Hirschsprung's disease: a regional experience

Background: Hirschsprung’s disease (HD) is widely quoted to have an incidence of approximately 1 in 5000 live births. However, it is also known that regional variation in incidence can occur. The aim of this paper was to study the incidence of Hirschsprung’s disease in Tasmania and to document a regional experience of HD. Methods: A retrospective review of all patients with newly diagnosed HD between January 1998 and December 2005 was carried out. Data were extracted from medical records and reported. Tasmanian birth statistics from 1998 to 2005 were obtained from the Australian Bureau of Statistics website and the incidence was calculated. Results: Over the 8‐year study period, 14 new cases of HD were identified in Tasmania. The estimated incidence of HD in Tasmania based on this study is 1 in 3429. This incidence is higher than the widely quoted incidence of 1 in 5000, but the difference did not reach statistical significance. Between 2003 and 2005, there was a surge in the number of cases with 11 of 14 cases being derived from these 3 years. No obvious reasons were found to explain this surge in the number of cases. Abdominal distension and vomiting were most common modes of presentation (100 and 71%, respectively). There was delayed passage of meconium in 43%. Conclusion: The incidence of Hirschsprung’s disease seems higher in Tasmania. The surge in the number of cases is also of interest, although the reasons behind this remain unknown. Delayed passage of meconium was also less common than previously cited.     

Thyroid abscess in a 14-month-old child

Suppurative thyroiditis occurring in childhood is rare. Progression to abscess formation is an even more uncommon occurrence. Only four thyroid abscesses occurring in children under 15 yr of age have been reported in the past 20 yr.^1–4A 14-mo-old white girl developed an enlarging mass in the anterior neck. Two weeks previously she was treated for otitis media by her local physician and subsequently was observed to develop a mass in the area of the thyroid gland. Her febrile course was not altered by antibiotics. Physical examination was entirely within normal limits except for the thyroid which was firm and hard with a 4-cm movable mass in the region of the left lobe of the thyroid. There was no associated erythema or apparent tenderness.Laboratory studies included a hemoglogin of 11.6 g/100 ml, hematocrit of 33.5 vol %, white blood cell count of 16,700/ml³ with a differential count of 65 neutrophils, 30 lymphocytes, and 5 monocytes. A urinalysis revealed no abnormalities. Stool culture grew normal enteric flora. A throat culture grew non-Group A beta hemolytic streptococci. A chest film revealed no abnormalities. Studies of thyroid function included a T-3 (30.4%) within normal limits and a T-4 (10.1 μg) in the high euthyroid range.The child received erythromycin 125 mg orally at 6-hr intervals without cessation of fever for 4 days. At this time, it was felt that the fever was related to the thyroid mass which appeared unchanged from the time of admission.At operation, an abscess cavity was noted in the superion of the left lobe of the thyroid gland. Approximately 10 cc of purulent material was removed from the cavity and a Penrose drain was placed in the abscess cavity. A biopsy specimen revealed inflammation and fibrosis consistent with the wall of the abscess. Bacterial, fungal, and acid-fast cultures of the pus were negative.The child became afebrile within 24 hr after operation. The postoperative course was uncomplicated except for the occurrence of a skin abscess at the site of the operative incision. Drainage of this abscess yielded 4 cc of purulent material from which staphylococcus epidermidis was grown. Subsequently the child has not experienced any further difficulty and remains euthyroid.     

Microparticles from stored red blood cells promote a hypercoagulable state in a murine model of transfusion

Background

Red blood cell-derived microparticles are biologically active, submicron vesicles shed by erythrocytes during storage. Recent clinical studies have linked the duration of red blood cell storage with thromboembolic events in critically ill transfusion recipients. In the present study, we hypothesized that microparticles from aged packed red blood cell units promote a hypercoagulable state in a murine model of transfusion.

Clinical results with a new acoustic device to identify the epidural space

Fifty patients scheduled for surgery under lumbar epidural anaesthesia were included in a study to evaluate the possibility of localising the epidural space solely by means of an acoustic signal. With an experimental set-up, the pressure generated during the epidural puncture procedure was translated into a corresponding acoustic signal. One anaesthetist held the epidural needle with both hands and detected the epidural space by means of this acoustic signal. At the same time, a second anaesthetist applied the loss of resistance technique and functioned as control. In all patients the epidural space was located with the acoustic signal. This was confirmed by conventional loss of resistance in 49 (98%) of the patients; in one patient (2%) it was not. We conclude that it is possible to locate the epidural space using an acoustic signal alone.     

Multiple level injuries of the cervical spine

In a group of 105 patients admitted to hospital with injuries of the cervical spine, the incidence of injuries at multiple levels was 24 per cent. Multi-level injuries occurred in 17 out of 54 patients (31 per cent) sustaining a noteworthy neurological injury and in 8 out of 51 when such an injury was absent. This incidence is higher than previously reported, probably due to increasingly elaborate investigations. In the majority of cases, treatment of the dominant injury was unchanged by the demonstration of injuries at other levels, but in a small number, serious errors in treatment arose or could have arisen. Careful multi-level assessment, including assessment of the cervicothoracic junction, is indicated before selecting management. While conventional or computerized axial tomography may occasionally be necessary to achieve this, good conventional radiography remains the most important investigation. Computerized axial tomography is particularly useful in establishing the anatomy of complex injuries in the upper cervical spine.     

