"A" for Agency, "B" for Basal cell, "C" for Corticotulle, "D" for Danger

Without any proof, a governmental agency has decreed that Corticotulle was not enough efficient to be reimbursed by National Health Security. Dealing with treatment of basal cell carcinoma, another governmental agency has published recommendations which even do not follow basic rules of logic. This paper points out that economical and political methods are not scientific or medical ones.     

Caring for non-combatants, refugees, and detainees

The recently reported abuses at Abu Ghraib prison have brought the issue of medical care for displaced persons (DPs) to greater prominence. Natural disasters in the United States (eg, Hurricane Katrina) and elsewhere also require significant medical resources in situations that lack basic infrastructure. Intimate knowledge of the basic tenets of international law is crucial to the care of DPsin any capacity. This article provides an introduction to the Geneva Conventions and the medical and administrative issues that form a framework on which to base DP care.     

Quest for Science,Spirit, and Skills

The 96th Annual Meeting of the Japanese Orthopedic Association will be held from May 11 to 14, 2023, at Yokohama in Japan. I decided to set the theme for this meeting as “Quest for Science, Spirit, and Skills.” We believe that the “quest” to master these elements is the basic principle of those responsible for well-balanced musculoskeletal medicine and is also essential to further developments of orthopedic surgery.The poster for the meeting incorporates Okayama Castle and an ukiyo-e painting of Miyamoto Musashi who was also famous for his nito-ryu or double-bladed swordsmanship. The idea behind using the ukiyo-e of Miyamoto Musashi on the poster is to draw an orthopaedic surgeon with “science” on one hand, “skills” on the other hand, and “spirit” in the heart. Moreover, novel perspectives and innovations may develop through working on more than two specialties. We believe that our interests to various clinical fields and science constitute the nito-ryu working style, which would accelerate the development orthopaedic science.It is important to challenge the unknown both in medicine and in life. Anyone would agree that it is fundamental to strive for new discoveries and technological developments in medicine. Sometimes we work hard because we cannot see the future, but there are times when we need to work hard even if we can anticipate the future. I think that your destiny may change depending on whether you make an effort or not. I would like young people to keep this in mind and continue to challenge the unknown. Finally, I would like to introduce the words of Shoin Yoshida in the Edo era: “Those without dreams have no success.”     

Proposed definitions for diagnosis,severity scoring,stratification, and outcome for trials on intraabdominal infection

Analysis of the experience with scientific studies on patients with secondary intraabdominal infection has revealed that problems of interpretation and comparability between studies exist as they relate to variable diagnostic criteria, unmeasured severity of disease, and unclear outcome measures. A consistent system of definitions has been developed to address these deficiencies. Intraabdominal infection is defined as clinical peritonitis requiring both operative and microbiological confirmation for proof of infection. The APACHE II system is proposed for grading the severity of the infection and for stratification of patient risk of mortality. Mortality and time until death, on one hand, and recovery and time until recovery, on the other, are proposed as the main outcome measures, both being independently and positively defined. It is anticipated that this system of minimum rules will produce studies that can be compared, hence, accelerating knowledge and understanding about intraabdominal infection and its best treatment.

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Resumen El análisis de los resultados de investigaciones científicas en pacientes con infección intraabdominal secundaria ha revelado que los problemas de interpretación y comparabilidad entre los diversos estudios se relacionan con criterios diagnósticos variables, con gravedad no definida de la enfermedad, y con parámetras indeterminados de desenlace. Se ha establecido un Sistema consistente de definiciones con el objeto de eliminar tales deficiencias. La infección intraabdominal es definida como una peritonitis clfnica que requiere confirmación, tanto operatoria como microbiológica como prueba de la infección. Se propone el sistema APACHE II para determinar el grado de gravedad de la infección y para la estratificación del riesgo de mortalidad. La mortalidad y el período hasta la muerte del paciente por un lado, y la recuperación y el perfodo hasta la recuperación por otro, son propuestos como los parámetras principales de desenlace, ambos definidos en forma independiente y positiva. Se espera que este sistema de reglas mínimas habrá de producir estudios que sean comparables, lo cual acelere la adquisición de nuevos conocimientos y la mejor comprensión de la infección intraabdominal y de su tratamiento.

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Résumé L'analyse des différentes études scientifiques sur les infections intra-abdominales a montré que les problèmes d'interprétation et de comparabilité relèvent de critiques diagnostiques variables, et de l'absence d'évaluation de la sévérité de la maladie, et de son évolution. Un système de définitions a été développé pour pallier ces déficiences. L'infection intra-abdominale se définit comme péritonite clinique exigeant la confirmation opératoire et microbiologique de l'infection. Le score APACHE II est proposé pour classer l'infection selon sa sévérité et prévoir le risque de mortalité. Mortalité et délai avant la mort, guérison st délai avant la guérison sont proposés comme critères d'évolution. On espére que le fait d'adopter ces règles permettra de comparer les études et fera progresser notre compréhension de l'infection intra-abdominale et son traitement.

