent UTIs in postmenopausal women.     

Appendiceal diverticulitis

The incidence of appendiceal diverticulitis in pathologic specimens is 0.004 to 2.1 per cent and is unusual in younger patients. Despite being first described in 1893, this condition is commonly dismissed by surgeons and pathologists as a variant of true appendicitis. However, appendiceal diverticulitis is a discrete clinical process that must be considered in the appropriate setting because of the much higher risk of perforation. The average age is older, the pain is often intermittent, and although it can be localized in the right lower abdominal quadrant, it is of longer duration. Although no further treatment in addition to appendectomy is needed, it is important that surgeons be aware of this condition, as the clinical presentation can be different from the classical acute appendicitis picture. Patients often seek medical treatment much later than those with classic appendicitis, and if there is a delay in establishing the correct diagnosis, perforation within the mesentery is found at the time of operation. Also, it is often mistakenly identified as carcinoma and it has higher rate of perforation and a longer convaslescence. We describe a case of a 42-year-old man and review the literature.     

Management of humeral fracture nonunion in severe osteoporosis by a combination of locking plating and intramedullary fibular grafting

Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.     

Is there a value of erythropoietin in pre-dialysis patients?

Summary: The use of erythropoietin (EPO) in anaemic dialysis patients is now well established: there is still some doubt, however, of its role in pre-dialysis patients. This was based on initial animal work that showed accelerated decline in the renal function. Since then several studies in pre-dialysis patients have shown that it is both effective and safe. For patients who are anaemic (haematocrit <30%), there is marked increase in their subjective well-being and ability to perform physical work. There is therefore no reason to deny EPO therapy to pre-dialysis patients who are symptomatic from anaemia. the evidence clearly shows that contrary to animal work, there is no accelarated progression in renal failure. There is is some evidence that it may even delay the need for dialysis in children and possibly in some adults. In patients who have rapid progression, it is more related to untreated hypertension. Some 30-40% of EPO treated pre-dialysis patients need initiation of or increase in anti-hypertensive therapy. Subcutaneous (s.c.) self administration (1–3/week) is convenient and accepted by patients. Detection and correction of iron deficiency plays an essential role in maximizing the success of EPO therapy. Oral iron is convenient and satisfactory in most patients. Ferrokinetic studies reveal similar findings as in dialysis patients. There is increase in effective erythropoeisis, except in patients who are on azathioprine (pre-dialysis failing transplants) where the effect may be blunted by an increase in ineffective erythropoeisis. Erythropoietin improves the quality of life in predialysis patients. the most important side effect is development of hypertension, which can be controlled.     

High tibial osteotomy for osteoarthritis of the knee: a changing concept.

High tibial osteotomy is most successful in patients with osteoarthritis with mild varus deformity which is not associated with subluxation of flexion contracture. Success in the valgus knee is limited. If tibial osteotomy is indicated, undercorrection is undesirable in the varus knee while overcorrection is undesirable in the valgus knee.     

Percutaneous bone biopsy in the diagnosis of renal osteodystrophy

Renal failure is associated with many complex bone and mineral complications. The spectrum of diseases is wide, encompassing defects in bone turnover, remodeling, and mineralization. Disease is currently defined in terms of whether a high or low turnover lesion is present. Measurement of serum parathyroid hormone levels (PTH) remains an important aspect in the management of renal bone disease, however, is limited by its lack of sensitivity in many clinical settings. Multiple biochemical markers are also available both commercially and experimentally to assist in assessing the degree of bone formation or resorption. However, when definitive diagnosis is important, when the clinical setting is confusing or complex, or when parathyroidectomy is being considered, the use of percutaneous bone biopsy is an essential tool in the understanding of underlying bone pathology and in directing therapy intervention.     

Evidence that rifampicin can be used safely for non-tuberculous diseases

The incidence of primary resistance to rifampicin in Mycobacterium tuberculosis has been analysed in countries where rifampicin is restricted to use for treating tuberculosis and in countries where its use is not restricted. There is no evidence that rifampicin-resistant M tuberculosis strains are more common where the use of the drug is unrestricted. Resistance to rifampicin is less common than is resistance to streptomycin or to isoniazid. We can thus see no danger of producing resistant strains of M tuberculosis if rifampicin therapy is used for short periods for non-tuberculosis infections. The problem of resistance mutants arising in the non-tuberculous species being treated is overcome by combining rifampicin with trimethoprim.     

Fournier's gangrene and reconstruction of its defects

Fournier's gangrene is remarkebly rare but severe, life threatening condition. Thanks to better earlz recongnition of disease in past few years, the percentage of patients which survive this condition is considerable, but consequence of this fact is large number of patients with defects of cutis and subcutis in perineal and scrotal reigions. Reconstruction of this defects is cimplicate and require helathy, well vascularised tissue from another anatomical region which is not involved in gangreneous process. Authors present two cases of reconstruciton of defects in perineal and scrotal regions. First case is large defect which is covered by transposition of musculus gracilis musculo-cutaneous flap. Second case is lesser defect which is enclosed by mobilisation of local skin flaps.     