Topical povidone-iodine reduces mortality from bacterial peritonitis

The efficacy of topical 10 and 1.5% povidone-iodine was assessed in a rat fecal peritonitis model. Both solutions were bactericidal in vitro. An LD₉₀ preparation of fecal peritonitis in the rat was then assessed and rats were assigned to control or four treatment groups consisting of lavage with saline, 10% povidone-iodine (2.5 ml/kg), povidone-iodine plus saline (600 ml/kg), or 1% cephalothin (600 ml/kg). Twenty-four-hour mortality rates were recorded. Quantitative peritoneal cultures were obtained before and 3 and 6 hr after lavage. Lavage was effective only with 1.5% povidone-iodine or when cephalothin was added. Each of these lavage solutions significantly reduced mortality (P < 0.05). Delayed intravenous cephalothin (200 mg/kg) reduced mortality significantly following 10 or 1.5% povidone-iodine. Failure of povidone irrigation is due to uncontrolled infection rather than to drug toxicity.     

Metabolic evidence that regional hypothermia induced by cold saline protects the heart during ischemic arrest

The rationale for cold saline induced hypothermic myocardial protection during ischemic cardioplegia has been limited for the most part to empiric and contractility observations. The aim of this study was to evaluate the degree of metabolic protection afforded by this procedure. In 21 dogs (C) placed on total cardiopulmonary bypass, normothermic ischemic arrest was induced for 60 min followed by 30 min of reperfusion. In 8 other dogs (CS), similarly treated, the heart was continuously cooled with saline at 5°C before and during the ischemia. Myocardial biopsies analyzed for ATP, ADP, creatine phosphate (CP), lactate and glycogen (Gly), were obtained before cross clamping at 15, 30, 45 and 60 min of ischemia and after 30 min of reperfusion.Significantly higher levels of ATP, CP and Gly were found in the CS hearts during and following the cross clamp period. These data indicate that local hypothermia slows the breakdown of high energy phosphate moieties during ischemic arrest. However, despite the protection afforded, ATP remains significantly depressed following reperfusion.     

Management of immature teratoma of the ovary in children by conservative resection and chemotherapy

Six patients with immature teratoma of the ovary were treated with surgery and chemotherapy. Surgical management consisted of unilateral salpingooophorectomy, biopsy and conservation of the contralateral ovary, and biopsy of peritoneal implants. Triple-agent chemotherapy with vincristine, actinomycin D, and cyclophosphamide was given to four patients and appeared to be beneficial. Radiation therapy was not employed. Local resection of teratomatous recurrences was frequently necessary. Thorough sampling of this tumor is mandatory for establishment of an exact pathologic diagnosis. All six patients are surviving in good health at 1–8-yr follow-up. The prognosis of immature teratoma in the child or adolescent appears more favorable than previously appreciated.     

Delayed flank approach to isolated renal trauma in children.

Seven cases of delayed operation for renal trauma are presented. The only kidney lost would have been lost with early operation. No undue friability of the renal tissue was found. The flank approach in delayed procedures for renal trauma has certain advantages over the transabdominal approach.     

Proximal row carpectomy with muscle transfers for spastic paralysis.

Fourteen patients with spastic paralysis from various causes (eight with cerebral palsy) who needed minimal two handed activities to assist in self-care and who desired improvement in appearance were treated by proximal row carpectomy. In twelve transfer of flexor carpi ulnaris to extensor carpi radialis brevis was done, and in two the extensors of the wrist were shortened. Various other procedures were done in some patients. Prolonged splinting was carried out. Better extension of the wrist was obtained and supination improved more when the transfer was subcutaneous around the ulnar border than when through the interosseus membrane. Less tendency for the carpus to displace ulnarward was seen when the distal half of the scaphoid was not removed. Strength of grasp and pinch improved, but ability to release objects was diminished due to the more dorsiflexed position of the wrist. Subjective use for two handed activities was improved and the patients were satisfied with the appearance.     

Fc and complement receptor integrity of polymorphonuclear (PMN) cells following thermal injury

In patients sustaining thermal injury, a sequential study was formulated to evaluate Fc and complement receptor expression of polymorphonuclear cells (PMN). Additionally, the role of factors in burn sera and maturity of PMN cells in the circulation were studied. The salient features of the study were:

1. 1. Marked reduction in Fc receptor expression by the 5th day of injury in both survivors and non-survivors. Thereafter levels gradually increased in survivors, though they were still below the normal range. In non-survivors, the depression was severe and persistent.

2. 2. In contrast to Fc receptor expression, complement receptor integrity was not grossly affected in both survivors and non-survivors.

3. 3. Burn sera collected from survivors on the 5th and 13th post-burn day showed reduction in Fc receptor expression of normal PMN cells, whereas sera obtained a month after the injury exhibited no inhibitory effect. Non-survivors sera inhibited Fc receptor expression of normal PMN cells on 5th, 13th and 21st post-burn days.

