Persistent cloaca: are we ready for a correct prenatal diagnosis?

Cloacal malformations are rare and can present in variable aspects. The importance of ultrasound in detecting these anomalies is well known. Sonographic features vary in accordance with the type of malformation and the gestational age. A positive diagnosis is not possible because of the lack of specific ultrasound findings, which can show similar aspects to other abnormalities. We present 3 cases of prenatal diagnosis of this malformation, emphasizing that in the presence of a plurilobed cystic pelvic fetal mass with associated malformations, such as cardiac, renal, and vertebral anomalies, a persistent cloaca can reasonably be suspected.     

Breast myiasis: Are we prepared for the correct diagnosis?

Cutaneous myiasis is an endemic infestation in Latin America and Africa. Many unusual sites of larval infection can cause diagnostic confusion, especially if the patient is not from an endemic area. In the breast, the furuncular aspect suggests some differential diagnosis. We report a case of an 84-year-old patient with an ulcerated lesion on the right breast, who was referred to the reference service to exclude malignancy. Considering the clinical aspects and after further evaluation with imaging methods, she was diagnosed with myiasis. This study reinforces the importance of differential diagnosis of myiasis in patients that come from endemic areas.     

Female epispadias: are we missing the diagnosis?

OBJECTIVE: To describe three of four female patients with occult epispadias, as usually epispadias is reported to be a rare condition in females (1/480,000), and obvious and easy to diagnose, but less severe variants may still involve urethral sphincter incompetence in the absence of obvious clinical signs. PATIENTS AND METHODS: The hospital records over a 10-year period (1 January 1991 to 31 December 2000) were reviewed to find all female patients diagnosed with epispadias. Data were collected from the Consultative Council on Obstetric and Paediatric Mortality and Morbidity for the number of live births per year for the decade studied, and the incidence of female epispadias determined. RESULTS: Over the 10-year period there were 13 patients with a diagnosis of epispadias, from 636,698 total live births; four were female and nine male. Each of the female patients had varying degrees of epispadias; three had subtle signs with apparently normal external genitalia, and only one had a bifid clitoris. However, even the most minor variant case had a palpable notch in the symphysis pubis, and an 'oblong' external urethral meatus. Thus the incidence of female epispadias is at least 1/160,000. CONCLUSION: Epispadias in females may be up to three times more common than previously expected, but even experienced clinicians can miss the diagnosis. The importance of a careful examination should be emphasized, especially in female patients with chronic wetting of unknown cause. A bifid clitoris is an important sign but not always present. Key diagnostic features include drug-resistant wetting, a very low leak pressure on cystometrography, a palpable gap in the pubic symphysis and an abnormal oval-shaped external urethral meatus.     

Pancreatic fistulae: are we making progress?

Background/Purpose  Pancreatic fistulae constitute a morbid outcome of pancreatic surgery. Yet, a definition of a pancreatic fistula does not exist that can be reliably used to report on and study this outcome. We compare reported fistula, morbidity, and mortality rates with fistula parameters in order to identify high-risk fistulae predictive of morbid outcomes. Methods  A systematic literature review was performed; of 1426 articles identified, 43 articles ultimately met inclusion and exclusion criteria and were reviewed. Fistula, morbidity, and mortality rates as well as fistula definitions were extracted and then compared and graphically reported. Results  Thirty-two different definitions of pancreatic fistulae were found in 43 articles; only 24 articles defined fistulae according to all three parameters examined in this study. The data trends suggest that fistula, morbidity, and mortality rates have remained relatively stable since 1980. Further, drainage volumes, amylase levels, and length of drainage do not appear to correlate with reported morbidity or mortality rates. Conclusions  This study suggests that pancreatic fistulae may not correlate with morbidity and mortality. Further, the parameters historically used to define fistulae do not appear to correlate with morbidity and mortality. A different system is needed to identify this outcome and determine its clinical significance.     

Immunotherapy: are we making a difference?

There is a 10-20 year history of immunotherapeutic approaches in metastatic renal cell cancer, which have produced a consistent demonstration of anti-tumour effect in a small percentage of patients. Clarification of dose and schedule of current agents continues to be modified. New technologies for immune system activation are attempting to enhance the response rate and improve outcome. Anti-proliferative effects of immunotherapy produce prolongation of stable disease, and new agents are being developed to enhance this approach.     

Alloplastic bladder substitution: are we making progress?