Selection criteria for aortic valve prostheses: mechanical, stented, or stentless valve or homograft?

A bioprosthesis is recommended for aortic valve replacement in patients 70 years (recently, 72 or 73 years) of age or older. The bovine pericardial valve is better suited in patients with a small aortic annulus less than 23 mm in diameter, and the porcine stented-bioprosthesis should be used in patients with an annulus larger than 25 mm. A mechanical valve is recommended in patients younger than 70 years of age with chronic atrial fibrillation or a history of thromboembolism. Moreover, a mechanical valve is selected in patients in whom it is necessary to enlarge the aortic root or annulus. When mitral valve replacement or coronary artery bypass grafting in performed concomitantly, the valve prosthesis is selected according to the age of the patient. A homograft is indicated in patients with active valve endocarditis having an abscess at the aortic annulus or root. When a patient with poor ventricular performance resulting from valvular disease is expected to undergo implantation of a ventricular assist device in the near future, a bioprosthesis is preferable.     

Errors in the differential diagnosis of incompetence of the popliteal vein and short saphenous vein by Doppler ultrasound

Doppler Ultrasound is now routinely used to demonstrate valvular reflux in the venous system. Incompetence detected at the back of the knee is located either in the short saphenous vein or in the popliteal vein. Whether the incompetence is in the deep or superficial venous system can be differentiated by digital compression over the short saphenous vein in the upper calf; if reflux is abolished then the incompetence is assumed to be in the superficial vein but if it is not prevented it must be in the popliteal vein. Sometimes the reflux is not controlled when the deep system is normal. This has been shown to be due to variations in the anatomy of the short saphenous vein and especially the pattern of its termination. Examples with venography are given, showing that in the presence of incompetence at the sapheno-popliteal junction there may be no reflux in the short saphenous vein; instead the proximal tributaries are involved and reflux in these veins is not controlled by pressure over the short saphenous vein. This explains the false positive diagnosis of valvular incompetence in the popliteal vein.     

Implications of hydronephrosis in the newborn with myelodysplasia

Hydronephrosis has been reported to be present at birth in 6 to 28 per cent of newborns with myelodysplasia. It is unknown whether this hydronephrosis is secondary to abnormal in utero voiding dynamics and is truly present at birth or whether it is acquired postnatally secondary to spinal shock after back closure. We reviewed the perinatal course of 47 myelodysplastic newborns and conclude that the true in utero incidence of hydronephrosis is lower than that suggested in the literature, and that the hydronephrosis seen in many of these newborns is acquired after back closure and is transient in nature.     

Some functional characteristics of the oesophageal vestibule in infants and children

The oesophageal vestibule lies immediately above the stomach and during quiet respiration is located partly in the thorax, partly in the hiatus in the diaphragm, and partly in the abdomen. An analysis of some aspects of function of the vestibule in infants and children who have a non-contractile gullet above the vestibule is presented. Opening of the vestibule is related to deglutition and is independent of the oesophagus above. In its opening and closing the vestibule is shown to have the characteristics of a `muscle throttle'. The rapidity of the event of either opening or closing is accounted for. The important relationship of calibre of lumen of the vestibule to flow through it is analysed. The effect of the indentations of mucosa into the lumen when the vestibule is partially open is analysed from a theoretical standpoint, and it is inferred that the vestibule when only partially open has the characteristics of a highly efficient choke.     

Refrigeration anesthesia

The use of refrigeration anesthesia for major amputations of the limbs is a sound surgical procedure. It is applicable in particular to the poor risk patient since there is scarcely any shock accompanying the procedure. It is possible to perform major amputations safely with this form of anesthesia in what formerly were hopeless cases because of debility or septicemia. It lowers the incidence of stump infections in those patients requiring amputation because of infection.Pain is relieved in most instances after the application of cold, thus adding to the ease and comfort of the patient as well as facilitating preoperative preparation. The postoperative period is likewise free from pain, and the patient may carry on without missing a meal. This is especially important in diabetics as the diet and insulin do not have to be changed.There is ease and quickness of operation in these cases. Poorly nourished tissues may be saved although refrigeration will not restore devitalized tissue. Edema and drainage may be controlled postoperatively when necessary. There is also a reduction in the incidence of thrombosis and embolism.This method of anesthesia is also valuable in severe crushing wounds of the extremities or other injuries that require amputation.This form of refrigeration is not intended to supersede other forms of anesthesia when the general condition of the patient is good, but is a valuable adjunct in the treatment of the poor risk patient.