4. 4. The appearance, increase and disappearance of immature PMN cells in the circulation was correlated with the clinical progress of the patient. Mechanisms involved in the aberrations and its implications are discussed.

     

原发性胆囊癌(附39例报告)

本文报告12年来我院收治的39例经手术及病理证实原发性胆囊癌。腺癌30例、腺瘤癌变3例、硬化性腺癌1例、透明细胞癌1例、印戒细胞癌1例、粘液腺癌1例、磷状细胞癌2例。本组男16例,女23例,年龄30～78岁,中位年龄65岁,均有胆道病史。结石合并率为51.3％(20/39),术前诊断率为43.5％(17/89)。胆囊切除率61.5％(24/39)。作者讨论了胆囊癌发病的相关因素,并建议对有癌危因素的胆囊息肉样病变应积极予以胆囊切除。强调术中对胆囊大体标本检查的必要性。     

Rodeo roping thumb injuries

Three men with thumb injuries sustained during rodeo roping competition have been treated recently. Two of the thumbs were amputated, and the third was partially avulsed. The mechanism of injury was identical in all three cases. The thumbs were entwined between the rope and saddle horn while reducing the slack in the rope and then subjected to shearing and crushing forces as tension was placed on the rope. These injuries emphasize the importance of keeping the thumb upward and clear of the rope to avoid entrapment between the rope and saddle horn.     

COMPARISON OF LENGTH OF STAY AFTER HERNIA REPAIR IN TWO VICTORIAN HOSPITALS

The objective of this study was to ascertain factors which determine the length of stay in relation to adult patients admitted for hernia surgery in two different hospitals. It was conducted prospectively on a total of 141 patients, 82 in a central hospital and 59 in a district hospital. There were no significant differences with regard to age, sex, type of hernia, pre-existing disease and postoperative complications. There was a significant difference between the average length of stay in the two hospitals (6.7 days in the central hospital and 3.9 days in the district hospital). There was a longer pre-operative stay in the central hospital through administrative problems, availability of operating time and admission for pre-operative investigations. In the postoperative period there was a significant difference between the day of operation and the time the surgeon stated that the patient could be discharged (i.e. the surgically advised discharge (SAD) date). This period was 4 days at the central hospital, as against 2 days at the district hospital. Once the SAD date was determined, there was no difference between the two hospitals with regard to placement. Consideration should be given to improving admission practices, including patient ‘work-up’ in the preadmission phase and to shortening the postoperative stay after hernia surgery.     

Pancreatic cyst fluid glucose: rapid,inexpensive, and accurate diagnosis of mucinous pancreatic cysts

Background

The most widely accepted biochemical test for preoperative differentiation of mucinous from benign, nonmucinous pancreatic cysts is cyst fluid carcinoembryonic antigen. However, the diagnostic accuracy of carcinoembryonic antigen ranges from 70% to 86%. Based on previous work, we hypothesize that pancreatic cyst fluid glucose may be an attractive alternative to carcinoembryonic antigen.

Preoperative pain in patient with an inguinal hernia predicts long-term quality of life

Background

Patients presenting for inguinal hernia repair report a wide range of pain. We hypothesized that patients presenting with less preoperative pain would experience a greater improvement in long-term quality of life after an inguinal hernia repair.

Congenital fibrosarcoma of the thoracolumbar region

A case of congenital fibrosarcoma of the thoracolumbar region is described in a newborn infant. Its clinical presentation and the presence of spina bifida from the tenth thoracic vertebra through the sacral segments suggested the possibility of a myelomeningocele. The tumor was excised and the patient remained neurologically intact.     

Emboli (debris) produced by bubble oxygenators. Removal by filtration

The screen filtration pressure (SFP) and its derivative, the screen filtration resistance (SFR), were measured in blood in the extracorporeal circuit of humans during cardiopulmonary bypass. It was confirmed that blood from the suction line had very high SFP and SFR. These were returned to normal by filtration through Dacron wool. During the first few minutes of bypass the SFR of venous blood was high, but thereafter it remained low. The SFR of oxygenated blood was elevated continuously during the procedure, especially after nearly 2 hours of bypass. Arterial blood consistently had a low SFR after Dacron-wool filtration. The high SFR values following oxygenation are interpreted as being due to particle (microemboli) production by the oxygenator. These were uniformly removed by a Dacron-wool arterial filter.     

神经源性骨化性肌炎

本文报告神经源性骨化性肌炎３例，结合文献，讨论了发病机理，临床表现和病理特点等。认为其发生与神经营养性变化和压迫性萎缩坏死有等有关，临床分早，中，后三期，阐明各期特点同时，提出Ｘ线透明带和组织学分带现象对诊断及鉴别诊断的意义。等     

腰椎间盘脱出碎片位移的临床观察

本文报道了93例腰椎间盘碎片位移,其中38例向上移动,32例向下移动,双向移位9例,向后移位3例,原位11例。脱出间盘碎片在椎体后面的硬脊膜前外间隙内移动,间盘碎片移动的径路是由硬脊膜前外间隙的解剖学所决定。