Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality

OBJECTIVE: To evaluate the outcome of aggressive conservative therapy in patients with esophageal perforation. SUMMARY BACKGROUND DATA: The treatment of esophageal perforation remains controversial with a bias toward early primary repair, resection, and/or proximal diversion. This review evaluates an alternate approach with a bias toward aggressive drainage of fluid collections and frequent CT and gastographin UGI examinations to evaluate progress. METHODS: From 1992 to 2004, 47 patients with esophageal perforation (10 proximal, 37 thoracic) were treated (18 patients early [<24 hours], 29 late). There were 31 male and 16 females (ages 18-90 years). The etiology was iatrogenic (25), spontaneous (14), trauma (3), dissecting thoracic aneurysm (3), and 1 each following a Stretta procedure and Blakemore tube placement. RESULTS: Six of 10 cervical perforations underwent surgery (3 primary repair, 3 abscess drainage). Nine of 10 perforations healed at discharge. In 37 thoracic perforations, 2 underwent primary repair (1 iatrogenic, 1 spontaneous) and 4 underwent limited thoracotomy. Thirty-4 patients (4 cervical, 28 thoracic) underwent nonoperative treatment. Thirteen of the 14 patients with spontaneous perforation (thoracic) underwent initial nonoperative care. Overall mortality was 4.2% (2 of 47 patients). These deaths represent 2 of 37 thoracic perforations (5.4%). There were no deaths in the 34 patients treated nonoperatively. Esophageal healing occurred in 43 of 45 surviving patients (96%). Subsequent operations included colon interposition in 2, esophagectomy for malignancy in 3, and esophagectomy for benign stricture in 2. CONCLUSIONS: Aggressive treatment of sepsis and control of esophageal leaks leak lowers mortality and morbidity, allow esophageal healing, and avoid major surgery in most patients.     

Adjuvant postoperative radiotherapy for colon carcinoma

BACKGROUND: The objective of this report was to review the role of adjuvant postoperative radiotherapy (RT) for patients with adenocarcinoma of the colon. METHODS: The authors reviewed the pertinent literature. RESULTS: Data suggested that locoregional postoperative RT improves both local control and survival for patients with T4N0-N1 tumors. There also may be a benefit for patients with T3N1-N2 tumors, but the data were equivocal. Whole abdominal RT may result in a similar benefit but is associated with increased toxicity. CONCLUSIONS: Postoperative RT should be considered for patients with T4N0-N1 colon carcinoma. Locoregional fields should be used.     

Acute renal failure due to acute tubulointerstitial nephritis

Acute interstitial nephritis (AIN) should be ruled out in children with unexplained acute renal failure. We present a 4 1/2 year old girl who presented with oliguric acute renal failure preceded by a febrile illness. Renal histopathology revealed features of drug induced AIN. She recovered with dialysis, other supportive treatment and a course of steroids.     

Epidural compared with general anaesthesia for caesarean delivery in conscious women with eclampsia

Objective To compare retrospectively the outcome of caesarean section under epidural anaesthesia with that of general anaesthesia in "stable" women with eclampsia.
Design Retrospective review.
Method Over the five–year study period, there were 533 women with eclampsia and of these 66 women (12.4%), fulfilled the criteria of being 'stable'. Of the 66 women, 37 received epidural, 27 general, and 2 spinal anaesthesia.
Results There were no major complications with either general or epidural anaesthesia. Epidural anaesthesia was associated with higher one–minute Apgar scores.
Conclusion This study indicates that both maternal and neonatal outcomes are not affected adversely by the use of epidural anaesthesia in selected cases of eclampsia.     

Attitude of unmarried girls towards family planning: a study in an Orissa City.