     

Azithromycin treatment for nongonococcal urethritis negative for Chlamydia trachomatis,Mycoplasma genitalium,Mycoplasma hominis,Ureaplasma parvum,and Ureaplasma urealyticum

Some patients with nongonococcal urethritis (NGU) are negative for Chlamydia trachomatis, mycoplasmas, and ureaplasmas. The optimal antimicrobial chemotherapy for such NGU has not fully been clarified. We assessed the efficacy of azithromycin for treatment of nonmycoplasmal, nonureaplasmal, nonchlamydial NGU (NMNUNCNGU). Thirty‐eight men whose first‐pass urine was negative for Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma parvum, and Ureaplasma urealyticum were treated with a single dose of 1 g azithromycin. Urethritis symptoms and polymorphonuclear leukocytes in urethral smears or in first‐pass urine were assessed before and after treatment with azithromycin. Thirty‐two (84.2%) of the 38 men with NMNUNCNGU showed no signs of urethral inflammation after treatment. The efficacy of this azithromycin regimen was comparable to that of the 7‐day regimen of levofloxacin, gatifloxacin, minocycline, or clarithromycin reported previously. A single dose of 1 g azithromycin, which is effective not only for NGU due to specific pathogens but also for NMNUNCNGU, is an appropriate treatment for NGU.     

Reoperation for aortic coarctation: techniques, results, and indications for various approaches

To define the safety and efficacy of operation for recurrent thoracic aortic coarctation, we reviewed the hospital records and subsequent courses of 53 patients who underwent such procedures over a 23-year period. Previous operations included end-to-end anastomosis, prosthetic patch or subclavian flap aortoplasty, and prosthetic interposition or bypass grafts, performed in patients ranging from 1 day to 44 years old. Several different reoperative procedures were used, including an ascending-descending aortic bypass graft in 4 patients who had had two previous repairs. There were no hospital or late deaths and only 3 relatively minor complications. Only 2 patients have hypertension requiring drug therapy at follow-up, which now averages 7 years. We conclude that operative management of severe, recurrent coarctation is both safe and effective, and that several techniques of reconstruction may have a place in such therapy.     

Transanal,full-thickness,Swenson-like approach for Hirschsprung disease

Purpose

Swenson’s procedure for Hirschsprung disease (HD) was thought to disturb fecal, urinary, and ejaculatory functions leading to other approaches including the Soave and Duhamel techniques. Given our Center’s experience with a full-thickness rectal dissection for anorectal malformations, and using the new transanal concept, we chose to apply these ideas to the primary treatment of HD, and describe technical aspects and impact on fecal, urinary, and sexual function.

Methods

We reviewed our series of HD patients who underwent a transanal, Swenson-like rectosigmoid dissection, assessing for postoperative stricture, anastomotic leak, enterocolitis, and long-term results for bowel, urinary, and sexual function.

Results

Of 67 patients, 28 had a transanal resection, 5 had transanal plus laparoscopy, and 34 had transanal plus laparotomy, of those, 28 patients had a leveling colostomy prior to referral. The average length of resection was 27 cm ± 12.7 cm. Mean follow-up was 17.2 months (range 1–96 months). 44 patients were at least three years old at follow-up and were assessed for urinary and fecal continence; all (100%) had voluntary bowel movements and urinary continence. Enterocolitis occurred in 9 patients (14%) and constipation (requiring laxatives) occurred in 21 (32%). Of 24 male patients, 21 (88%) reported the occurrence of spontaneous erections post-operatively.

Conclusion

Our data support the fact that a modification of Swenson’s original transabdominal dissection concept using the recently described transanal approach is an excellent technique for Hirschsprung, and produces excellent long-term outcomes for fecal and urinary continence, and seems to preserve erectile function.     

Active Surveillance for Favorable-risk Prostate Cancer: Background,Patient Selection,Triggers for Intervention,and Outcomes

With the advent of increasingly sensitive and widely used diagnostic testing, cancer overdiagnosis in particular has emerged as a problem in multiple organ sites. This has the greatest ramifications in the case of prostate cancer because of the very high incidence of latent prostate cancer in aging men, the availability of the prostate-specific antigen (PSA) test, and the long-term effects of definitive therapy. The condition of most men with favorable-risk prostate cancer is far removed from the consequences of a rampaging, aggressive disease. Most of these men are not destined to die of their disease, even in the absence of treatment. Unfortunately, most of these patients are treated radically and are exposed to the risk of significant side effects. Therefore, a selective approach to treatment is appealing. The concept is to identify the subset that harbor more aggressive disease early enough that curative therapy is still a possibility, thereby allowing the others to enjoy improved quality of life, free from the side effects of treatment. This review article summarizes the evidence supporting active surveillance, and the current approach to this management strategy, including the roles of serial biopsy, PSA kinetics, and MR imaging.     

Anesthesia for radical prostatectomy, cystectomy, nephrectomy, pheochromocytoma, and laparoscopic procedures

This article presents some of the more salient aspects of the anesthetic management of the common major renal surgical procedures and discusses the physiology and anesthetic implications of minimally invasive laparoscopic urologic surgery.