Radical cystectomy with lymphadenectomy and urinary diversion is the gold standard treatment for bladder cancer in organ-confined muscle-invasive disease and selected patients who have high-grade non-muscle-invasive disease or are non-responders to BCG. The main and most morbid complications of this challenging surgery are related to the use of bowel for urinary tract reconstruction. For this reason, many past projects were devoted to finding an alternative to the use of bowel. The aim of this review is to provide a summary of the evolution of alloplastic bladder substitution. A comprehensive review of the literature was performed using the Medline National Library of Medicine database and Google Scholar. Keywords used were cystectomy and intestine/bowel, replacement, bladder substitution, organ replacement, artificial bladder, alloplastic material, biomaterial, and tissue engineering. Various prostheses have been proposed for replacement of the urinary bladder, silicone being the most frequently used material. The first published model of an alloplastic bladder was described by Bogash et al. in late 1959, while the last, in 1996, was suggested by Rohrmann. Interprofessional collaboration, recent advances in technology, and tissue engineering may help in developing suitable bladder prostheses. Urologists as well as engineers and the industry need to give this matter serious attention.     

Ventilation - how often are we correct?

Traditional mechanical ventilation used tidal volumes (Vt) of between 10 to 15 ml/kg of body weight in order to achieve normal values of pH and partial pressure of carbon dioxide (PaCO2). Many clinicians today however, adopt lower volumes as a conservative 'safe' ventilation strategy in most mechanically ventilated patients. The method by which this is done varies between facilities, but anecdotally doctors use Vt of 6 to 8 ml/kg, and they commonly estimate these volumes at the bedside. This observational study was undertaken in a 23-bed level 3 intensive care unit at a metropolitan tertiary hospital in order to determine whether or not intensive care clinicians are accurately determining the Vt during mechanical ventilation which they purport to do. The primary outcome measure was the Vt being delivered at the time of observation. Thirty patients were recruited into the study, resulting in 55 observations of synchronised intermittent mandatory ventilation with autoflow mode ventilator settings. Although volumes between 6 to 8 ml/kg were recorded in 33 (60%) observations, more detailed exploration of the individual's clinical circumstances reflects that the actual dialled volumes were correct in all but two patients. Intensive care unit mortality was 13% (n=2) in those patients receiving higher than anticipated Vts (n=15). This study has demonstrated that while we achieve a protective ventilation strategy by adopting lower Vts in most mechanically ventilated patients, we should be constantly monitoring exactly what volume is being achieved, not just what is dialled up to be delivered.     

Flail chest injury: are we making any progress?

Flail chest represents a severe injury with mortality historically reported at up to 30 per cent. Although management has changed dramatically over the past several decades, there is a paucity of large recent series. With Institutional Review Board approval, a retrospective review of all patients with flail chest admitted from January 2001 through May 2010 was undertaken. Patient demographics, outcomes, and cause of death were specifically analyzed with univariate and multivariate analysis. There were 164 patients at a median age of 51.4 years. Head injury and pulmonary contusion were present in 67 (40.8%) and 125 (77%), respectively. Pneumonia developed in 72 (43.9%). There were 41 deaths (25%), for which flail chest contributed to 15 (9.1%). Of the patients with flail chest-related death, the majority (n = 10 [66.7%]) died within 48 hours of presentation. There were only five deaths (3.0%) related to flail chest after 48 hours. Multivariate analysis of ventilator dependency revealed requirement for laparotomy (P = 0.019) or tracheostomy (P < 0.0001) and pneumonia (P = 0.0002) as significant. Pneumonia was the most significant independent predictor of overall (P < 0.0001) and intensive care unit length of stay (P < 0.0001). The mortality associated with flail chest has greatly improved; however, the rate of pneumonia remains high. Further efforts at pneumonia prevention are thus warranted.     

Submuscle saline breast augmentation: are we making sense in the new millenium?

Historically, it appears that the problems of capsule contracture, the alleged risk of human adjuvant disease, and the problems due to migration of smooth walled breast prosthesis have had a major impact on the techniques used in breast augmentation. As a consequence of the above, the primary cosmetic goal may have been lost (a naturally enlarged aesthetic breast). It is suggested, that from a purely cosmetic point of view, that the best result is obtained with a subglandular textured gel prosthesis. Reasons for selecting this method are advanced and well documented limitations to the submuscle pocket are highlighted. Various incisions are also discussed. The inframammary fold is a critical landmark of the breast and should not be violated in a cosmetic procedure.