In 1987-88, 281 females from the Government Women's College in Berhampur, Ganfam District, Orissa State in India were surveyed to determine their knowledge and attitude toward family planning (FP). 80% came from urban areas. Educated fathers (72%) had considerable influence over the education of their daughters (p.001). Higher income families (70%) were more able to educate their children than lower income families (30%; p.001). 50% of the students had discussed FP and family ties with their parents. 91% recognized the need for FP. 95% did not favor early marriage (p.02). 66% knew the legal marriage age for females to be 18 years, but only 47% knew it to be 21 for males. In fact, 46% believed the age for males to be 25 years. 24% k new of only 1 FP method, 23% of 2 methods, and 14% of 3 methods. The leading method to be used after marriage according to the students was condoms (16%) followed by IUDs and oral contraceptives (OCs) (6%). The predominant method to use after childbirth was sterilization (13%) followed by IUDs (8%) and condoms and OCs (5%). Most students did not advocate using any method after marriage or after childbirth. 45% mentioned the best time to start FP was after 2 children and 26% after 1 child. Most, (83%) preferred 2 children (p.001) because of better child care and education (37%). 71% felt couples should wait 3 years before having another child. No one believed 1 or 4 years to be adequate birth spacing. Birth spacing was needed in the interest of the mother's health (30%) and for better health of the next child (29%). The mass media provided 50% of the students with FP knowledge. Most (70%) felt that insufficient FP education and basic education were the reasons for unplanned families. 82% believed the FP program would be successful in the future. 68% considered population control important to national development.     

Recurrent swelling of the upper lip. A case report

Recurrent swelling of the lips may be due to a number of causes. A case is presented of recurrent swelling of the upper lip caused by trauma from a displaced and apically dilacerated 1. There was abnormal development of 32 which were also displaced although 123 appeared unaffected. The surgical, endodontic and orthodontic management of this problem is discussed.     

Harnessing collaboration to build nursing research capacity: a research team journey

This paper discusses a qualitative evaluation study, designed to explore nursing lecturers' research capability development through their engagement as co-researchers in a larger case study project (referred to as the 'main project'). It explores the justification for supporting research capacity development using this collaborative approach, the process and experience of undertaking collaborative research, and the effectiveness of this model of collaboration in developing new researchers. The paper also makes connections between the process of undertaking the research (designed to offer opportunities for inexperienced researchers to be involved) and the main project findings (which explored the ways in which academic schools develop research capacity). We first set the main project in its wider context and map key issues relating to research capacity development and collaboration in the literature, before outlining how we involved neophyte and 'midiphyte' researchers. The evaluative study, which is the focus of this paper, discusses the experiences of the neophyte researchers, and explores the synergies between the main project's key findings and the process of undertaking it. We conclude with some principles for using collaboration to build research capacity, visualised through a conceptual model. While this project was located within two universities in the UK, the development of research skills amongst nurses is likely to have broad international relevance. NB1 References to 'nursing', 'nursing research', and 'nursing education' are taken throughout to apply equally to midwifery, midwifery research, and midwifery education. NB2 For the purpose of this project, neophyte researchers are defined as staff needing formal training in research and involvement in others' research, and 'midiphyte' researchers as those with some training but needing support to develop research ideas.     

Primary carcinoid of posterior mediastinum: truth or myth!

Mediastinal masses present challenging problems in thoracic practice. Most of them remain asymptomatic for long and by the time the pressure symptoms develop, these are quite advanced. Carcinoids arising from the mediastinum are invariably related to thymus. Non-thymic origin of mediastinal carcinoids is rare, especially in the posterior mediastinum. Only two cases of posterior mediastinal carcinoids have been reported so far. These were assumed to be arising from ectopic thymus tissue. We report a case of a 45-year-old woman who presented with dyspnoea and dry cough due to giant carcinoid tumour of the mediastinum, the pedicle originating from the posterior mediastinum, not related to thymus. She underwent thoracotomy and resection that provided relief. The immunochemical studies revealed positive reaction to cytokeratin, chromogranins and synaptophysin, and negative reaction to S100, CD99 (MIC2) confirming the tumour being neuroendocrine in nature.